Previous reviews

Ten years ago, Holder and Jolley (2012) conducted an important and comprehensive international review of the literature on ‘involuntary relocation’ (though not solely within a social care context) (for an earlier example, see Smith and Crome, 2000). The review aimed to identify international empirical evidence about the consequences and impact of relocation, as well as good-practice recommendations to shape future approaches – albeit with a focus particularly on forced relocation between nursing homes, though also involving residents transferring inter-service (including hospitals and community-based settings). This is crucial work, as the received wisdom is that some forms of relocation can have extremely negative consequences for older people, possibly even increased mortality, if the move is handled less than optimally.

However, in practice, very few of the studies included in previous reviews focus on closures of care homes for older people. Instead, many of the insights generated focus on older people moving into existing services, or on relocations from a variety of different health and social service settings. Thus, despite reviewing over 3,500 initial results, Holder and Jolley found no studies about the outcomes of care home closures in the UK and only one previous UK research team exploring closure processes, while Smith and Crome identified only one UK study that specifically explores care home closures. This was a four‐page article from the early 1990s, where 59 residents moved from one large care home and from one psychiatric service initially opened to rehouse long‐stay hospital patients – perhaps more of an article on deinstitutionalisation than on the closure of current care homes. Therefore, when Glasby et al (2018) published the results of an evaluation of a single-site closure programme in 2018, they concluded that this was one of only a handful of studies conducted in the UK and probably internationally, with the issue of care home closures still a largely evidence-free zone. In particular, the literature at that time seemed extremely limited in terms of insights around the outcomes of care home closures. Previous studies were also predominantly clinical in nature/professionally led, making virtually no attempt to involve or consider the different experiences of older people, families and care staff. However, these contentions require empirical analysis through a structured review.

Ten years on from Holder and Jolley, this article revisits and reviews literature relating to care home closure, seeking to contribute to improved outcomes for older people and to minimise the risk of harm by ensuring that future closures are planned in an evidence-informed manner. This is the backdrop to a new national study on care home closures funded by the National Institute for Health and Care Research (known as ‘Achieving Closure’) but is also particularly timely considering the increased rate of closures that is anticipated following the pandemic and in response to the current cost-of-living crisis. In doing so, we empirically demonstrate what is known about the process of care home closures, the perspectives and experiences of the different stakeholders involved, potential outcomes, and any recommendations as to what might constitute good practice in such a complex and contentious area of policy and practice. Given that service models, policy priorities and terminology all vary so much across different systems, we focus here on evidence from England (which, as set out earlier, has a very particular type of care home market, with some in-built tensions and complexities). However, we recognise that there are likely to be insights emerging from this context that speak to, or can influence, care home closure processes and outcomes internationally.

The nature of the evidence

Overall, we identified 323 initial outputs for title/abstract review (which reduced to 248 after 75 duplicates were removed [see Table 2]). Ultimately, 12 outputs met our criteria for inclusion in the review, and these form the basis of this subsequent article. Importantly, these 12 studies emerged from eight overarching studies or programmes of research (for summaries, see Table 3). When we refreshed our searches in July 2022, another 67 abstracts were reviewed, but none were identified for inclusion (for an overview of this process, using the PRISMA framework [see Hewison et al, 2020], see Figure 1). As discussed later, this feels like a very small number of outputs/studies for such a crucial (and growing) policy and practice issue, and many of the individual studies are either very dated or provide only brief snapshots of the issues at stake.

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PRISMA flowchart of the integrative review process

Citation: International Journal of Care and Caring 8, 3; 10.1332/239788221X16753558695396

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The outcomes of care home closures

Of the 12 studies, only five reported empirical outcomes from care home closures, including both quantitative and qualitative outcomes (for a summary, see Table 4).

A sixth provided a structured review of outcomes evidence from a broader series of relocations (Holder and Jolley, 2012).

In 1994, Hallewell et al studied the residents of two care homes for one year after closure (which closed at short notice due to financial problems). They explored whether it was possible to predict which residents would be negatively impacted by closures. Before residents moved, age, sex, length of stay and physical and psychiatric diagnoses were recorded. Care home staff were also interviewed using the Crichton Geriatric Behavioural Rating Scale (CGBRS) (a scale used to assess function across eight different activities: mobility, orientation, communication, cooperation, restlessness, dressing, feeding and continence). This was repeated at three months after relocation and then again one year after moving. While relocation had a statistically significant impact in terms of higher restlessness in the short term when compared with a control group, there was no statistically significant difference between the relocation and control groups after one year. Residents with high CGBRS scores before closure were associated with increased mortality (as perhaps might be expected), and requiring assistance getting dressed was also a good indicator of increased likelihood of mortality following relocation. While 12 residents died in the year after closure, the research could not show that closure itself had a statistically significant impact on mortality.

In 2003, Williams et al found that 14 per cent of the residents in their sample died after their care home closed, with 9 per cent dying within three months of moving. The health of a further 2 per cent of residents deteriorated, and 2 per cent were unsettled. A total of 60 per cent of relocated residents reported no continuing health issues, and half were settled in their new homes. However, this was simply a reporting of patterns of mortality (within a small sample), with no attempt to explore issues of causality. A third study has similarly been unable to show that care home relocation had a statistically significant impact on increased mortality one year after closure compared with care homes that had recently closed (Gascoigne and Mashhoudy, 2011). Importantly, in all three of these studies, research was limited by small sample sizes, indicating the methodological challenges that arise when trying to research these issues (Holder and Jolley, 2012).

Looking at outcomes other than mortality, Glasby et al (2018) evaluated outcomes for older people from a very large care home closure programme in Birmingham, collecting data on health and well-being at three time points (at closure, after 28 days and then after 12 months). After initial distress and anger from older people and care staff in particular, outcomes after 28 days and one year were either the same or slightly better than before, suggesting that some things ultimately stayed the same for some residents and actively improved for others. The authors describe this as a ‘game of two halves’, where initial distress might be inevitable but where closures (where existing services were less than optimal and relocation is managed well) might not make things worse for many people and might actively improve the situation for some residents. This was supported by local social workers, who felt that some older people were very upset or disorientated during the initial closure process but that it was ultimately the right thing to do to improve outcomes for older people in the longer term. Although some residents had died after the closures, this was thought locally to be consistent with what would have occurred with or without the closures, and not outside the boundaries of usual mortality in a group that, by definition, tends to be very frail and to have a significant number of physical and mental health problems.

A similarly mixed picture emerges from the qualitative research carried out by Leyland et al (2016). Here, some stakeholders believed that mobility improved following closure and that the amount of personal care required lessened. Others believed that there had been some deterioration in the health of residents. Leyland and colleagues additionally briefly considered negative social outcomes associated with the closure of care homes, such as a lack of integration into a new care home (especially where residents moved without friends or in advance of friends). However, detailed analysis of social outcomes was limited throughout the studies reviewed – and there seems to be scope for further research in this regard.

Relatedly, none of the studies included in this review consider potential differences in outcome by social divisions/protected characteristics, such as gender or ethnicity. Although Leyland et al (2016: 391) discuss residents ‘finding a role within the social structures in their new home’, they do not analyse if and how positionality might shape the experiences of closure or the ability to integrate into a new care home. Indeed, most of the research reviewed is very broad-brush in terms of the distinctions drawn between different groups, and the research reviewed does not examine differential outcomes between social groups.² As is discussed in more detail later, there is also very little research that tries to understand the issues at stake from multiple perspectives (such as older people, families, care staff, social workers and senior leaders) (for rare exceptions, see Glasby et al, 2011; 2018; Robinson et al, 2013).

The process of care home closure

Table 5 provides an overview of insights into potential good practice during the process of closing care homes. In the early 2000s, for example, researchers at the Personal Social Services Research Unit (PSSRU) at the University of Kent produced a series of linked outputs on the care home market. This included an attempt to collect and analyse any written guidelines/local protocols and to identify good practice (Williams and Netten, 2003; 2005). Information was collected from 55 of 150 local councils in England. Nearly two thirds of responding authorities reported having a closure protocol, though document scope varied greatly. While we do not know about arrangements in councils that did not respond, this still suggests that a significant number of local authorities at this time did not have policies in place to guide local closures. From the policies that were able to be analysed, good practice was felt to include taking residents’ social and personal needs into account (for example, existing friendships with residents, preferred geographical location and ability of family and friends to visit) and maximising residents’ ability to make informed choices. However, it was noted in several policies that enabling choice was likely to be difficult to achieve in practice. A quarter of the protocols referred to the length of notice care home owners should or ideally would provide (typically, these recommended notice of around one month or as much notice as possible). Considerable importance was also placed on involving care staff in the closure process, respecting their friendships with residents and their likely concern for residents’ future welfare.

Around a decade later, Robinson et al (2013) placed the issue of care home closures in the broader context of health and social care disinvestment, rationing and decommissioning. They highlight a lack of national guidance and a tendency for local areas to develop their own local approaches, often in isolation from each other and without sharing lessons learned outside their own authority. In particular, the linked studies by Robinson et al (2013) and Glasby et al (2011) place a significant emphasis on meaningful, honest and ongoing communication between local authorities and residents, families and care staff. While local closure processes try to prioritise communication, it is crucial that key stakeholders (especially older people and their families) feel they have had a chance to contribute to initial decisions to close services and feel that their voices have been heard – even if they do not agree with the actual decision that has been taken. Communication should also be ongoing, particularly when there are delays or plans change. It should also be honest, even if this leads to difficult conversations or people to admit that they simply do not know the answer to a particular question yet. Robinson et al also found that care staff were a crucial source of information for older residents. No matter how much effort had been put into communicating, many older people could not really remember the information they had received from the council, tending to get the bulk of their information and updates from chatting to care staff. In situations where care staff did not feel sufficiently involved in the closure process, therefore, this sense of dissatisfaction and a sense of frustration at not knowing what might happen next could easily be transmitted to residents. This points to the need for really good communication with care staff/providers. However, this study also found that basing social work assessors in homes that are closing helped these practitioners to get to know residents, families and care staff better, potentially helping with the communication.

When reflecting on their experience of care home closures, directors of adult social services stressed the importance of having sufficient time to undertake such complex and sensitive work at the pace of individual older people (Glasby et al, 2011). Often, there can be a balance to be struck between working in a person-centred way and trying to conduct the closure in a timely manner so as not to extend uncertainty. Nevertheless, it was felt that once the decision to close a care home had been made, it was crucial to stick to established deadlines and timescales. Williams et al (2007) highlight the types of time-intensive tasks involved in the closure process (such as paperwork, face-to-face interactions and calls), which also indicates the importance of adequate time frames when conducting closures. Sufficient time for residents to talk to residents and staff in care homes prior to relocation is also shown to be salient (Reed et al, 2003).

Other outputs have evaluated the use of closure guidelines during real closures, highlighting what was and was not perceived to have worked in practice. For example, Williams et al (2007) analysed care managers’ experiences of care home closures and associated good-practice recommendations. Interestingly, care management staff from four councils in England interviewed in this research reported that they did not use local council closure guidelines and their belief in the value of guidelines varied. In particular, staff noted dilemmas in the closure process, including the need to balance the availability of places at different homes, a desire to take into account the perspectives of residents and relatives, and a recognition of the importance of promoting rights and freedom, and not being seen to ‘recommend’ specific homes, which might be interpreted negatively by providers. These potential tensions could appear incompatible at times or result in serious compromises.

Similarly, Leyland et al (2016) explored whether a protocol designed by a local council was adhered to in practice and the influence it had on the experiences of residents relocated between care homes. The research considered the perspectives of multiple stakeholders. In terms of protocol adherence and translation into practice, the authors articulate four themes, including: (1) involvement, (2) staff approaches, (3) consistency/familiarity and (4) preparation. First, in terms of involvement, visits were offered to relocating residents, though they were not always taken up, and residents also felt that these visits were short. The presence of choice was emphasised by stakeholders, including of care home and even of bedroom. Family members were able to be part of decision making relating to relocation, though residents had a choice about how involved relatives could be. Provision of information and consultation were identified as important, and it was said that this occurred throughout the process for the majority. Independent advocacy was said to be useful for residents who lacked capacity and did not have relatives to support them.

Second, staff were supported and offered reassurance throughout the process, and this was facilitated by existing positive relationships. The process of closure was felt to be person centred and particularly successful in pacing moves and being flexible in relation to individual needs. Staff were able to separate their own concerns about moving jobs from the needs of residents – and this was achieved because of being well informed about closures by managers.

Third, in terms of consistency and familiarity, friendships between residents were maintained when moving, which helped with residents acclimatising to their new home. Additionally, similarities in room and building layout were thought to be important, as well as residents being able to bring furniture with them. Finally, in the theme of preparation, the protocol and its translation into practice meant that relevant paperwork was used consistently across care homes, which helped with the transfer of documentation. Additionally, clear leadership/communication/continuity resulted from a single care manager working full time on the process, which resulted in positive working relationships and accessibility. The logistics of relocation were also felt to be important and given close attention, including transport, enhanced staffing levels, the scheduling of moves and the consideration of impacts on residents who were the first or last to move (particularly as the moves were near to Christmas). Overall, Leyland et al (2016) provide salient qualitative evidence about what aspects of planning and preparation work in practice on a small scale at a local level.

In a similar manner, Reed et al (2003), as part of a broader project on care home relocation, have discussed the experiences and perspectives of older people moving between care homes. Although choice and involvement in the closure process is typically recognised as good practice in most accounts, Reed and colleagues found that the extent to which resident views were considered and residents were involved in relocation decisions varied substantially. They suggest that residents’ experiences of involvement in relocation can be described under four types or categories (which could vary for the same person across different moves). People in the category of ‘residents reluctant to move’ often had little involvement in decision making around their move, which was based on an assessment of their needs, rather than their preferences. Where residents were ‘passive’, it was, however, unclear whether they had been offered a range of possibilities. The authors indicate that this category was defined by a lack of autonomy and choice. They suggest that a continuum of involvement in relocation decisions is evident in their data (reflecting certain personal and institutional conditions). Thus, Reed et al (2003) highlight a potential disjuncture between choice and involvement as good-practice recommendations and what is actually feasible or occurs in reality. In contrast, Glasby et al (2018) argue that even apparently well-conducted closures might not be able to prevent anger and distress en route, even if longer-term outcomes are positive for some. As they suggest, ‘success can often look like failure part way through’ (Glasby et al, 2018) and it might sometimes be a question of social care leaders holding their nerve – understanding and acknowledging the anxiety and distress that closures cause, whilst also working to improve longer-term outcomes.

The voices heard during the closure process

There are a range of stakeholders involved in, or impacted by, care home closures. Table 6 sets out the types of stakeholders that existing research has included as participants, revealing the limited nature of the evidence from different perspectives. Crucially, only four of the reviewed outputs directly include the experiences of older people (Reed et al, 2003; Williams et al, 2003; Leyland et al, 2016; Glasby et al, 2018). Indeed, Hallewell et al (1994), rather than asking older people directly about mobility, restlessness and other outcomes, instead asked care staff for these data. There are even fewer outputs (three) analysing evidence collected from relatives/family members. Importantly, Glasby et al (2018) asked older people and family members about the experiences of the closure, while Williams et al (2003) sought relatives’ reflections on good practice during various dimensions and stages of the process. The other output, however, analyses data from only two (n = 2) family/relative participants (Leyland et al, 2016).

The experiences of care staff are similarly poorly represented in research, with their voices found in only four outputs. In the research by Hallewell and colleagues (1994), although care staff participants were asked to contribute outcomes evidence relating to older people, their own experiences and the outcomes for care staff themselves are neglected. Glasby et al (2018) and Reed et al (2003) do analyse the experiences of residents, but as in the research by Leyland et al (2016), the focus is on maximising the experience of, and outcomes for, older people, and again, such research does not examine the outcomes of closure for care staff themselves (for example, in terms of employment/financial outcomes, or stress and anxiety).

Despite the considerable potential impacts of closure on older people, their families and care staff, our review shows that there are very few examples of research engaging with the experiences of these stakeholders. The evidence that does exist is also now quite dated (with only two studies including the views of older people, their families and/or care staff in the last 15 years). This might suggest that limited value is attached to the experiences of older people, their relatives and care staff, and that such stakeholders have limited power to influence care home closure processes. However, there have additionally only been a limited number of attempts to understand the experiences of the more powerful groups within adult social care (relatively speaking) who are leading the difficult work of care home closure, including social workers and social care leaders/commissioners (see, for example, Glasby et al, 2011; 2018; Robinson et al, 2013). In this regard, a dearth of research attention is evident across the breadth of stakeholders who are influencing or are impacted by care home closures.