A step towards stability in Scottish care home design?

Image credit: White Crow Studios

An uncertain picture

The COVID-19 pandemic has had a significant impact on the care home sector in Scotland, with large care homes being disproportionately affected by COVID-19 compared to medium or small services.  (Care Inspectorate, September 2020)

In late summer 2020 we were made aware of a draft publication prepared by the Care Inspectorate “Care Home for Adults Design Guide” which aimed to describe and illustrate what good building design would look like, for care homes for adults, following the impact of COVID-19.

The draft document outlined several areas which proposed significant changes to the design and build of care homes in Scotland which would have serious implications for the sector, whilst creating uncertainty and wariness regarding new builds and the re-registration of existing homes in Scotland.

Initial Proposals (Sept 2020)

The original draft design guide made numerous proposals, and we have outlined below the most significant in terms of deliverability and impact on cost:
Size

• The Care Inspectorate recommends that care homes for adults should have no more than 60 residents in total, with large institutional buildings not being considered.
• No more than ten people living in a small group setting, which must be self-contained and able to operate independently.
• Each small group setting must be accessed without going through other settings.

Layout and design

• Ideally, buildings should be single storey however, if the building is built on more than one floor, there must be safe, independently accessible outdoor space such as a balcony or roof garden for each small group setting.

Bedrooms

• Single room: minimum of 16 square metres of usable floor space.
• Shared bedroom: minimum of 18 square metres of usable floor space.

Toilets and bathrooms

• En suites must be at least six square meters to provide enough room for assistance from staff.

Communal areas

• There must be at least six square metres of communal space for every person within each small group living setting.
• Sitting and dining rooms must not be thoroughfares to other parts of the care home or small group setting.
• There must be a choice of at least two public spaces within each small group setting. 
• Smaller lounges and dining areas for groups of no more than 10 people

Potential Impact on cost

Following on from this, we undertook a cursory exercise to illustrate the cost implication of the new proposals on any new development with in-depth discussions with a number of active operators and professionals within the care home development sector. The main findings were as follows:

• The additional cost of the proposed changes would equate to circa £20,000 per bedroom - this was lower for operators already building to a larger luxury standard.
• The cost in acquiring sites to accommodate the additional floor area was perhaps the most significant finding, with prime sites looking at an additional £645,000 to £1.29 million to facilitate development over one or two storeys.
• The cost was less pronounced for semi-rural or low value locations at circa £118,250 - £150,000.

Perhaps of most significant concern for existing care homes was that very few (if any) private care homes in Scotland would currently comply with these proposals. If they were to be enforced upon existing operators, then it could result in:

• Significant capital expenditure to extend / expand the current home with a large degree of internal reconfiguration required.
• Those that do not have scope for external development would be required to significantly reduce the number of bedrooms in the home to create sufficient communal areas.

Both of which would result in significant costs which, in turn, could reduce their operational ability and place the viability of the home in serious doubt. 

These additional costs would come at a time of intense scrutiny on the cost of care and the how the care sector is funded. Put simply, if these changes were enforced there would be inadequate funding to address the capital cost of reconfiguration. At worst, it was predicted that this could result in mass closure of non-compliant homes and a significant reduction in the number of beds available in Scotland. 
 
Recent changes to the initial Proposals (May 2021)
 
The Care Inspectorate has recently published an amended draft to the new Design Proposals in May 2021which has thankfully ‘softened’ the original proposal somewhat. Significant changes include the minimum space recommendation of 16 square metres for bedrooms being reduced to 12.5 square metres usable size, with the requirement for en suites size reduced from 6 square metres to 3.5 square metres. 
 
These main changes should alleviate some concerns regarding provision of the additional living space which was a major issue in terms of the actual size of site required to build the home but also the additional build cost for the extra space.
 
The recommendation that homes are designed with smaller living units of up to 10 residents and a limit of up to 60 bedrooms in total has been retained. The majority of developers are currently building to 60 or less bedrooms so the size of home is probably less of a concern. The smaller living units, however, may still cause issues in terms of the actual size and shape of sites and whether homes can be accommodated in single storey buildings or two-storey with appropriate external balcony space etc. This may be a particular issue in more built-up areas where site acquisition costs are high and care home developers are in competition with residential developers. 
 
It is also good to see the continued drive to improve the digital experience for residents in care homes with a specific layout and design recommendation being for ‘Wi-Fi accessibility for digital devices with sufficient connection strength throughout the care home so that people can remain connected with family and friends’.  It has been well documented and discussed over the past several years of the importance of digital connectivity in assisting with the wellbeing of elderly residents.
 
Conclusion
 
The initial proposals drafted in September 2020 undoubtedly led to widespread alarm within the care sector with significant concerns over the cost of providing new developments but also the uncertainty for the existing operators regarding the impact upon re-registration particularly during a proposed sale period and grading at the next Care Inspectorate visit.
 
Thankfully, the amendments to the original draft appear to have addressed some of these concerns, with the over-arching emphasis being on the realistic deliverability of a safe environment which supports high-quality care. Lessons have will have been learned over the past 16 months regarding how new infections spread within homes and what can realistically be done from a design perspective to best limit this in the future.
 
Questions remain which require clarification:

• How rigorously will these recommendations be applied to existing homes, particularly around how smaller living units can be provided in buildings that simply cannot accommodate this without a significant reduction in the number of beds?
• How will smaller group settings be delivered by developers particularly where the layout of the site may not necessarily allow this over a maximum of two-storeys?

 
Is this a step towards stability in care home design? It is certainly a big step forward from the uncertain position the sector has been in since September 2020. It will be interesting to hear the results of the wider consultation which has been undertaken with further feedback expected from the Care Inspectorate in late August 2021.