Introduction The Local Authority (LA) a type of local government in the United Kingdom - is responsible for social care services. It commissions organisations to provide social care services for UK residents. These contracts are often renewed and up to tender on a regular basis. MetCare is one of the organisations that has been commissioned by a London LA to provide social care services. MetCare operates several different care homes, including Osborne House, a residential care home supporting adults with learning disabilities. Arnold is employed by MetCare and Osborne House is one of the properties of MetCare in Arnold's patch as an Area Manager. He has been informed that the Osborne House contract is up for renewal and the LA has invited bids from other organisations to provide these social care services. To prepare for the impending tender bid, Arnold decides to review the business case for MetCare and explore their commercial viability as they plan to submit a bid to continue providing residential care at Osborne House. Arnold needs to understand the limitations of government funds and the changing demands of the customers, as well as the effects of both these factors on staff morale. He hopes to gain insight into the broader complexities and challenges of managing a residential care home in London, as well as the managerial implications of those challenges, to help him prepare for the bid. Adult Social Care Services in the UK To begin his assessment of the broader complexities facing him as a manager of a residential care home, Arnold begins with a review of the adult social care service system in the UK. He finds that people who use adult social care services have differing needs, aspirations and circumstances (Care Quality Commission, 2017). They may need social care because of a learning disability, mental health problems, or due to ageing. As the population continues to age, the demand for care will increase (CMA, 2017) and the types of care needed will change. The Office for National Statistics predicts a 36% increase in the number of people aged 85+ between 2015 and 2025, from 1.5 million to 2 million. This is expected to lead to a substantial increase in the demand for social care services. Arnold knows there is a shared commitment between the government, local councils and providers to meet these growing needs. Las are directly responsible for care provision in their areas and generally commission care services from independent care providers. LAs have a legal duty to meet people's 'eligible needs', subject to their financial circumstances. Adult social care services are worth around GBP 15.9 billion a year in the UK, with around 410,000 residents and around 5,500 different providers. The Care Quality Commission (2017) recognises four different forms of adult social care provision, which offer different levels of independence and support, ranging from specially designed accommodation for people with dementia to support for adults with complex physical needs and learning disabilities. To review the landscape of social care services in the UK, Arnold draws up a quick table to compare the four forms of provision (Table 1). Table 1. Features of Four Forms of Adult Social Care Provision Community social Residential care Domiciliary care Nursing home care home A rented room within a residential A rented flat or room in the community within sheltered accommodation, Description Support from visiting carers for a client living in their own home. home (could have up to ten rooms) with support staff living and working onsite. A rented room with the care of various support staff and healthcare professionals. with support provided. Recorded number 1,493 5, 511 10,858 4,042 of homes a Residents are Independence is relatively independent: thev Residents may be quite independent Residents are less independent and Level of maintained as the Click here for EXCEL Click here for CSV Click here for PDF Some providers like MetCare may have different forms of adult social care provision within their portfolio.. Arnold notes that reports by the Care Quality Commission (2017) show that the number of residential homes is decreasing and that there is a long-term trend towards increased numbers of nursing home beds and increased numbers of domiciliary care agencies of various sizes. Arnold knows this represents a challenge for the managers of residential care homes, especially considering the financial pressure that many find themselves under. The majority of customers of most service providers are funded by their LAS. The Competition and Markets Authority notes that over 75% of care home residents are funded in this way, while the remaining are self-funding customers who can afford to pay more (CMA, 2017). Arnold is particularly concerned with the fact that, with impending cuts, service providers are at risk of failure due to the reduction of their main income from LAs, unless they can attract more self-funding customers. Osborne House Arnold moves on to review pertinent details about the residential care home he is focused on preparing for a tender bid. Osborne House is a 10-bedroom property that provides care and support for adults with learning disabilities. It has been in business since 1994, and MetCare is the second owner it has had in that time. Under the terms of their contracts, residents (sometimes called customers, service users or clients) rent one room in the property, generally funded by the LA. They support themselves to some extent, with some of them attending day services. Day services are places where adults with learning disabilities attend during working days, leaving home in the morning and coming back in the evening. Often, they describe it as going to work and they look forward to going there. There are activities and events which offer opportunities to meet other people from other residential homes, making long-term friendships. They develop new skills and improve on skills they already have. In addition, many of them engage the support of key workers to access the community, unlike people living in a nursing home. Keyworkers are members of staff who are responsible for ensuring each resident is known and valued and that their needs are recognised and supported. Arnold notes that there are 15 permanent staff at Osborne House. Arnold draws up a quick organisational chart of Osbourne House (Figure 1) to visualise the roles and duties of the staff. There is a registered care manager - Asha - who is responsible for the overall management of the project, and she reports to Arnold. Reporting to Asha are Annuella, the team leader/deputy manager, five senior support workers, and eight support workers. The senior support workers also serve as keyworkers to the customers. Figure 1. Organisational Chart of Osbourne House, Part of MetCare Director of Care and Support(MetCare) Area Manager (London) Arnold Care Manager (Osborne House) Asha Team Leader Senior Support Workers Support Worker Click here to download Upon learning about the impending tender, Arnold visited Osborne House. In his meeting with Asha and the staff, he realises that he needs to consider several major issues facing residential care and support as MetCare prepares to submit its bids. These issues include challenges such as competition with other providers, limited funding from the LA, demands on support workers due to limited funding and increasing needs of residents over time. Challenges for Staff Changing Needs of Customers In his meeting with staff at Osborne House, Arnold gained insight into their challenges and concerns regarding providing adequate care to residents. Tony, one of the senior support workers, who is also a keyworker to two of the customers, informed Arnold that the changing needs of the residents is a key challenge. Tony noted that he had worked at Osborne House since 1994 when the home opened, and he had seen how the customers had changed over the years. He noted that they had become older and were not as able to engage or help themselves as they were before. As a result of such changing profiles, some of the residents were not able to go to the day services as previous residents had; as a result, residents of Osborne House were going out less often and spending more time in the house. This resulted in a need for more staff to support them. In addition, Tony noted that the residents had tended to become more demanding in terms of their need for personal care, putting extra pressure on staff, who may not be trained to provide such services. When such a situation persisted for a prolonged period of time, such residents may be transferred to a nursing home. When Arnold asked about the changing profiles of residents, Tony noted that the changing needs included their dietary, physical, and personal care needs. While residents in the past were often able to eat solid foods, many were now eating mashed and blended food because they suffered from difficulty swallowing (dysphagia). Previously, staff just served the food and were able to attend to other demands while residents fed themselves. Now staff have to mash the food, put thickener in their drink, and feed residents, which Tony noted may often result in staff spending an extra hour with a single resident. Upon hearing Tony's examples, other staff members began offering examples of residents requiring more care and the challenges it posed for staff. Alex noted that Mr. C, a very large resident, was able to walk around the house before but lost his mobility due to a stroke. Mr. C was now using a wheelchair and, whenever he needed to access the community, the female support staff were unable to support him because they could not push his wheelchair. Thus, in most cases, Alex had to be the one to push Mr. C. Carrie was a keyworker to Miss D and noted that, while the heavy-set resident was previously able to go to the toilet independently, her needs had changed and she needed to wear incontinence pads and have staff support her in using the toilet about eight times a day. Carrie noted that this increased demand took a toll on her as a staff member, especially given the weight of Miss D and the fact that she often needed an extra staff member to support her in helping Miss D with toileting. Carrie further indicated that this extra demand was affecting her administrative duties as a Keyworker. She had to update Miss D's risk assessment and support plans on a regular basis because of Miss D's changing needs. Furthermore, there were many more appointments to attend and there were no additional staff to take up that role. Carrie noted that her Manager has pointed out that she is falling behind in her work, but Carrie argued that there was not enough time to sit at a computer to complete paperwork because she was so busy on her feet attending to residents during every shift. Pressures on Staff Avi, another a senior support worker, corroborated Tony's points and argued that the effect of customers' changing needs on staff could not be overemphasised. Support workers had to do extra work to meet the increased demands and they felt like they were doing the work of nursing home staff. In addition, staff still had to do the cleaning and cooking and oversee the administration of medication. Avi illustrated his point by citing the example of one of the residents who previously needed 30 minutes of personal care each day but now required two staff spending an hour each. Avi explained that extra demands like this caused strain on the staff and made them feel stressed. He said staff were feeling demotivated, and thus not wanting to work or frequently calling in sick. Arnold asked if this meant staff were leaving, and Avi confirmed and noted it would result in short-staffing and further staff pressures. Tony spoke up and noted that this was also corroborated by findings from Communities and Local Government (CLG). The CLG found that nearly half of UK care home workers leave within a year, highlighting the severe challenges associated with maintaining staffing levels (Bulman, 2017), and the Office of National Statistics (ONS) revealed that care workers in the UK have a suicide rate that is almost twice the national average (Cox, 2017), which reflects the pressures placed on staff in the sector, and thus it is not surprising that many end up leaving. Quality of Care Service Arnold was getting a clearer picture of the situation at Osborne House and asked the staff about the quality of care they were able to offer. Bani, who had spent about three years at Osborne House as a support worker, spoke up to say she was very concerned about the quality of care being offered. She believed that the changing needs of residents were putting pressure on staff and inadvertently affecting the quality of care services being provided. She shared her concern with Arnold that this pressure could lead to accidents as staff were stressed and distracted or rushing. She feared it could also result in improper care and abuse. The issue of medication error was raised by Abel, who cited an incident where he was called in early to a shift to administer medication. He explained that the staff on shift were too tired to administer medication and, to avoid error, he was called in. Abel felt that, in addition to the pressure the staff were facing, the lack of funds from the LA was contributing to the poor quality of services. He believed staff were not really motivated to work because their salary was poor and noted that his salary had reduced since he first joined the organisation 10 years ago. Tony agreed with Abel and argued that poor compensation resulted in a shortage of staff and intense pressure on the few staff available. Arnold asked what the staff thought about filling the vacant rooms at Osborne House and thus increasing the number of residents. Abigail recognised that the vacant rooms should be filled; however, she said residents with extra needs should be screened out. She explained that residents who were not suited to residential home care were being accepted for the sake of filling a vacant room to address income pressures. She gave an example of Miss B who appeared to need nursing care based on her needs but was admitted into Osborne House because the family and LA could not afford 24-hour nursing care and the manager of the home needed the income to remain commercially viable. Although the staff of the home cannot take the added pressures, they feel there is little they can do in this situation. The staff are not motivated and trained enough to provide nursing care, and this affects the level of care provided to Miss B and residents like her. Challenges for Management Funding Cuts After his meeting with the staff, Arnold, Asha, and Annuella shared a private meeting to discuss feedback from staff and their concerns to better understand how Osborne House was being managed in the face of multiple challenges. Asha cited the funding cuts as a key challenge for the commercial viability of her project. She noted that she knew the sector was under huge pressure to remain sustainable in the face of funding cuts. Public expenditure on adult social care in England had declined by 8% in real terms between 2009/10 and 2015/16 (CMA, 2017). Even when the management asked for extra funds to provide the required support, this was often met with refusal. She cited the example of Mr. A, who had been at Osborne House for many years, typically needing about four hours of care a day. Asha said that, as with other residents, Mr. A's needs were changing, and he now needed more care. She approached the LA for funding for the extra hours for Mr. A, but the request was rejected. As a result, the home had to pay for the extra care and suffer the long-term implications that this may have on the survival of the business. Asha also acknowledged the demands on staff to meet the needs of Mr. A and residents like him. She told Arnold that, although she is trying her best to motivate the staff, it has not been easy because she is stuck between the LA not providing more money and overstressed and unmotivated staff. Limited Numbers of Residents Asha also noted the issue of limited residents and its implications for revenue. Arnold asked if the issue was that Osborne House was home to people that needed long-term residential care, but they could only house a limited number of residents at any given time. Asha agreed and noted that the residents rent a room within the house and pay for care and support services, and some of the current residents had been living there since 1994 and had had no reason to move out. Residents typically leave due to death or a change in their care needs; either they become more independent, and move on to supported living, or they become less independent, and move into a care home. As a result, Asha noted the business can remain the same for very long periods of time, and with few prospective customers to replace the residents when they leave, it can be difficult to get a suitable replacement resident because people now tend to prefer domiciliary care in their own homes. She gave an example of a room that was empty for almost a year and the pressure she was facing from the previous Area Manager to fill the void room. As a result of that pressure, Asha conceded to accept a less-than-ideal resident, Miss E. Although Miss E required more personal care, it was better than having a vacant room. Asha further indicated that, with ever-increasing property prices in London, it could be tempting to convert these social service care properties into residential flats, which may be more commercially viable than having vacant rooms that cannot be rented out. Arnold agreed and they mused that these press made it difficult to keep such homes in business. Competition Arnold was concerned that the LA commissioned providers like MetCare to provide care and support for residents at places like Osborne House but that the LA tried to save money by changing contractual agreements, paying lower fees, negotiating bulk purchase discounts, and commissioning care and support to providers who can offer cheaper service (NAO, 2014). Arnold noted that MetCare were finding it difficult to remain commercially viable. He and Asha commiserated on the difficulties associated with replacing residents, dealing with competition, and still wanting to pay their staff above the living wage to keep them motivated. Asha explained that she has to deal with staff coming in to request salary increases regularly but she cannot afford to accommodate those requests. The sector is quite tight, and the company typically cannot afford salary increases. She noted that it does not help to ask the LA for additional funds because they may be rejected or the LA may decide to invite another provider to tender for the service. She further noted that she believed such providers often paid staff only minimum wage. Arnold thought about this issue for a moment and noted that such competition within the sector could influence the quality of care and the level of support provided. Family Involvement Annuella, the team leader/deputy manager, offered Arnold some key insight into how residents' family members factor into the challenges of managing Osborne House. Annuella explained that she was often around during the weekend when the families came to visit residents and she had witnessed how residents who had been living at Osborne House for many years came to see it as their home, and as a result, their families preferred not to move them. Although a resident's changing needs may require a decision about moving them to secure proper care, Annuella said that family involvement had resulted in such moves being delayed. Annuella said she believed this caused additional strain on the management and staff dealing with such issues. She shared the example of Mr. F whose family members did not want the social services to move him to a more suitable accommodation after his health declined. The family did not want him moved to a nursing care facility outside London because they wanted him to stay in Osborne House because it was very close to them. Even with the financial implications of another vacant room, Osborne House was ready to support Mr. F's move, but the family declined. A best-interests meeting between different professionals had to be organised to effect the move. Conclusion After the meeting with staff at Osborne House, Arnold pondered how they could address these myriad challenges. He also wondered about the ethical issues that were raised. Arnold was aware that service providers in the healthcare industry faced certain ethical issues as they wanted to provide good quality care, but they were financially restricted in their abilities. Would Osborne House have to keep a resident to avoid having a vacant room and lose an income stream even though they knew the customer could receive a better care elsewhere? Would they have to cut corners and make savings because they wanted to stay afloat? Would they be willing to report incidents and accidents, or would they want to hide it so as not to show their low level of staffing? To address such issues and prepare for the upcoming bid, Arnold reflected on the challenges the staff at Osborne House identified. How could he deal with these challenges to improve service and ensure the viability of the care home? Perhaps he could consider how to improve staff training and motivate them to do more by rewarding processes and policies. Perhaps he could find ways to support the management team at Osborne House. He could also consider reaching out to new customers, including self-funded residents, with new marketing campaigns to supplement what they are being commissioned by the LA. AS he considered the task before him, he was confident he could come up with a plan for improving efficiencies to reduce costs, sustain profitability and service quality, and, importantly, retain the contract with the LA. Discussion Questions 1. What are the holistic implications of the financial issues at play in keeping Osborne House viable? How are these issues influencing the quality of care and support being provided? 2. Who is affected most by challenges and issues of service at Osborne House? 3. Who could have the most influence on changes to the provision of adult social care and support? 4. What kinds of tactics and strategies could Arnold implement to deal with the different stakeholders and their challenges? 5. How could Arnold address the operations management and service quality issues at Osborne House? Introduction The Local Authority (LA) a type of local government in the United Kingdom - is responsible for social care services. It commissions organisations to provide social care services for UK residents. These contracts are often renewed and up to tender on a regular basis. MetCare is one of the organisations that has been commissioned by a London LA to provide social care services. MetCare operates several different care homes, including Osborne House, a residential care home supporting adults with learning disabilities. Arnold is employed by MetCare and Osborne House is one of the properties of MetCare in Arnold's patch as an Area Manager. He has been informed that the Osborne House contract is up for renewal and the LA has invited bids from other organisations to provide these social care services. To prepare for the impending tender bid, Arnold decides to review the business case for MetCare and explore their commercial viability as they plan to submit a bid to continue providing residential care at Osborne House. Arnold needs to understand the limitations of government funds and the changing demands of the customers, as well as the effects of both these factors on staff morale. He hopes to gain insight into the broader complexities and challenges of managing a residential care home in London, as well as the managerial implications of those challenges, to help him prepare for the bid. Adult Social Care Services in the UK To begin his assessment of the broader complexities facing him as a manager of a residential care home, Arnold begins with a review of the adult social care service system in the UK. He finds that people who use adult social care services have differing needs, aspirations and circumstances (Care Quality Commission, 2017). They may need social care because of a learning disability, mental health problems, or due to ageing. As the population continues to age, the demand for care will increase (CMA, 2017) and the types of care needed will change. The Office for National Statistics predicts a 36% increase in the number of people aged 85+ between 2015 and 2025, from 1.5 million to 2 million. This is expected to lead to a substantial increase in the demand for social care services. Arnold knows there is a shared commitment between the government, local councils and providers to meet these growing needs. Las are directly responsible for care provision in their areas and generally commission care services from independent care providers. LAs have a legal duty to meet people's 'eligible needs', subject to their financial circumstances. Adult social care services are worth around GBP 15.9 billion a year in the UK, with around 410,000 residents and around 5,500 different providers. The Care Quality Commission (2017) recognises four different forms of adult social care provision, which offer different levels of independence and support, ranging from specially designed accommodation for people with dementia to support for adults with complex physical needs and learning disabilities. To review the landscape of social care services in the UK, Arnold draws up a quick table to compare the four forms of provision (Table 1). Table 1. Features of Four Forms of Adult Social Care Provision Community social Residential care Domiciliary care Nursing home care home A rented room within a residential A rented flat or room in the community within sheltered accommodation, Description Support from visiting carers for a client living in their own home. home (could have up to ten rooms) with support staff living and working onsite. A rented room with the care of various support staff and healthcare professionals. with support provided. Recorded number 1,493 5, 511 10,858 4,042 of homes a Residents are Independence is relatively independent: thev Residents may be quite independent Residents are less independent and Level of maintained as the Click here for EXCEL Click here for CSV Click here for PDF Some providers like MetCare may have different forms of adult social care provision within their portfolio.. Arnold notes that reports by the Care Quality Commission (2017) show that the number of residential homes is decreasing and that there is a long-term trend towards increased numbers of nursing home beds and increased numbers of domiciliary care agencies of various sizes. Arnold knows this represents a challenge for the managers of residential care homes, especially considering the financial pressure that many find themselves under. The majority of customers of most service providers are funded by their LAS. The Competition and Markets Authority notes that over 75% of care home residents are funded in this way, while the remaining are self-funding customers who can afford to pay more (CMA, 2017). Arnold is particularly concerned with the fact that, with impending cuts, service providers are at risk of failure due to the reduction of their main income from LAs, unless they can attract more self-funding customers. Osborne House Arnold moves on to review pertinent details about the residential care home he is focused on preparing for a tender bid. Osborne House is a 10-bedroom property that provides care and support for adults with learning disabilities. It has been in business since 1994, and MetCare is the second owner it has had in that time. Under the terms of their contracts, residents (sometimes called customers, service users or clients) rent one room in the property, generally funded by the LA. They support themselves to some extent, with some of them attending day services. Day services are places where adults with learning disabilities attend during working days, leaving home in the morning and coming back in the evening. Often, they describe it as going to work and they look forward to going there. There are activities and events which offer opportunities to meet other people from other residential homes, making long-term friendships. They develop new skills and improve on skills they already have. In addition, many of them engage the support of key workers to access the community, unlike people living in a nursing home. Keyworkers are members of staff who are responsible for ensuring each resident is known and valued and that their needs are recognised and supported. Arnold notes that there are 15 permanent staff at Osborne House. Arnold draws up a quick organisational chart of Osbourne House (Figure 1) to visualise the roles and duties of the staff. There is a registered care manager - Asha - who is responsible for the overall management of the project, and she reports to Arnold. Reporting to Asha are Annuella, the team leader/deputy manager, five senior support workers, and eight support workers. The senior support workers also serve as keyworkers to the customers. Figure 1. Organisational Chart of Osbourne House, Part of MetCare Director of Care and Support(MetCare) Area Manager (London) Arnold Care Manager (Osborne House) Asha Team Leader Senior Support Workers Support Worker Click here to download Upon learning about the impending tender, Arnold visited Osborne House. In his meeting with Asha and the staff, he realises that he needs to consider several major issues facing residential care and support as MetCare prepares to submit its bids. These issues include challenges such as competition with other providers, limited funding from the LA, demands on support workers due to limited funding and increasing needs of residents over time. Challenges for Staff Changing Needs of Customers In his meeting with staff at Osborne House, Arnold gained insight into their challenges and concerns regarding providing adequate care to residents. Tony, one of the senior support workers, who is also a keyworker to two of the customers, informed Arnold that the changing needs of the residents is a key challenge. Tony noted that he had worked at Osborne House since 1994 when the home opened, and he had seen how the customers had changed over the years. He noted that they had become older and were not as able to engage or help themselves as they were before. As a result of such changing profiles, some of the residents were not able to go to the day services as previous residents had; as a result, residents of Osborne House were going out less often and spending more time in the house. This resulted in a need for more staff to support them. In addition, Tony noted that the residents had tended to become more demanding in terms of their need for personal care, putting extra pressure on staff, who may not be trained to provide such services. When such a situation persisted for a prolonged period of time, such residents may be transferred to a nursing home. When Arnold asked about the changing profiles of residents, Tony noted that the changing needs included their dietary, physical, and personal care needs. While residents in the past were often able to eat solid foods, many were now eating mashed and blended food because they suffered from difficulty swallowing (dysphagia). Previously, staff just served the food and were able to attend to other demands while residents fed themselves. Now staff have to mash the food, put thickener in their drink, and feed residents, which Tony noted may often result in staff spending an extra hour with a single resident. Upon hearing Tony's examples, other staff members began offering examples of residents requiring more care and the challenges it posed for staff. Alex noted that Mr. C, a very large resident, was able to walk around the house before but lost his mobility due to a stroke. Mr. C was now using a wheelchair and, whenever he needed to access the community, the female support staff were unable to support him because they could not push his wheelchair. Thus, in most cases, Alex had to be the one to push Mr. C. Carrie was a keyworker to Miss D and noted that, while the heavy-set resident was previously able to go to the toilet independently, her needs had changed and she needed to wear incontinence pads and have staff support her in using the toilet about eight times a day. Carrie noted that this increased demand took a toll on her as a staff member, especially given the weight of Miss D and the fact that she often needed an extra staff member to support her in helping Miss D with toileting. Carrie further indicated that this extra demand was affecting her administrative duties as a Keyworker. She had to update Miss D's risk assessment and support plans on a regular basis because of Miss D's changing needs. Furthermore, there were many more appointments to attend and there were no additional staff to take up that role. Carrie noted that her Manager has pointed out that she is falling behind in her work, but Carrie argued that there was not enough time to sit at a computer to complete paperwork because she was so busy on her feet attending to residents during every shift. Pressures on Staff Avi, another a senior support worker, corroborated Tony's points and argued that the effect of customers' changing needs on staff could not be overemphasised. Support workers had to do extra work to meet the increased demands and they felt like they were doing the work of nursing home staff. In addition, staff still had to do the cleaning and cooking and oversee the administration of medication. Avi illustrated his point by citing the example of one of the residents who previously needed 30 minutes of personal care each day but now required two staff spending an hour each. Avi explained that extra demands like this caused strain on the staff and made them feel stressed. He said staff were feeling demotivated, and thus not wanting to work or frequently calling in sick. Arnold asked if this meant staff were leaving, and Avi confirmed and noted it would result in short-staffing and further staff pressures. Tony spoke up and noted that this was also corroborated by findings from Communities and Local Government (CLG). The CLG found that nearly half of UK care home workers leave within a year, highlighting the severe challenges associated with maintaining staffing levels (Bulman, 2017), and the Office of National Statistics (ONS) revealed that care workers in the UK have a suicide rate that is almost twice the national average (Cox, 2017), which reflects the pressures placed on staff in the sector, and thus it is not surprising that many end up leaving. Quality of Care Service Arnold was getting a clearer picture of the situation at Osborne House and asked the staff about the quality of care they were able to offer. Bani, who had spent about three years at Osborne House as a support worker, spoke up to say she was very concerned about the quality of care being offered. She believed that the changing needs of residents were putting pressure on staff and inadvertently affecting the quality of care services being provided. She shared her concern with Arnold that this pressure could lead to accidents as staff were stressed and distracted or rushing. She feared it could also result in improper care and abuse. The issue of medication error was raised by Abel, who cited an incident where he was called in early to a shift to administer medication. He explained that the staff on shift were too tired to administer medication and, to avoid error, he was called in. Abel felt that, in addition to the pressure the staff were facing, the lack of funds from the LA was contributing to the poor quality of services. He believed staff were not really motivated to work because their salary was poor and noted that his salary had reduced since he first joined the organisation 10 years ago. Tony agreed with Abel and argued that poor compensation resulted in a shortage of staff and intense pressure on the few staff available. Arnold asked what the staff thought about filling the vacant rooms at Osborne House and thus increasing the number of residents. Abigail recognised that the vacant rooms should be filled; however, she said residents with extra needs should be screened out. She explained that residents who were not suited to residential home care were being accepted for the sake of filling a vacant room to address income pressures. She gave an example of Miss B who appeared to need nursing care based on her needs but was admitted into Osborne House because the family and LA could not afford 24-hour nursing care and the manager of the home needed the income to remain commercially viable. Although the staff of the home cannot take the added pressures, they feel there is little they can do in this situation. The staff are not motivated and trained enough to provide nursing care, and this affects the level of care provided to Miss B and residents like her. Challenges for Management Funding Cuts After his meeting with the staff, Arnold, Asha, and Annuella shared a private meeting to discuss feedback from staff and their concerns to better understand how Osborne House was being managed in the face of multiple challenges. Asha cited the funding cuts as a key challenge for the commercial viability of her project. She noted that she knew the sector was under huge pressure to remain sustainable in the face of funding cuts. Public expenditure on adult social care in England had declined by 8% in real terms between 2009/10 and 2015/16 (CMA, 2017). Even when the management asked for extra funds to provide the required support, this was often met with refusal. She cited the example of Mr. A, who had been at Osborne House for many years, typically needing about four hours of care a day. Asha said that, as with other residents, Mr. A's needs were changing, and he now needed more care. She approached the LA for funding for the extra hours for Mr. A, but the request was rejected. As a result, the home had to pay for the extra care and suffer the long-term implications that this may have on the survival of the business. Asha also acknowledged the demands on staff to meet the needs of Mr. A and residents like him. She told Arnold that, although she is trying her best to motivate the staff, it has not been easy because she is stuck between the LA not providing more money and overstressed and unmotivated staff. Limited Numbers of Residents Asha also noted the issue of limited residents and its implications for revenue. Arnold asked if the issue was that Osborne House was home to people that needed long-term residential care, but they could only house a limited number of residents at any given time. Asha agreed and noted that the residents rent a room within the house and pay for care and support services, and some of the current residents had been living there since 1994 and had had no reason to move out. Residents typically leave due to death or a change in their care needs; either they become more independent, and move on to supported living, or they become less independent, and move into a care home. As a result, Asha noted the business can remain the same for very long periods of time, and with few prospective customers to replace the residents when they leave, it can be difficult to get a suitable replacement resident because people now tend to prefer domiciliary care in their own homes. She gave an example of a room that was empty for almost a year and the pressure she was facing from the previous Area Manager to fill the void room. As a result of that pressure, Asha conceded to accept a less-than-ideal resident, Miss E. Although Miss E required more personal care, it was better than having a vacant room. Asha further indicated that, with ever-increasing property prices in London, it could be tempting to convert these social service care properties into residential flats, which may be more commercially viable than having vacant rooms that cannot be rented out. Arnold agreed and they mused that these press made it difficult to keep such homes in business. Competition Arnold was concerned that the LA commissioned providers like MetCare to provide care and support for residents at places like Osborne House but that the LA tried to save money by changing contractual agreements, paying lower fees, negotiating bulk purchase discounts, and commissioning care and support to providers who can offer cheaper service (NAO, 2014). Arnold noted that MetCare were finding it difficult to remain commercially viable. He and Asha commiserated on the difficulties associated with replacing residents, dealing with competition, and still wanting to pay their staff above the living wage to keep them motivated. Asha explained that she has to deal with staff coming in to request salary increases regularly but she cannot afford to accommodate those requests. The sector is quite tight, and the company typically cannot afford salary increases. She noted that it does not help to ask the LA for additional funds because they may be rejected or the LA may decide to invite another provider to tender for the service. She further noted that she believed such providers often paid staff only minimum wage. Arnold thought about this issue for a moment and noted that such competition within the sector could influence the quality of care and the level of support provided. Family Involvement Annuella, the team leader/deputy manager, offered Arnold some key insight into how residents' family members factor into the challenges of managing Osborne House. Annuella explained that she was often around during the weekend when the families came to visit residents and she had witnessed how residents who had been living at Osborne House for many years came to see it as their home, and as a result, their families preferred not to move them. Although a resident's changing needs may require a decision about moving them to secure proper care, Annuella said that family involvement had resulted in such moves being delayed. Annuella said she believed this caused additional strain on the management and staff dealing with such issues. She shared the example of Mr. F whose family members did not want the social services to move him to a more suitable accommodation after his health declined. The family did not want him moved to a nursing care facility outside London because they wanted him to stay in Osborne House because it was very close to them. Even with the financial implications of another vacant room, Osborne House was ready to support Mr. F's move, but the family declined. A best-interests meeting between different professionals had to be organised to effect the move. Conclusion After the meeting with staff at Osborne House, Arnold pondered how they could address these myriad challenges. He also wondered about the ethical issues that were raised. Arnold was aware that service providers in the healthcare industry faced certain ethical issues as they wanted to provide good quality care, but they were financially restricted in their abilities. Would Osborne House have to keep a resident to avoid having a vacant room and lose an income stream even though they knew the customer could receive a better care elsewhere? Would they have to cut corners and make savings because they wanted to stay afloat? Would they be willing to report incidents and accidents, or would they want to hide it so as not to show their low level of staffing? To address such issues and prepare for the upcoming bid, Arnold reflected on the challenges the staff at Osborne House identified. How could he deal with these challenges to improve service and ensure the viability of the care home? Perhaps he could consider how to improve staff training and motivate them to do more by rewarding processes and policies. Perhaps he could find ways to support the management team at Osborne House. He could also consider reaching out to new customers, including self-funded residents, with new marketing campaigns to supplement what they are being commissioned by the LA. AS he considered the task before him, he was confident he could come up with a plan for improving efficiencies to reduce costs, sustain profitability and service quality, and, importantly, retain the contract with the LA. Discussion Questions 1. What are the holistic implications of the financial issues at play in keeping Osborne House viable? How are these issues influencing the quality of care and support being provided? 2. Who is affected most by challenges and issues of service at Osborne House? 3. Who could have the most influence on changes to the provision of adult social care and support? 4. What kinds of tactics and strategies could Arnold implement to deal with the different stakeholders and their challenges? 5. How could Arnold address the operations management and service quality issues at Osborne House