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Published: 08 May 2017
Sector: Healthcare

Care Home Performance. Profit driven or Care Quality Commission subjectivity?

Care homes and the quality of care received is sadly rarely out of the news. With recent research (Independent Age – Jan 2017) showing the percentage of care homes with ‘inadequate’ or ‘requires improvement’ ratings, we ask the question, is there any tangible link between being able to afford to provide good care and actually providing it?

If there is a link, then the former may facilitate the latter and create a virtuous circle. At the opposite end of the spectrum of course, we can end up with a downward spiral.

Evidence of affordability and the provision of good care

We started our research by taking the regional rankings from the Independent Age research and placing it alongside the Knight Frank 2016 Care Homes Trading Performance Review regional averages for EBITDARM as a percentage of income.

(English Regions) 
% of homes rated ‘inadequate’ or ‘requires improvement’ (Independent Age)  Regional EBITDARM ranking as a % of income (Knight Frank) 
London 20.3% 1
East of England 20.8% 3
South West 21.1% 6
West Midlands 22.8% 4
East Midlands 24.2% 5
North East 25.6% 9
South East 28.2% 2
Yorkshire and The Humber 32.2% 7
North West 33.6% 8


Out of the top six performing Regions in terms of EBITDARM, five of these regions also have the lowest percentage of homes in the bottom two ratings categories.

The three worst performing Regions in terms of EBITDARM feature in the four regions with the highest percentage of homes rated ‘inadequate’ or ‘requires improvement’.

QED?  Is it that simple?

Well….probably not. Otherwise why would the ‘prosperous’ South East, which ranks second in terms of EBITDARM performance, have the third worst performance in terms of ratings? Clearly money can helps with most things but it doesn’t produce happiness or provide a good quality care on its own.

In care homes there are lots of factors that to be taken into account, such as funding levels and the mix between public sector and self funders, together with socio-economic factors which lead to differing levels of health, wellbeing and complexities. There is a lot of commentary on the supposed healthcare and wealth North/South divide but it’s clear that two neighbouring London Authorities can also face very different circumstances in terms of the health and care needs of their populations; as well as the ability of those populations to pay for their own care. As for the South East, we believe the data may be skewed by the relatively high number of smaller and older care homes in Kent and East Sussex compared to other areas, which present different management challenges.

The table below, again from Independent Age, shows those Local Authorities which have the lowest percentage of homes rated ‘inadequate’ or ‘requires improvement’.


Local Authority  Region  % of homes rated ‘inadequate’ or ‘requires improvement' 
Worcestershire West Midlands 10.8%
Reading South East 10.5%
Redbridge London 10.4%
Brent London 10.3%
West Berkshire South East 10.0%
Peterborough East of England 10.0%
Bournemouth South West 10.0%
Bedford East of England 9.5%
Blackburn with Darwen North West 9.4%
Croydon London 9.2%
Telford and Wrekin West Midlands 8.9%
Camden London 8.3%
Bracknell Forest South East 7.7%
Slough South East 7.7%
Wokingham South East 6.3%
Thurrock East of England 2.9%
Richmond upon Thames London 2.3%
Rutland East Midlands 0.0%
Islington London 0.0%
Isles of Scilly South West 0.0%


The table below shows the Local Authorities which have the highest percentage of homes rated ‘inadequate’ or ‘requires improvement’.

Local Authority Region  % of homes rated ‘inadequate’ or ‘requires improvement'  
Stockport North West 62.9%
Salford North West 61.5%
Tameside North West 54.8%
Manchester North West 51.3%
Kensington and Chelsea London 50.0%
Oldham North West 48.6%
Liverpool North West 48.1%
Trafford North West 47.2%
Hackney London 47.1%
Bradford Yorkshire and The Humber 46.3%
Wakefield Yorkshire and The Humber 46.0%
Portsmouth South East 44.8%
North Somerset South West 44.7%
Calderdale Yorkshire and The Humber 43.1%
Hartlepool North East 42.9%
Wirral North West 42.1%
Wigan North West 42.0%
Westminster London 41.7%
North Tyneside North East 40.5%
Kirklees Yorkshire and The Humber 39.7%  


Two points jump out. First, whilst the North West region is the worst performing in terms of inspection ratings, the local authority district of Blackburn with Darwen is ranked twelfth best out of all 151 local authority areas across the country. And yet on the face of it Blackburn with Darwen doesn’t appear to be significantly different to many other areas in the North West in terms of its socio-economic profile.

Second, whilst London region has the lowest percentage of homes rated ‘inadequate’ or ‘requires improvement’, there are stark differences between authorities in close proximity to each other. Kensington, Chelsea andWestminster are affluent areas and yet they rank amongst the worst performing 20 authorities.Immediately to their Northare Camden and Islington, which feature in the top 20 best performing local authorities. Whereas right next door to Islington, which has no  homes rated ‘inadequate’ or ‘requires improvement’, is Hackney, which is the ninth worst performing authority in the country, with 47.1% of its homes falling into these two categories.

Are the ratings skewed due to sample size base?

Could variations be a function of how many care homes are in each of the local authority areas? If some areas have far fewer homes than others the data might be skewed.Let’s take a quick look. (Please note that for the purposes of this analysis we have assumed the same mix of elderly and specialist care homes to rule out one possible variance.)

Area Number of care homes   Independent Age. % of homes rated “Inadequate” or “Requires Improvement”
Stockport  67 62.9%
Salford  46 61.5%
Tameside  41 54.8%
Blackburn with Darwen  36 9.4%
Kensington and Chelsea  12 50.0%
Hackney  16 47.1%
Westminster  14 41.7%
Camden  12 8.3%
Islington   20 0.0%


This suggests that the number of homes in an area is not a material factor.  In the North West there are other authorities which have similar numbers of care homes to Blackburn with Darwen but a much higher percentage of homes in the bottom two rating categories. In London we can see that areas with similar numbers of care homes but dramatic differences in ratings performance. Hackney could argue that it has a lower affluence profile to Islington and Camden but Kensington and Chelsea and Westminster couldn’t!

Care Quality Commission influence

Finally, could the results in different areas be down to the subjectivity of different CQC inspectors? We understand that CQC try to allocate inspectors to the areas in which they live. There may be good reasons for that in terms of picking up local information and feedback from various sources on the homes in their locality. However, does this run the risk of creating a greater divergence of ratings between authority areas than would otherwise be the case if a range of different inspectors, with different perspectives, were deployed into each area? Is there scope for greater overview within CQC to ensure objectivity on the part of inspectors?

National and indeed regional care home groups have been wondering for some time how homes which they believe are run on identical models and cultures, receive very different ratings dependent upon which part of the country those homes are in and who inspects them.

What the future holds

We believe that the CQC have now completed its full suite of inspections under the new ratings system and will be presenting its own analysis within the next couple of months. We sincerely hope that, in addition to the various leadership, innovation and care categories they will consider whether profitability affects ratings performance. The ‘last government’ promised to come up with solutions to the crisis in social care just ahead of the last budget. Let’s hope that the new government carries that through and that the CQC’s own analysis can inform the decisions which need to be made.

"This is exactly why we like to work with people who understand the industry and can identify potential issues and create solutions."

Jon Saltinstall, Senior HealthCare Banking Consultant, Lloyds Bank