"There is a presumption among some politicians that care homes don't really have a future", says the man in charge of overseeing the sector in Scotland.

However the aim of allowing older people to live independent lives for as long as possible must be balanced with the rights of those who are unable to see out their days in the comfort of their own home, says Donald Macaskill, chief executive of Scottish Care.

The Herald:

"There will always be a need for people to be supported to lead meaningful lives when they are no longer able to be supported at home", he says.

Where there is greater consensus, is the need for residential care to evolve and change, to meet growing demand and learn lessons from the pandemic.

Around a third of Scotland's 10,000 Covid-related deaths occurred in care homes.

The Care Inspectorate is proposing new requirements for providers which could see resident numbers capped at 60. The consultation, which closes today, follows studies focussed on the first wave of the virus, which showed outbreaks were more likely in bigger care homes. However the evidence is as yet unclear why this happened.

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"In Canada, where large scale homes are uncommon, it did not stop the country having one of the worst international case numbers, says Mr Macaskill.

"We know that the transmission for the virus has been more common in larger environments but we do not know why that is the case and the Care Inspectorate do not know even though they may defend themselves with certain papers.

“Is it because there are more staff and more footfall, is it because larger care homes tend to have more people with greater acuity, or is it because as we now know the virus significantly transmits itself through air and it’s easier to ventilate smaller homes?

“A lot of the evidence is based on the first wave. We still don’t have data from the second wave where there were deaths in smaller care homes and equal rapidity to larger care homes. 

The Herald:

"So I think the epidemiological evidence on which they are basing these changes is not robust, isn't independent and doesn't reflect international thinking at the moment.”

Aside from infection control implications, there is widespread support around the world for a smaller unit model. The Care Inspectorate say evidence suggests that people living in smaller homes usually experience better care. From its own research, 53% of 60+ capacity homes had a minimum grade of 4 and above, compared with 69% with 10-59 places.

In Australia, a major review examining the safety of care homes pre-pandemic urged providers to move towards smaller, cottage style models.

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The report by the Royal Comminssion found smaller, lower-density congregate living arrangements generally promote better quality of life for everyone saying large, noisy institutional environments can worsen the adverse consequences of dementia. 

Hammond Care, which is one of the country's biggest providers, has been at the forefront of this model, which caps numbers at between 10-15 residents, since the 1990s.

The Herald:

“One of the insights we all agree on is that people prefer to live in smaller units," says Mr Macaskill.

"What the pandemic has done is lead to a dramatic change in aged care because of our emphasis on infection prevention and control.

"And that presents major challenges because care homes are places of collective living, they will always be that but that doesn’t mean that they should be changed into acute sector infection control units.

"Undoubtedly aged care planners, internationally are thinking small is best but because of personal choice, rather than risk."

Mr Macaskill says the changes being proposed in the design of care home, which also include a preference for single storey buildings, will lead to major logistical and financial challenges for care providers and residents, if this is reflected in fee rises. 

The surveyors, Christies have estimated that it would cost tens of millions of pounds to equip existing homes to meet the standards being proposed.

"I think there are about 2% of homes who meet these new design criteria.

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"Local authorities don’t run nursing homes, they only run residential care homes. If you take Glasgow for example the three new care homes are between 150 and 200 in size so I don’t know practicably how it’s possible for those new care homes to be able to meet these new design criteria. 

"Any new design demands substantial financial investment. The physical size will be much bigger even if the number of people will be smaller and that presents a real problem because that’s going to cost a lot of money.

Alison Dawson, co-leader of the Dementia and Ageing Research Group at Stirling University, says ventilation will be a key issue for providers. The Care Inspectorate review is considering setting a minimum level of communal space per resident.

She said:"It's not as simple as just opening windows.

"What I very much hope we will see is a significant amount of research effort being put into understanding and helping individual care homes to understand about air flow and air quality generally within the buildings they currently have but also when we are building new homes."

She says there is likely to be greater use of tele-medicine in residential care settings to help minimise infection control risk.

Nicola Sturgeon and health secretary Jeane Freeman have admitted the Scottish Government’s guidance around discharging patients into care homes was a “mistake”.

A revised official report concluded that it was not possible to rule out a link between transfers and outbreaks of Covid-19.

Almost 5,000 elderly patients were transferred from wards to care homes between March 1 and May 31 last year, many without being tested for the coronavirus.

An updated report from Public Health Scotland (PHS), a national health board of NHS Scotland, found that 675 died within 30 days of being discharged, with Covid linked to almost a quarter of the deaths.

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"I think we are now much more sensitive and attuned to the issues and I'm sure that there will be thoughts as to how that could be better managed," says Ms Dawson.

" In terms of how that affects care home design, I think there is a lack of clarity about that. 

The Herald:

"What there will be in the future is the potential for technology to play a greater role.

"That might include having the capacity within a care home to get decent teleconferencing solutions in so that perhaps it avoids people having to move between care homes and hospitals.

"There is a lot more opportunity for the near me type services because it avoids the transfers, it avoids the disruption and avoids the potential for the transmission of disease."