quality of life and charges in private old people's homes in great britain

I A N GIBBS A N D J O N A T H A N B R A D S H A W

Q U A L I T Y O F L I F E A N D C H A R G E S IN P R I V A T E

O L D P E O P L E ' S H O M E S IN G R E A T B R I T A I N

(Received 15 October, 1989)

ABSTRACT. Over half the residents in old people's homes in Britain have their fees wholly or partly paid from the public purse. Understandably, there is considerable concern that the fees charged should be reasonable in the light of the services and facilities provided. In a recent study, local authority registration officers attempted to relate important qualitative features of private homes to the fees they charged. Taken together, these features provide a measure of the quality of life in homes. Results indicate little relationship between the charges made by homes and the measures reflecting the quality of life for residents. On the other hand, however, it was evident that the quality of life was an important consideration when registration officers made an assessment of the reasonableness of charges in homes. In short, homes assessed as having reasonable charges received higher ratings on the qualitative features. Con- versely, homes judged as charging too much were much more likely to be rated poorly.

I N T R O D U C T I O N

The main objective of the research discussed in this article was to see whether local authorities in Great Britain were in a position to offer advice to the central government's Department of Health and Social Security (DHSS) on the reasonableness of financial charges in those private residential care homes containing residents supported wholly or partly from public funds. In short, it was an exercise concerned with identifying possible mechanisms for controlling charges and not improving the quality of life in homes. However, in the course of the work with local authorities, and exploring with them how and by whom this advice would be offered, the question of quality of life became an important consideration.

Before describing the function of registration officers it is necessary to outline the policy background to the research.

P U B L I C S U P P O R T A N D P R I V A T E C A R E

The term 'residential care for the elderly' is often used in Great Britain

SocialIndicators Research 23: 269--282, 1990. �9 1990 Kluwer Academic Publishers. Printed in the Netherlands.

270 I. GIBBS AND J. BRADSHAW

to refer to two main forms of accommodation -- nursing homes and residential care homes. Apart from three experimental homes within the national health service the majority of nursing homes are within the private and voluntary sectors. Although independent in one sense, private and voluntary nursing homes are regulated by District Health Authorities.

The situation is slightly different for residential care homes where, in addition to the private and voluntary sectors, there is a large and well established public sector created by the National Assistance Act of 1948. Although regulated by local authorities, private and voluntary residential care homes now provide more beds than the public sector. The private sector in particular has grown at an enormous rate encour- aged, to a large extent, by changes in the regulations governing the payment of state benefits to those in residential care and nursing homes.

The Registered Homes Act of 1984 sought to strengthen and improve the registration and inspection of private and voluntary residential homes in England and Wales. In particular, those responsible for framing the legislation aimed to ensure that minimum acceptable standards of accommodation and care were provided. However, the 1984 Act did not give local authorities any control over the charge made by a home or any power to judge whether the charge was reasonable in the light of the services and facilities provided.

In Great Britain the number of people receiving financial support from the state in independent homes, the majority catering for the elderly, has risen from 7000 in 1978 to 150000 in 1988. Over the same period the associated supplementary benefit budget has increased from s million to s 000 million. The latest figures indicate that over half the residents in independent residential care and nursing homes are in receipt of public funds (DHSS, 1987).

Given the dramatic increase in expenditure there have been calls on government to impose tighter control over at least those charges in independent homes that are met wholly, or partly, from public funds (Audit Commission, 1986). Accordingly, the issue of charges was a major focus of a Joint Central and Local Government Working Party, which asked in its first report (DHSS, 1985) whether local authorities were in a position to offer advice on the level of charges which it would be reasonable for supplementary benefit to meet in particular cases.

Q U A L I T Y O F L I F E A N D P R I V A T E O L D P E O P L E ' S H O M E S 2 7 1

The research recommended by the working party to answer this question was undertaken in four areas of Great Britain: Lothian in Scotland; Clwyd in Wales and Sefton and Devon in England. The four local authorities were chosen to represent different parts of Britain and within England different types of authority -- a metropolitan borough and a shire county. Although the four were located in very different geographical areas of Britain they were not selected at random or chosen to represent a cross section or typical perspective. They were selected on very different criteria, namely the existence of a substantial independent residential care sector in each area and the willingness of the four authorities to participate in the pilot studies. On these grounds they must be counted as unrepresentative of the rest of the country. However, their experience of the rapid expansion in residential care provided greater opportunities for exploring the issues than would have been otherwise available.

Table I sets out for each of the four areas the number of private and voluntary residential care homes included in the present study. One feature of the table to note is the large proportion of voluntary homes in Lothian -- a reflection of a different tradition to be found throughout the rest of Scotland in the provision of residential care homes.

TABLE I Type of home by area

Lothian Clwyd Sefton Devon All n % n % n % n % n %

Private homes 11 30.6 25 92.6 74 86.0 68 93.2 178 80.2 Voluntary homes 25 69.4 2 7.4 12 14.0 5 6.8 44 19.8 Total 36 100.0 27 100.0 86 100.0 73 100.0 222 100.0

A S S E S S I N G C H A R G E S

Although local authority finance officers seemed to be the most obvious people to assess the reasonableness of charges, it was soon clear that they lacked the detailed knowledge of these homes to make the judgements required by the research project. Registration officers on the other hand had close contact and intimate knowledge of such


homes. For these reasons they, rather than finance officers, were asked to carry out the assessments -- a request which they readily accepted.

The exercise involved all registration officers in the four local authorities participating in the research. There were two officers making assessments in Lothian, one in Clwyd, four in Sefton and three in Devon. The six men and four women came to their present posts from a variety of social work and residential care backgrounds.

Their task was to complete a detailed questionnaire for every home in their area known to have residents in receipt of supplementary benefit. As one purpose of the research was to gauge the extent to which local authorities were in a position to offer advice on charges, no attempt was made to train registration officers to reach consistent judgements. In total, 222 questionnaires were completed.

REGISTRATION OFFICERS

The relevant legislation in Britain (the Registered Homes Act of 1984) has laid general responsibility on local authorities to ensure that standards of care in residential homes meet at least prescribed minimum standards. They also have a duty to ensure that residents are offered the best quality of life. Registration officers are responsible therefore for making sure that these obligations are properly dis- charged.

There are three main areas of registration. The first relates to prospective homes that seek to open in an area; the second to existing homes that wish to register for additional categories of care; and the third to those where a change of ownership is intended, The first is probably the most time consuming of the three, involving considerable consultation with other related agencies such as the district planning authority, environmental health and fire service. However, even before these checks are carried out, registration officers provide the first point of contact between the prospective home owner and the registering authority. During this pre-registration period many authorities send out packs which set out in detail the requirements for registration. Some registration officers will provide advice, among other things, on the general financial implications of establishing a new home. This is especially important where substantial loans are necessary to start a

QUALITY OF LIFE AND PRIVATE OLD PEOPLE'S HOMES 273

home. Registration officers are not in a position to offer specialist financial advice, home owners must seek this from accountants, but they can say whether the proposed charge is reasonable in the light of the local market conditions.

Once a home has received the relevant approval from the local authority, registration officers will then undertake inspection, monitor- ing and support. It is not uncommon for a new home to be visited within three months of being established. Thereafter homes will be visited at least once a year for a formal comprehensive review which will identify any issues or items that need attention. Registration officers stress the importance of improving standards by consultation and advice rather than rigid dictate. This consultative and gradualist approach is part of the partnership that many authorities are attempting to establish with homes.

Broadly speaking therefore, registration officers are engaged in a number of activities related to quality of life:

(a) Providing preliminary advice to prospective proprietors. (b) Inspecting premises prior to registration. (c) Liaising with other statutory agencies to ensure standards and

compliance with other legislation. (d) Co-ordinating the procedures necessary for the local authority

to approve registration. (e) Inspecting homes on a regular basis after registration. (f) Providing support and advice.

On the basis of the above list it is clear that registration officers do not make judgements about the reasonableness of charges. However they know most about the state of the local market -- demand and supply; they inspect homes at least annually; they make several other visits; they know about and have records of the facilities offered in each home. In this sense they are better equipped than most to make comparisons and arrive at judgements on the basis of the quality and the range of various services and facilities, including quality of life.

ASSESSING REASONABLENESS OF CHARGES

Registration officers relied to a considerable extent on their records in carrying out the assessments for this study. These were mainly derived


from the statutory annual inspection carried out under the 1984 Registered Homes Act and the 1968 Social Work (Scotland) Act.

It is important to emphasise that the research did not set out to measure quality of life as its major focus. Instead, it was important to identify at an early stage a list of items that registration officers would want to consider when deciding whether the charge within a home was reasonable or not. It is these items that, taken together, reflect a picture of the quality of life in residential homes as seen by registration officers. The items broke down into two broad groups. The first contained a number of factors that required an evaluative judgement to be made, for example, the 'atmosphere within a home'. The second group, consisting of such items as proportion of single rooms and the number of residents per bathroom, represent the 'safe' and 'objective' measures which on their own 'do not give an adequate picture of quality of care' (aiggs, 1987).

FACTORS ABOUT THE HOME

The two sets of items formed part of the instrument completed by registration officers on the basis of their knowledge and records of the 222 homes. They were first asked to rate the home for 11 evaluative items or factors.

Factors wei.ghting/relative importance

(1) Localarea Low (2) Upkeep of garden and exterior of property Low (3) Decorative order and standard offurnishing Low (4) Range and quality of facilities Medium (5) Presence of experienced staff Medium (6) Quality of care High (7) Atmosphere within the home Medium (8) Catering Low (9) Turnover of staff Low (1 O) Competence of staff Medium (11) Amount of on-going training Medium

From the rating of the 11 factors above, and further information provided by registration officers about the relative importance they placed on each, raw and weighted overall rating scores were generated.

QUALITY OF LIFE AND PRIVATE OLD PEOPLE'S HOMES 275

Alpha coefficients were calculated for the two scales as measures of

their reliability or internal consistency. Coefficients in excess of 0.87 were found for both the raw and weighted scales, an indication that

sufficient internal consistency existed for the sum of the individual items or factors to be taken as a reliable measure.

Registration officers were then asked 'taking into account all the things that you would consider important, how would you assess this

home' - - poor, adequate, good, very good, excellent. This variable was referred to as the 'overall assessment' to distinguish it f rom the raw and weighted rating scores.

The results derived f rom the raw and weighted rating scores and the

overall assessment are given in Table II. Five per cent of homes were assessed as poor and five per cent as excellent. The majority of homes

were good or better but just over a quarter were only adequate or poor. Both raw and weighted rating scores increased directly in line with the overall assessment.

TABLE I1 Overall assessment by rating scores

Rating scales

Raw score Weighted score Overall assessment N % Mean SD Mean SD

Poor 11 5.0 15.4 (1.7) 30.7 (4.2) Adequate 51 23.0 20.7 (2.5) 42.4 (5.0) Good 83 37.4 24.4 (2.3) 51.2 (4.8) Verygood 66 29.6 29.4 (2.5) 61.1 (4.2) Excellent 11 5.0 33.4 (1.5) 69.4 (3.5)

All 222 100.0 25.1 (4.9) 52.0 (10.1)

p < 0.001 p < 0.001

THE FACILITIES IN THE HOME

The questionnaire also asked about the different facilities available within homes. Whereas registration officers made a judgement about

the factors outlined above, they were only asked to say whether a facility, such as chiropody, was available within the home, or how many


people shared a particular facility. At this stage no form of rating or assessment was involved. From the following list of items it was possible to construct a raw or unweighted index of facilities:

Weighting/ Facilities relative importance

(1) Single rooms High (2) Baths Medium (3) WCs High (4) Sitting rooms High (5) Call system High (6) Lift Medium (7) Hairdressing Low (8) Chiropody Low (9) Physiotherapy Low (10) Occupationaltherapy Low

At a later stage registration officers were asked about the relative importance they placed on each facility. On the basis of this information it was then possible to construct a raw and weighted index of facilities.

The raw and weighted indices yielded alpha coefficients of less than 0.40, an indication that there existed little internal consistency between the individual items. However, given that we were not attempting to measure attitudes, where internal consistency between items is essential before employing a global score, the relatively low alpha coefficients did not prevent us from using the raw and weighted indices of facilities in our analysis.

As a starting point the research examined the relationship between facilities and the overall rating and assessment measures outlined in the previous section. Table III shows quite clearly that there is a modest but statistically positive relationship between registration officers' assessment of homes and the facilities within them.

The research then examined more closely the relationship between the facilities and the overall assessment. The results set out in Table IV indicate that both raw and weighted indices of facilities increased directly in line with registration officers' overall assessment of homes.

Q U A L I T Y OF L I F E A N D P R I V A T E O L D P E O P L E ' S H O M E S 277

TABLE III Correlation between ratings, overall assessment and facilities

Indices of facilities

raw scores weighted scores R p R p N

Raw rating score 0.338 Weighted rating score 0.333 Overall assessment 0.330

0.001 0.316 0.001 222 0.001 0.318 0.001 222 0.001 0.334 0.001 222

TABLE IV Overall assessment by facilities

Indices of facilities

raw score weight score Overall assessment N % mean SD mean SD

Poor 11 5.0 5.8 1.6 13.3 5.6 Adequate 51 23.0 5.9 1.3 13.3 4.0 Good 83 37.4 6.5 1.2 16.0 3.7 Very good 66 29.6 7.0 1.5 16.8 4.2 Excellent 11 5.0 7.4 1.1 18.1 3.0

Al l 222 6.5 1.4 15.6 4.3

p < 0.001 p < 0.001

The relationship between the raw and weighted indices of facilities and the independent variables 'area' and 'type of home' were also examined. Again there were no significant differences between the four authorities, or between private and voluntary homes and the two indices. On the basis of all homes in the sample the relationship between charges and the two indices of facilities was weak and barely discernible. In case this might have been a reflection of four different local residential care home markets, and two types of homes in the independent sector, the analyses were limited to private homes for each area. Although the correlation coefficients increased slightly none were statistically significant at the one per cent level. In the light of this evidence the conclusion was drawn that there existed no necessary relationship


between the facilities within a home and the charges made by the home -- a conclusion also reached by Darton and Knapp (1984).

CHARGES AND OVERALL ASSESSMENT OF THE HOME

Table V examines the relationship between charges and the overall assessment of the care home in two ways. First the mean charge is broken down by the overall assessment ranging from 'poor' to 'excellent'. The mean charge for poor homes tends to be lower than that for excellent homes but the differences are very slight. Secondly, the correlations between the charges and the raw and weighted rating scores, reveal no discernible relationships.

Before considering the reasonableness of charges it is worth sum- marising the main findings so far. Whereas the rating and overall assessment of a home, and the facilities within a home, were related to one another, these measures were found to have very little relationship with charges. Insofar as these measures reflect quality of life, there would appear to be little relationship between the fees paid by residents and the quality of life offered.

REASONABLENESS OF CHARGES

The judgement that the registration officers made about the reasonableness of charges in the home was a general one -- that is, it was not made in relation to a particular individual with a given level of dependency. In addition, it was a general judgement of the average charge in the home which took no account of the minimum or maximum charge where this varied.

The registration officers thought that the average charge was reasonable in 181 (82 per cent) homes. In seven homes (3.2 per cent) they considered too little was being charged and in 34 homes (15.3 per cent) too much was being charged. There was some variation in the propor- tions judged as unreasonable by different registration officers. Thus, for example, one registration officer thought 29 per cent of the homes he visited were charging too much -- while a colleague considered that only 14 per cent were charging too much. Most striking was the one

Q U A L I T Y O F L I F E A N D P R I V A T E O L D P E O P L E ' S H O M E S 279

> . . ~

.d

�9

t ' q

c 5 ~ I c 5 II II

I c 5 I c 5 II II

":3" O

I ~ I c 5 II II

II II

C O

280 I. G I B B S A N D J. B R A D S H A W

registration officer who considered 37 per cent of his homes were charging too much and 15 per cent were charging too little.

Private homes were also more likely than voluntary homes to be charging too much but the latter were more likely to be charging too little.

Q U A L I T Y O F L I F E A N D R E A S O N A B L E N E S S O F C H A R G E S

Although, as noted above, there was little relationship between actual charges and measures reflecting the quality of life in a home, this was not the case for the reasonableness of the charge. This is illustrated in Table VI which shows that homes judged by registration officers to be charging too much were much more likely to be assessed overall as adequate or poor and to have lower rating scores. In those seven homes that were rated good or very good and yet were still considered to be charging too much, the judgement appeared to be a comparative one mainly with the facilities and charges in local authority residential care homes.

D I S C U S S I O N

From the brief analysis set out above, quality of life as interpreted by registration officers does have an influence on the judgements they make concerning the reasonableness of charges in homes. Among the 'subjective' factors quality of care and the presence of experienced and

T A B L E VI Reasonableness of charges by overall assessment of h o m e

Overall assessment

Charges: reasonable too much too little

N % N % N

Poor 2 1.1 9 26.5 - - Adequate 32 17.1 18 52.9 1 Good 74 41.4 6 17.6 2 Ferygood 62 34.3 1 2.9 3 Excellent 10 5.5 - - - - 1

Totals 181 100.0 34 100.0 7 Rating score Mean (SD) 26.1 (4.3) 20.1 (4.8) 28.0 (4.7)

X 2 = 70.63 p < 0.0001

Q U A L I T Y OF LIFE AND PRIVATE OLD PEOPLE 'S HOMES 281

competent staff were important ingredients of the quality of life in homes. 'Home Life', the code of practice developed for all residential care homes (Centre for Policy on Ageing, 1984), attaches considerable weight to these and other concepts such as privacy, autonomy, esteem and choice, but offers little advice on how they might be measured. However, to the extent that these concepts are intelligible and not completely intangible, judgements can be formed even though the decision may be more difficult to make and less reliable than those concerning such physical features of the home as contained in the indices of facilities.

While judgements can be made about the quality of life in a home and the underlying philosophy of care, and the tenets that give them substance, these 'soft' judgements might prove to be more open to interpretation and difficult to defend if contested. However, registration officers have to defend similar judgements at appeal when existing proprietors contest decisions to de-register and prospective owners challenge decisions which fail to provide them with initial registration.

Among the registration officers who participated in this study there were mixed views about whether it was appropriate for them to take on the role of advising central government about the reasonableness of charges in private old people's homes. It was not so much that they had doubts about their qualifications for doing it though there was anxiety about variation in officers' judgements and conflict that might result. More important, however, was the possible impact of the task on their existing duties. There were a number of rather separate points.

Registration officers saw their role as both inspectorial and advisory, with the latter as a necessary condition for creating a collaborative relationship with home owners for promoting the quality of life through an improvement in standards. Some felt that adding authority over charges would ruin this shared endeavour. Instead of setting standards for the home to work towards, without responsibility for or control of charges, they might now be in a double bind with home owners resisting improvements unless their limits were also lifted. It was thought that in a local market comparisons would soon be made between charges and facilities. Homes would withdraw services if their charges were the same as another home not providing it.

In contrast some of the registration officers felt that taking on responsibility for recommending charges would enhance their role by


adding to the range of interventions they had. It might lead in turn to a closer relationship between the quality of the home and the level of charges that had been found in this study. These officers felt that a working relationship with the home owner could be too cosy. The kind of judgements they would have to make and sustain were no different, for example, from those made by the District Valuer in assessing the value of different properties when setting local authority rates.

Quality of life is a difficult concept to define in relation to elderly people in residential care settings, not least because different groups will have different perceptions of what is important. Clearly any future attempt at a definition will have to take into account the views of those centre stage, the patients and residents in nursing homes and residential care homes. Notwithstanding this point, quality of life is shaped to a very large extent, according to the code of practice 'Home Life', by the attitudes of owners, managers and staff at all levels. In addition to their concern for physical standards registration officers are also in a position to influence attitudes. The extent to which they are able or willing to promote quality of life in this indirect way will depend on how interventionist they are in their relationship with homes.

REFERENCES

Audit Commission: 1986, Making a Reality of Community Care (HMSO, London), p. 2.

Biggs, S.: 1987, 'Quality of care and the growth of private welfare for old people', Critical Social Policy 20(7), pp. 74--82.

Centre for Policy on Ageing: 1984, Home Life: a Code of Practice for Residential Care, Report of a Working Party convened by the Department of Health and Social Security (Chairman: Lady Avebury).

Darton, R. and Knapp, M.: 1984, 'The cost of residential care for the elderly: the effects of dependency, design and social environment', Ageing and Society 4(2), 157--183.

DHSS: 1985, Supplementary Benefit and Residential Care, Report of a Joint Central and Local Government Working Party (Chairman: Mr Scott-Whyte).

DHSS: 1987, Public Support for Residential Care, Report of a Joint Central and Local Government Working Party (Chairman: Mrs Firth).

University of York, Department of Social Policy and Social Work, York, Y01 5DD, U.K.

quality of life and charges in private old people's homes in great britain

Documents