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Is Big always Best?


Given the current uncertainty of ever getting back to any “normal” within the Health and Social Care sector, you begin to wonder what was our “normal” and in the case of Care Homes where is “normal” in the future?

Big changes have crept into care home thinking, and not all of them have worked. We used to look for a residential home for our loved ones, which somehow had a different connotation to a care home, some of which now include nursing.

Residential homes conjured up somewhere homely, not too big, often converted from large family homes, which somehow never lost their “homely” feel. What they did not have in modern up to date facilities , they made up for in their constant strive to stay “homely”, furniture we could recognise  from our grandmothers homes, no illuminated signage telling you where the toilets are, the odd fixtures which indicated it was a care home, such as door closers, ensuites maybe, but still essentially, crucially retaining their “homely” feel.

Now, we appear to be losing “homely” to a care home model which could not be further from home if we tried.

It is not just the furnishings that have change, but the whole ethos of “home” itself. Their size for one thing. New homes are being built on a scale of old community hospitals. 85 beds, 114 beds are being approved throughout England, yet try to build a facility that size for Learning Disability needs and you will not be welcome, even the NHS is no longer in this arena

The amalgamation of residential and nursing, for registration purposes, has helped to drive this idea of a “home”. Specialism, such as dementia are now enveloped within these facilities. These are purpose built, large facilities but are they “home” or are they slowly but surely taking us back to a model of institutional care, abandoned because of their size and de personalisation.

As you view care homes for your loved ones, these facilities all look the same, furnishings and colour schemes more reminiscent of hotels, not “homes” and the size of these homes make it very difficult to personalise the care and the services for each individual.

There are now very few care homes that are described as small. Try finding any choice of small homes and its very difficult, to say the least. Seaside locations are almost blighted by the applications to build these facilities, as are areas of outstanding beauty.

The costs which come with delivering care services are also a factor in the size of homes, because without the size, they simply would not be viable.

Proportionality has gone out the window. There would still be variety of small homes around if the inspection regime brought back some proportional elements in terms of size.

For small homes, the administration is as much of a burden as for a larger home and rarely adds to the overall profitability of such homes. Add to that the plethora of polices and procedures required not just for the Care Quality Commission, but also Local Authority Commissioners whose reports are now taken into consideration by inspectors and the reasons for the drive to” bigger and better” homes are plain to see.

Yet the regulator seems to be unable to learn the lessons about size and vulnerable people within them. In the 2014 report, Winterbourne View- Time for Change, it was recognised how institutions can quickly take over from the idea of a “home”. Winterbourne View – 24 beds, Whorlton Hall -17 beds. Not big homes, yet the move from institutions such as these, to community provision is still to become a reality. The regulators at least acted, within Learning Disability registration processes, to seek to redress by refusing to register big homes, deeming even the two mentioned above to be a risk in bed size terms.

However, the march continues, in older persons care provision, to bigger and bigger facilities.

In 1851, the American Physician and philanthropist, Samuel Grindley Howe wrote about the “evils” of institutional care. He wrote “all such institutions are unnatural, undesirable and very liable to abuse.  We should have as few of them as possible, and those few should be kept as small as possible. The human family is a unit of society.

As we look back to the days of smaller homes, the change in the provision is also now reflected in the ownership of homes.

In 2019 almost 84% of care home beds were owned by profit companies

By contrast 13% of care homes beds are provided by the voluntary sector and 3% by Local Councils

As the number of over 75s and over 85s is expected to rise sharply over the next decade, it is important to question the rise of bigger facilities and their role in the provision of care home beds.

Choice of care provision should include homes where individuals can live in an extended family environment, where it does not take weeks to get to know the staff simply because of the numbers needed to staff it.
We seem to be drifting into another institutional model, dressed up for our 21st Century needs, but without proportional oversight and the means to scrutinise closely their inner working, how do we make sure these large care homes remain just that, “homes”

Margaret Ross- Sands

Consultant – W&P Assessment and Training


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