Thirty-two years ago, in 1990, Merry Cross and I carried out a review of 48 Boundary Road, a residential service catering for disabled people of working age in the London Borough of Camden.
This had been a radical new service when it opened in the late 1970s in a specially designed building. It was intended to offer disabled people the kind of choice and control in their lives which was sadly lacking in more traditional residential services. As we wrote in our report:
When the building was first opened in 1979, it quickly established a progressive and exciting reputation amongst both professionals and the disabled community….The early days of Boundary Road were part of a growing recognition of the rights of disabled people to live independently and the organisation did much to make this possible for a number of people.
Despite this, we found that - partly due to the poor design of the building and partly due to poor management - the service fell short of its original intentions. We concluded that “it has lost its way and there is a high level of dissatisfaction amongst both residents and staff”.
We recommended that the building was transformed into an Independent Living Resource Centre, with a small amount of residential provision which should only be for short stays. It should be a base for services which would make it possible for young disabled people to live in homes of their own with choice and control over the support they needed to go about their daily lives.
Recommendations such as these fell on fertile ground in the 1990s, when the Independent Living and wider disability movements were gathering pace. Camden’s Social Services Committee accepted our recommendations.
At that time, an increasing number of local authorities were making it possible for disabled people to have control over the support they needed by providing cash payments in lieu of services (direct payments) enabling them to live in their own homes rather than in residential settings. The Independent Living Fund was also providing cash payments to more and more people and in 1996 direct payments for younger disabled people were finally legislated for by the Conservative government and then for older people by the subsequent Labour government.
So what happened to 48 Boundary Road?
Well, if you do a search for that address now, it comes up as a purpose built 100 bed nursing home. The original building must have been demolished sometime in the 1990s and I went down a veritable rabbit hole of trying to establish the ownership and inspection details of the nursing home which was built on the site. As far as I can see it was initially registered as a nursing home in 2001 and passed through different ownerships since then.
One owner was Southern Cross Healthcare, a provider of a large number of care homes which was taken over in 2004 by Blackstone Capital Partners, an American private equity business. They expanded the business by taking over other care home companies and continued the practice of the previous private equity owner of selling and leasing back the properties, thereby releasing capital gains for the owners but increasing the overhead costs of running the services. In 2006 the company was floated on the stock exchange.
By 2011, Southern Cross was in financial difficulties caused by annually rising rents combined with a squeeze on the fees which could be afforded by local authorities and self-funders. It went into administration in 2012.
The nursing home at 48 Boundary Road has had a variety of owners since then, mostly for only two or three years at a time. Its inspection rating by the Care Quality Commission has never been great - in 2015 an unannounced inspection found five breaches of regulations; in 2016 the CQC found improvement but still one breach of regulations; in 2019 (under a new owner) CQC rated the service as inadequate; in 2020 (under yet another owner) two inspections rated it as requiring improvement.
When the building first opened as a care home it was called St John’s Wood Care Centre. But in 2022 it re-opened, under yet another owner, as Hampstead Court Care Home. It is marketed as being a ‘luxury care home’ in Westminster (though it is in Camden) and now has 82 bedrooms (down from 100) so presumably it has been refurbished. Like the previous care providers on this site it is registered for both older and younger people. Its CQC registered owner is Willowbrook Healthcare Limited but Avery Healthcare has recently welcomed it to its ‘portfolio’.
Public and political debate on social care has been dominated by two narratives - one that social care is in crisis because not enough money is going into publicly funded residential and nursing care (with one of the consequences being that self-funders are charged more and are thus subsidising local authority funded care); the second that people are being forced to sell their homes in order to pay for their care, with a particular emphasis on the injustice that some conditions attract funding from the NHS whereas others, particularly dementia, do not.
However, instead of just focussing on how much money is going into social care, perhaps we should pay more attention as to where the money goes and what are the other factors responsible for both the cost and the quality of social care.
Privatisation of social care - both of care homes and of help provided to people in their own homes - was encouraged by the Conservative governments of the 1980s and 1990s and was part of the major reforms introduced following the 1990 NHS and Community Care Act which transferred funding for residential care from the social security system to local authorities. All governments since then have continued the policy that the role of local authorities should be confined to commissioning rather than providing social care services.
Today, more than 80% of nursing and residential home places are provided by private companies with some of the largest being owned by private equity firms. These companies treat their investments as high risk and high return, loading the businesses with debt and creating complicated ownership structures which often involve offshore registration and tax avoidance. During the pandemic, the profits of the largest private providers of social care increased while the gap between the pay of directors and that of workers widened.
The investment companies who take over care homes tend to employ financial engineering measures which aim to extract a large sum out of the business by selling off and leasing back properties, taking out cash from the business on an ongoing basis, and/or increasing its value prior to selling it on.
High quality services require a valued, well trained and stable workforce. Yet the social care sector is dominated by low pay, insecure and poor working conditions and this undoubtedly helps explain the high level of staff vacancies. That so many care-workers still manage to provide good care, when investment in many care homes is motivated not by a public service ethos but instead by how much money can be taken out of the business, is a tribute to the humanity of each of those workers.
If we don’t change the current model of how residential social care is provided there is a danger that any increase in funding will merely make the sector more profitable for private investors in residential and nursing homes with little impact on the quality of care or the working conditions of staff. Or indeed little impact on people's ability to remain living in their own homes, which is what most of us want to do.
Avery Healthcare, now the owners of 48 Boundary Road, was recently acquired by a joint venture between Reuben Brothers and the US real estate investment trust Welltower Inc. The press release announcing the acquisition said it was expected to “generate significant future growth opportunities”.
