ONE of Scotland's leading care experts says he is "profoundly concerned" that a shortage of care home places and home care provision in rural Scotland is leaving vulnerable elderly people at risk.

Donald Macaskill, chief executive of Scottish Care, the umbrella body for private and charity-run care providers, said community-based social care was also "singularly unsuitable" for people with advanced dementia, but that the collapse of residential care homes for older people in remote parts of the country, including islands, Argyll & Bute and parts of the Highlands, meant that families have increasingly faced the agony of sending loved ones miles away for care.

READ MORE: 'Poorly resourced' dementia training blamed for abuse cases 

Speaking to the Herald on Sunday as part of our 'Think Dementia' campaign, Dr Macaskill said: "There is a real struggle to find dementia places on the islands and in rural areas.

"In the end, families have to make a choice: either to take their relative closer to where they may be on the mainland, or if they live in an island community themselves to move that person off the island and small islands like Arran and Bute are classic examples of that.

"We know the disproportionately negative impact that is going to have on a resident who is living with dementia - that loss of familiarity, of the known, of the relationship with a local community - that is really damaging.

"Care-at-home is singularly unsuitable if you've got advanced dementia. Everybody agrees that the best place for people is to be as independent as possible in their own home, and care homes today reflect that - most of the people in them are in the advanced stage of neurological decline and health frailty.

"We've got 33,000 care home beds in Scotland, and 25,000 of them are effectively hospice beds.

"But in accepting that reality, I am personally profoundly concerned that we have a growing number of people who are too vulnerable to be on their own in their own homes, especially in areas where the home care sector is on its knees.

"I was with a provider in rural Central Scotland last week. Last year, her advert per worker would get around 20 people walking through the door; now she's lucky if they get two.

"And that's just in the space of a year. She spoke about having 160 staff as what she requires in order to deliver her service. At the moment, she's only got 84."

READ MORE: A vision for dementia care in Scotland 

The number of care homes for older people in Scotland has declined from 886 in March 2015 to 826 by March this year.

Although that is in line with an agenda that wants more people to be looked after in their own homes, the fall has been steepest in one of Scotland's most rural areas: Argyll & Bute.

According to the most recent care homes census, the total number of registered places in facilities for the elderly plummeted by 21 per cent - from 728 to 576 - between 2007 and 2017.

Over the same period in the Scottish Borders and Orkney the number of beds dropped by 14% and in the Highlands by 13%, in comparison to 3% and 6% respectively in Edinburgh and Glasgow.

The sector as a whole is struggling financially. More than two thirds of residents in care homes for older people are paid for at lower rates by councils, with the remaining self-funders charged substantially more for their places - in some cases more than £1000 a week.

However, increasing overheads - including the introduction of the Scottish Living Wage - have led several providers to fold.

READ MORE: Families are facing 'unimaginable hurdles' to secure care for loved ones 

In rural Scotland, the number one pressure is recruitment and retention of staff - something that Dr Macaskill says has worsened over the past two to three years.

"Undeniably there is a Brexit influence which is felt nationally, but it is felt more acutely in rural and remote areas," he said.

"The overall social care workforce, in terms of the EEA, is between 6-8% for our overall membership. But that can rise to as much as 30% in single care homes in remote parts of Scotland."

Care homes in rural Scotland tend to be more reliant on expensive agency staff, and some even resort to paying care workers' accommodation on top of their wages in order to attract them from cities.

"I think virtually every care home I know in the Highlands and in Argyll & Bute in particular, parts of the Borders, are trying to do these things. But ultimately there is a cost factor to that - a big one.

"There are care homes who are literally getting agency nurses to come from Glasgow to do a couple of shifts, and then go back home. That's not a model that's sustainable."

If a care home does not crumble under the weight of unaffordable staff costs, another risk is that it might simply be stripped of its licence due to staffing shortages.

The Care Inspectorate has the right to issue improvement notices to operators if it is not meeting required standards, including adequate staffing. If these improvements are not achieved by a deadline then inspectors can apply to the Sheriff Court for a service to be cancelled.

Although a measure last resort, there have been six emergency cancellations issued since March 2018, compared to one in the previous three years.

Improvement notices have also increased - from 21 in the three years to March 2018, to 20 in the past 18 months.

A spokesman for the Care Inspectorate said: "The Care Inspectorate works closely with care providers across Scotland to support improvement wherever it is needed.

"The majority of care homes for older people in Scotland perform well, but where things are not good enough we can and do take action to support improvement.

"It is rare for us to seek the closure of any care service through the courts, and we do this only as a last resort, and after all other methods to support improvement have been exhausted."

A spokeswoman for the Scottish Government said: "Significant work and investment has gone into supporting older people and people with disabilities to live well in their own home or in a homely setting, with more than £700 million additional investment this year in integrating health and social care.

"We are working with COSLA, people using social care support, carers, and the social services sector on a national programme to support local reform of adult social care support.

"It will specifically look at the value and cost of social care, how it is funded and developing new structures for a sustainable future.

"We’re launching recruitment campaigns for adult social care, nursing and medical professions with £4m investment recognising certain areas face particular challenges.

"We will do all we can to ensure that, despite the challenges posed by Brexit, we continue to attract and retain the right people and benefit from the valuable contribution the EU workforce make to the sector.”