Nursing provision in care homes has been hit by funding issues, poor pay and negative perceptions of the sector. But those working in social care are piecing together promising solutions, reports Emily Roberts
As vacancies for registered nurses in adult social care continue to rise, with thousands leaving the profession, there are calls for a complete rebrand of the sector.
Figures from Skills for Care1, which represents those in adult social care, show the vacancy rate for registered nurses in adult social care in England is 14.65% – almost 5,000 unfilled posts.
Its most recent data estimate that two in five registered nurses in social care have left their role within the past year. The number of filled registered nurse posts has also fallen by 5% from 2020/2021 to 32,000.
Research suggests increasing numbers of care homes in England are having to respond by dropping their nursing provision.
According to latest Sector Pulse Check report2, produced jointly by the charities Hft and Care England, one-third of adult social care providers have considered exiting the sector in the past 12 months.
Sector leaders have also expressed frustration and disappointment with government plans that appear to have slashed funding promised for the sector, with only £250m set to be invested into the workforce over the next two years – half the £500m promised in the social care white paper in December 2021.
So what impact is this situation having on the ground, and what is being done to address the sector’s current struggles? Skills for Care CEO Oonagh Smyth says: ‘The recruitment and retention challenges which the social care sector is facing with nursing mean there has been a decrease in the number of small independent providers able to provide nursing care.’
She believes there are several reasons why the social care sector is struggling.
Perhaps the most obvious is the Covid-19 pandemic, which Ms Smyth says ‘has had a huge impact on all our care workers, including nurses’.
She adds: ‘Since society and industry opened back up, this has been the time for some workers to choose to move on. This has been true across many sectors.’
She also points out that social care is ‘incredibly sensitive to labour market conditions’, making it less likely for people to work in social care when other jobs are available.
Liz Jones, from the National Care Forum, says one of the problems is the negative perception of working in social care.
She explains: ‘The challenge we have is an overall shortage of nurses and that’s impacting social care because we are competing with nursing roles across the wider NHS.
‘There’s a perception across the health workforce that being a nurse in social care is not as skilled as in a health setting. Actually, it’s totally the opposite because if you are the nurse on duty, you might be the only one and therefore have full responsibility for all of those people and staff. You don’t have the backup you would have in a hospital, so you have to be so many things to deliver that role well.’
‘In the long term, we have to make nursing in social care as attractive as nursing in the NHS,’ Ms Jones says.
She suggests the sector’s profile could be enhanced by more a positive media portrayal. ‘One of the best things we could do is have a soap opera based in a nursing home. It’s people’s real lives and real homes and it’s never seen as particularly glamorous.’
Ms Smyth agrees, and adds: ‘The most immediate fixes must be focused on helping social care compete with other sectors. That means reviewing pay and terms and conditions, and talking more about the rewarding career opportunities that nursing in social care offers.’
Caron Sanders-Crook, a professional nurse advocate and operations manager at residential care provider Canford Healthcare, underlines the competition the sector faces with the NHS.
‘There are lots of nurses who left after the pandemic. There are also geographical shortages. We have lost some overseas nurses who have gone home and chosen not to come back. Some nurses have joined agencies to give flexibility,’ Ms Sanders-Crook says.
She says it is vital to attract good-quality nurses, explaining: ‘One of the biggest barriers that care homes need to overcome is the misguided perception of what working in a care home is like. For generations it’s been seen as a job on the side, or for someone who has kids and needs a bit of extra money. But there is now a clear career pathway, and the skills they have to offer and bring to the table are amazing. They are making really complex decisions every day in coordinating and managing care.
‘People think they need to go into the NHS because they will gain more skills but that view is misguided, because you can gain more skills in nursing care.’
Ms Sanders-Crook, who has worked in care homes for 30 years, said it offers a rewarding career.
‘We all have bad days but when you hear the difference you make to someone’s mum or dad, all the horrible stuff just melts away, and I think I couldn’t do anything else.’
Thankfully, positive changes are in the pipeline, following the government’s appointment in 2020 of Professor Deborah Sturdy as England’s first-ever chief nurse for adult social care.
Professor Sturdy has been working to ‘shine a light’ on the social care sector and raise its profile.
She said its biggest challenge is recruitment and retention, ‘particularly with the backdrop of a global shortage of registered nurses’.
However, there is no ‘magic solution’ she explains, adding: ‘It’s about long-term investment.’
Margot Whittaker, director of nursing compliance at Devon-based provider Southern Healthcare, believes the sector is ‘desperately underfunded’ and has seen a trend in homes dropping nursing provision.
‘We’ve always had problems attracting nurses into our sector. Historically it’s always been seen as the Cinderella profession and the poor relation to the NHS,’ she says.
But why is it seen in such a negative way?
‘There is a perceived lack of career progression,’ says Ms Whittaker, who has spent three years working with Bolton University on an innovative advanced diploma training programme for social care nurses4, to provide accreditation through training and support.
‘As a sector we are not able to support our nurses well enough due to financial restraints [preventing us] giving them the opportunities they need,’ she says.
‘Nurses have a lot of support in the NHS and there’s a lot of career potential – there also is in social care, but we’re not shouting about it. There’s a feeling that we put nurses into nursing home roles expecting that they will be super-nurses and be able to cope with the increasing complexities that the sector now has. They need more understanding, knowledge, training and support than ever before to do that,’ asserts Ms Whittaker.
She continues: ‘If people feel they are looked after, supported, encouraged and empowered, they will stay.’
However, she says the key to offering such support is proper investment and education.
‘Attitudes need to change and there is a core of people who really want to make things happen for social care nursing. It’s a very exciting time. I think if we can support nurses with further continuing education at a higher level, we will be able to meet the needs of a growing aging population with increasingly complex conditions.’
‘We are turning the tide’
Chief nurse Professor Deborah Sturdy is among those ready to drive a change in approach.
She says social care nursing involves ‘practising with the highest autonomy’, and therefore the sector needs ‘the most highly skilled nurses’.
Professor Sturdy, who trained as a nurse 42 years ago, believes change needs to happen across the board, from providing graduates with experience of social care nursing to help attract them to the sector, to offering better career progression and training.
She also believes recognition for those working in the sector is vital, such as more social care nurses being put forward for honours.
‘You can change every system and process in the world but if you don’t change attitudes you aren’t going to get very far.
‘We need to shine a light on social care nursing. We have people doing phenomenal things supporting people living with dementia, and nurses managing really complex care in the community. They are stepping in where the NHS can’t provide that support.
‘People telling their stories is important, including those who have transferred out of the NHS because social care fits more with their values.’
Professor Sturdy adds: ‘I think we are on a journey with this and we are turning the tide. We needed someone to light the fire and the fire has been lit. What’s been amazing for me is seeing the breadth of talent in social care. People who are the absolute future leaders in the sector.’
In April, the government published the Next steps to put People at the Heart of Care white paper3, which aims to reform adult social care over the next 10 years.
Helen Whately, the minister of state for social care, said in her foreword to the document: ‘For decades
adult social care has not had the attention, resource or support from government that it deserves. But we are changing that.
‘Front and centre of these reforms are my ambitions for the adult social care workforce. I want to support care workers to develop their skills and their careers, and to be recognised for those skills.’
The minister also acknowledged that ‘new and innovative ways of providing care and support can improve outcomes for people’.
There are many examples of innovative work already happening in the social care sector to tackle some of the challenges.
Walter Chikanya is head of care quality for Royal Star and Garter, a charity providing care to veterans with disability or dementia, which runs three homes.
He has supported various innovations in response to recruitment challenges, including upskilling staff.
‘We have created clear pathways for our care staff for career progression. We upskill our staff internally, which can lead to further qualifications and an increase in pay to acknowledge that,’ he says.
‘We have some of the best rates of retention and our own staff are filling the gaps we had.
Mr Chikanya adds: ‘Social care is looked down upon and that’s what I’m trying to address. Nurses working in ICU or A&E think social care is somewhere a nurse comes to retire, not realising that the nurses who work in social care have a specific skillset that is quite unique.
‘Deborah Sturdy recognises that we play a crucial role and she is driving to ensure we are represented and our voices are heard. I’m hopeful of change.
‘The benefits are giving someone a better quality of life. I think there’s nothing more rewarding.’
This has a positive impact on the whole health sector, says Mr Chikanya. ‘It’s helping the NHS because we are trying to make sure our residents are cared for by us, which avoids admissions to hospitals.’
Some care homes are turning to overseas recruitment to address the shortage of nurses.
Marisa Spice, is a Queen’s Nurse and learning development manager for major care provider Nellsar Ltd, which employs 900 staff across 13 homes.
Ms Spice qualified 25 years ago and worked for the NHS for six years before moving to Spain and then returning to the UK in 2013.
Her experience of working abroad has helped her recruit and train nurses from overseas, although she says this is not without challenges.
‘There’s a lot to consider with people coming from so far away. The biggest thing is explaining what a care home is because they don’t have social care. You have to educate them about a whole system.’
In the past six years, Ms Spice has recruited 50 nurses from overseas, including from India and Nepal. Her own experience has helped her develop a successful programme: ‘When I moved to Spain I thought, I’m a nurse, I can work anywhere. I think you take for granted that how you train is how they do it everywhere.’
She also recognises the importance of providing placements for university students, saying: ‘If we don’t make available opportunities for students to come into our workplace, they won’t know what social care nursing is about – and they are our nurses of the future.
‘Social care has always had to compete with the NHS for attractiveness. But we have people coming in who wish they had done so sooner. It’s about a person’s life and contributing to that person’s life. Assisting someone at mealtimes isn’t just about giving them food. It’s about looking at their posture, seeing how comfortable they are, whether they have a risk of choking or weight loss.
‘Everything is about understanding a person, which in a hospital you don’t have. That’s the luxury of nursing in social care and those are the additional skills people don’t consider. When you go home at the end of the day, you know you made a difference.’
‘Creativity and flexibility’
George Coxon, director at Classic Care Homes, is optimistic about the prospects for change.
He is working to raise the social care profile and said: ‘Implying it’s a job you do at the end of your career is an insult and perpetuates the myth that social care is the end of the road for your career.’
He says nurses in social care setting need a different skillset to those in the NHS: ‘You can’t train a nurse in the NHS and drop them into a care home. It’s like training an electrician and asking them to be a plumber.
‘I’m keen to change the language and recognise the different environment and image and culture. We need people to enthuse about the values of social care nursing and why it’s a better option, and I really believe it is a better option than working in the hierarchy of the NHS.’
Professor Sturdy believes people’s perceptions of social care are beginning to change.
‘Nursing in social care resonates with people’s core values and the longevity of the relationships you build up with people. You develop those relationships with families. It’s about the autonomy of your practice and the creativity and flexibility. You can make things happen quickly because you don’t have layers of bureaucracy. You are helping people to live their best life until the end.
‘The complexity and diversity appeal to people,’ she says. ‘We are on a journey of making a difference… the future is challenging, but I do think it’s bright.’
Anita Astle MBE has been a nurse for more than 30 years and is a huge advocate for social care nursing. Now managing director of Wren Hall Nursing Home in Nottingham, she is keen to highlight the importance of nurses in social care.
‘To manage the complexity of people’s needs you need people with the knowledge base and understanding. I think that’s why we need nurses in social care because it is nurse led and it is delivering and maintaining quality of life, despite increasing complexity and frailty.’
Ms Astle adds: ‘People need to live well. We have got an ageing population with complex needs. Their complexity of need is increasing. But people need to live well, despite those needs.
‘They don’t necessarily want a medicalised model they want a social care model and the only way that can happen is if nurse-led care is delivered.’
Emily Roberts is a freelance writer
- Skills for Care. Workforce intelligence: regsitered nurses. 2022. tinyurl.com/SfC-nurses
- Hft. Sector Pulse Check 2022. tinyurl.com/Hft-sector
- DHSC. Next steps to put People at the Heart of Care. 2023. tinyurl.com/socialcare-plan
- University of Bolton. AdvDip Principles of Adult Care Home Nursing. tinyurl.com/Bolton-AdvDip