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2020 UK Care Homes Trading Performance Review
Additional government funding until March 2021
Operators adapt quickly and show resilience
Occupancy down 8.5% by mid-year 2020
knig
htfra
nk.c
o.uk
/res
earc
h
67Counties
and island dependencies
819UK towns and cities
112kCare beds
1/4of UK care
home market
71%of the corporate
group market
FIG 3
2 0 2 0 R E S U L T S A T A G L A N C E
OCCUPANCY AVERAGE WEEKLYFEES
STAFF COSTS(% OF INCOME)
EBITDARM(% OF INCOME)
87.9% 89.2% 87.4%
NursingPersonal All Care
£889 £766 £953
NursingPersonal All Care
58.0% 55.1% 59.0%
NursingPersonal All Care
26.8% 28.5% 26.3%
NursingPersonal All CareFIN
ANC
IAL
YEAR
2019
/20
Q2
2020
79.4% £938 61.3% 26.2%
OCCUPANCY AVERAGE WEEKLYFEES
STAFF COSTS(% OF INCOME)
EBITDARM(% OF INCOME)
87.9% 89.2% 87.4% 889 766 953 58.0% 55.1% 59.0% 26.8% 28.5% 26.3%
NursingPersonal All Care NursingPersonal All Care NursingPersonal All Care NursingPersonal All Care
FIN
ANC
IAL
YEAR
2019
/20
Q2
2020
79.4% £938 61.3% 26.2%
T H E S U R V E Y I N
N U M B E R S
I N T R O D U C T I O N
his year, we have adapted our annual Care Home
Trading Performance Index to incorporate the usual
industry-leading benchmarks for the 2019/20 financial year,
but also any changes in performance that occurred from April
onwards when the pandemic emerged. This has allowed us to
measure the impact of Covid-19 across the sector. A special
thank you this year to all the operators that have helped to
keep the survey sample as robust as ever.
As you can see from Figure 1, our survey includes care
homes spread far and wide across the UK. Nursing care homes
T account for two-thirds of the sample, versus one-third for
personal (residential) care homes. This reflects the survey’s
weighting towards the corporate market, with most group-
owned homes registered to deliver full-time nursing care,
including dementia care. Figure 2 also shows how the
regional split of this year's sample mostly mirrors the total
UK market. The only clear exception being Wales, where our
sample is slightly underweight.
2020 has been a year like no other, and especially so for the UK care home sector which has adapted immensely well to a
challenging operating environment
Occupancy declines by 8.5% between March and June, but
recovers 1.2% by October 2020 (more on pages 4 and 5)
Fees increase for the 10th consecutive year and a
further 5.6% is showing in the 2020/21 financial year.
(more on pages 6 and 7)
COVID-19 adds to staffing challenges, but the Adult
Social Care Infection Control
Fund provides a buffer. (more on pages 8 and 9)
Limited impact on profitability thus far in the pandemic, but a challenging period ahead. (more on pages 10 and 11)
C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0 C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0
2 3
Source: Knight Frank Source: Knight Frank, Tomorrow's Guides
FIG 2 | Regional share – Knight Frank survey vs Total UK stock
FIG 1 | Regional spread of 2020 survey
Source: Knight Frank
5%
0%
10%
15%
20%
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Knight Frank survey Total UK market
EASTMIDLANDS
EAST OFENGLAND
LONDON
WESTMIDLANDS
NORTH WEST
NORTH EAST
YORKS & THE HUMBER
WALES
SOUTH WEST
SOUTH EAST
NORTHERN IRELAND
SCOTLAND
Nursing care home
Personal care home
ajor operators are equipped to
deal with outbreaks of seasonal
flu and diseases such as dementia and
Alzheimer’s, but Covid-19 has been an
unprecedented challenge.
Fears of substantial occupancy
loss seemed justified in March, when
academic studies were suggesting case
fatality rates of 15-20% for those over
the age of 80, and higher for those with
multiple health conditions. The rapid
discharge of vulnerable elderly people
from NHS hospitals and into care homes
also posed an additional challenge.
Over six months on, we can
retrospectively assess the impact
of the outbreak on the care home
sector. ONS data, compiled from the
General Register Office, shows that
from 1st March to 7th June there were
approximately 29,178 excess deaths
(over and above 2019 levels) across care
homes in England and Wales (Figure 5).
Close to 2,000 Covid-19 deaths were also
All other deaths in 2020 Covid-19 deaths All deaths 2019
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
07Jun
31May
24May
17May
10May
03May
26Apr
19Apr
12Apr
05Apr
29Mar
22Mar
15Mar
08Mar
01Mar
23Feb
16Feb
09Feb
02Feb
26Jan
19Jan
12Jan
05Jan
recorded in Scottish care homes in this
period ¹, suggesting that Covid-19 has
directly and indirectly resulted in over
30,000 excess deaths across the UK care
home sector.
What has this meant for occupancy rates?
As shown in Figure 4, the uptick
in mortality produced an 8.5%
decline in occupancy across the
UK. Encouragingly, mortality rates
normalised by early June and we
have since seen a steady rise in new
admissions, helping to stabilise
occupancy levels. Pent up demand
is expected to support a recovery
in occupancy, but stringent testing
procedures for new residents and some
hesitancy among enquiring relatives
may soften the pace of recovery.
There are varying stories across
providers and individual homes. As
shown in Figure 6, 28% of homes
surveyed have experienced either no
change in occupancy or even made
gains over the summer. This section
of the survey has excluded homes that
received block bookings from the NHS,
and therefore any gains reflect usual
business. Figure 6 also shows that of the
homes that lost occupancy in Q2 2020,
most lost between 0% and 10%. In many
cases, declines were less than 5%.
Regional comparison
No region of the UK has been sheltered
from the virus, although occupancy
has generally dropped lower in
more densely populated and urban
regions. This has been the case in
London and the East Midlands where
occupancy has slipped to 75-76%.
Densely populated regions have seen
more severe outbreaks, but greater
demand for care beds could facilitate a
swifter recovery in occupancy as new
admissions return.
Despite the challenges, the data shows how resilient major care providers have been over the summer period
O C C U P A N C Y
Source: Knight Frank
60%
70%
80%
90%
100%
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2019/20 FY Q2 2020 UK: Q2 2020UK: 2019/20 FY
So
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We
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0% 5% 10% 15% 20% 25% 30% 35%
GAIN
LOSS30%+
20% to 30%
10% to 20%
0% to 10%
No change
0% to 10%
10% to 20%
20%+
Percentage of surveyed care homes
M
C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0 C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0
4 5
Following the outbreak of Covid-19 in
March there was a clear concern for care
operators regarding the direct threat of
the virus to residents and staff, but also
concern surrounding the tracking and
monitoring of the situation. Since then,
we have been working with many major
operators to provide an objective weekly
measure of occupancy levels. While this
is separate from the annual Care Home
Trading Performance Survey, the data
collected provides a timely indication of
occupancy levels across the market and
will serve to track the pace of recovery in
months to come.
Figure 4 shows how occupancy
fell by 8.5% across our main survey
respondents during the second quarter
of 2020. However, our additional weekly
Tracking the pandemic
tracking shows an estimated recovery of 1.2%
in the third quarter as death rates normalised
and operators have begun to confidently admit
new residents. There remain concerns over a
second wave, but rigid testing procedures are
now in place among large group operators,
who report being in a much stronger
position than in March. As of the end of
October, we had not seen a meaningful
increase in care home fatalities.
FIG 5 | Care home deaths registered in England & Wales
Source: ONS, General Register Office
FIG 7 | Average occupancy by region, 2019/20 financial year vs Q2 2020
FIG 6 | Occupancy changes during Q2 2020
Source: Knight Frank Source: Knight Frank
89.3
%
88.8
%
88.9
%
87.7
%
87.2
%
87.8
%
87.2
%
87.6
%
88.3
%
88.4
%
89.2
%
89.4
%
88.9
%
87.9
%
79.4
%
80.6
%
Q32020
Q22020
2019/20
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
2012/13
2011/12
2010/11
Covid-19OUTBREAK
2009/10
2008/09
2007/08
2006/07
FIG 4 | UK care home occupancy rate
Source: Knight Frank
F E E S A N D F U N D I N G O F C A R E
teeper rises in recent years look
less dramatic in real terms when
adjusted for inflation. As shown in
Figure 8, care home fees have increased
50% in nominal terms since 2008/09,
but inflation-adjusted growth amounts
to only 8% over the same period.
Operators continue to adjust
fees to counterbalance a number
of increasing costs, in particular
staffing costs. Furthermore, with
much of the care home real estate
market older than twenty years, extra
revenue is increasingly needed to fund
refurbishments and upgrades. We expect
this trend to continue going forward as
many existing homes will need to adapt
the design and layout of their facilities
as a legacy of the pandemic.
What determines fee levels?
Care type: The average weekly fee for
a nursing home in the UK in this year's
index was £953, compared to £766 per
week for personal care homes. The
premium is due to the level of care
provided, with nursing homes typically
designed for higher-dependency
residents requiring full-time medical
care delivered by qualified nurses.
Region: As shown in Figure 9, there is
significant variation in fee levels across
regions and more granular localities
within the UK. Fee levels in Southern
England tend to be higher than the
North of England, matching the higher
staff costs seen in the South. In the
2019/20 financial year, fee increases
were seen across all regions of the UK,
except Wales, where average fees for the
personal care segment held flat at £650
per week.
Funding type: The majority of care
homes derive their funding from a
combination of local authorities and
private-paying residents (self-funded).
As you can see from Figure 10, the split
varies significantly across regions. In
the North East and London, a significant
amount of residents qualify for full
local authority support, or at least part-
funding. In contrast, more affluent areas
like the South East and South West of
England derive more of their income
from private-paying residents. Average
weekly fee rates in the UK private-pay
market measured £1,086 in 2019/20,
compared to £746 a week for local
authority funded fees.
Further fee uplifts have occurred in the new
financial year, recorded from April to June 2020
2019/20 saw care home fees increase across our index by a further 6% year-on-year, averaging £889 per week across all care types.
FIG 8 | UK Average weekly fee growth
Source: Knight Frank
£400
£600
£800
£1,000
20
19/2
02
018
/19
20
17/1
82
016
/17
20
15/1
62
014
/15
20
13/1
42
012
/13
20
11/1
22
010
/11
20
09
/10
20
08
/09
NominalReal Terms (less RPI inflation)
Source: Knight Frank
£300
£400
£500
£600
£700
£800
£900
£1,000
£1,100
£1,200
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Nurising UK Avg PersonalUK Avg NursingPersonal
0%
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60%
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100%
Private-pay (self-funded) LA funded
NHS funded Other funding
S
C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0 C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0
6 7
FIG 9 | Average weekly fees, by region and care type 2019/20
FIG 10 | Funding split by region
Source: Knight Frank Source: Knight Frank
This year we are also able to report
preliminary data on changes in fee levels
in the new financial year. As shown in
Figure 11, further fee uplifts have been
unanimous across both care types and
Fee uplifts in the 2020/21 financial year (preliminary)
funding types. Homes in our sample that are
primarily funded by local authorities have seen
a 5.5% rise in fees in Q2 2020, suggesting
that some of the additional £3.2 billion funding
supplied to local authorities by the government
is making its way into the residential care
sector. It is not yet clear if these rises
will be permanent or temporary, with the
government yet to finalise a long-term
solution to the care funding crisis.
ALL CARE NURSING CARE PERSONAL CARE
FUNDING TYPE
PRIVATE-PAY LA
CARE TYPE
4.9%5.5% 5.9% 3.9% 5.5%
ALL CARE PERSONAL CARE NURSING CARE
FUNDING TYPE
PRIVATE-PAY LA
CARE TYPE
4.9%5.6% 5.9% 4.0% 5.5%
FIG 11 | Average weekly fee uplifts for 2020/21 financial year (Q2 2020)
Source: Knight Frank
C O S T S
Staffing
Following the trend in recent years, staff
costs across the index increased 3.7%
to an average of £26,956 per resident
per annum for the 2019/20 financial
year. Further increases to the National
Living Wage (NLW) have contributed to
this, especially for personal care homes.
For those over the age of 25, the NLW
increased by 4.9% in April 2019 followed
by a further increase of 6.2% in April
2020, to reach £8.72 per hour.
As a percentage of income, staff
costs represented 58.0% of income
in the 2019/20 financial year and are
especially high in the nursing care
sector. There are a number of reasons for
this. Pay scales are significantly higher
for skilled nurses, with the hourly rate
almost double that of a carer (Figure 12);
Workforces are larger – our index shows
that for every nursing home resident,
there are approximately 0.85 full-time
nurses or carers employed to ensure
the appropriate level of care (Table 1);
Finally, nursing homes are more heavily
reliant on agency staff, whose use always
costs a premium (Table 1).
Property and food costs
Property costs (which we define
as utilities, council tax, insurance,
repairs and day to day maintenance)
increased by 3.7% across the UK in
2019/20, reaching on average £2,399
As operators look to support their workforces during the pandemic, increasing staff costs remain
a significant challenge
FIG 12 | Average wage rates, per hour
TABLE 1 | Staff costs, agency costs and resident to staff ratios 2019/20
per registered bed per annum. We
suspect certain property costs to jump
in the new financial year as a result of
Covid-19. Soaring indemnity insurance
premiums have been reported since the
outbreak and this could turn a relatively
small outlay into a larger one unless
more support is given to operators. Food
costs also increased by 3.1%, measuring
on average £1,629 per occupied bed
across the UK. Our index shows some
noteworthy variation across countries
in the UK with food costs in Scotland
(£1,489 per bed) close to 10% lower than
food costs in England (£1,646 per bed).
STAFF C OSTS, PER RESIDENT P. A .
YEAR- ON-YEAR CHANGE
STAFF C OSTS, % OF INC OME
AGENCY C OSTS, % OF STAFF C OSTS
RESIDENT: STAFF (RATIO*)
Nursing Care £29,322 4.0% 59.0% 9.9% 0.85
Personal Care £21,351 4.1% 55.1% 6.2% 0.58
All care £26,956 3.9% 58.0% 9.0% 0.76
Source: Knight Frank *Includes all nurses and carers. Part-time staff calculated as half a staff member
C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0 C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0
8 9
The most obvious additional cost
resulting from the pandemic is that of
personal protective equipment (PPE)2.
To gauge the extent of these costs we
asked operators to detail spending on
PPE before and during the pandemic.
While noting significant variation across
operators, our analysis shows that
operators spent an average of £160
per bed per annum on PPE during the
2019/20 financial year, compared to
£260 per bed during the second quarter
of 2020 alone. While these numbers
may seem small, PPE will represent a
significant extra cost to operators
over the course of the pandemic and
even beyond.
As well as PPE, irregular spending
on staffing will have added to existing
high staff costs. Many care homes have
had to remunerate and support existing
staff during periods of isolation, while at
the same time recruiting new staff to fill
gaps in the workforce. Our survey shows
Additional costs prompt Adult Social Care Infection Control Fund
that operators spent as much as 61.3% of
income on staffing in the second quarter
of 2020 (Figure 13). This partly reflects a
reduction in income, but is also down to
increasing staffing costs.
Any further escalation of staff costs
may be contained by the Adult Social Care
Infection Control Fund. Introduced on the 13th
May, the fund will inject a much needed
£1.15 billion to support infection control
and related staffing and recruitment costs.
Local authorities must ensure that 80%
of the grant goes directly towards care
homes within their geography, including
private homes. This will certainly provide a
lifeline for many homes.
53%
54%
55%
56%
57%
58%
59%
60%
61%
62%
2020Q2
2019/20
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
2012/13
2011/12
2010/11
2009/10
2008/09
FIG 13 | Staff costs as % of income, since 2009/09
Source: Knight Frank
Source: Knight Frank
2018/19 2019/20
£16.04
£16.90
£8.33
£8.75
CARER
NURSE
additional funds provided via the Adult
Social Care Infection Control Fund may
only partially show up in our mid-year
numbers, but will be a vital cushion
against the additional cost of the
pandemic for many care homes.
The challenge of Covid-19 is by
no means over, but operators have
demonstrated an ability to limit the
human and financial impact of the
virus so far and are in a strong position
as we approach winter. Going under
the radar are the broader long-term
issues of the funding crisis in care
and Brexit, the latter of which serves
to reduce the pool of migrant carers
and nurses at a time when they are
desperately needed. Hopefully a legacy
of the pandemic will be to raise the
profile of these issues.
Source: Knight Frank
5%
0%
10%
15%
20%
25%
30%
35%
Nursing UK Avg: PersonalUK Avg: NursingPersonal
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York
s &
Th
e H
um
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r
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s
Source: Knight Frank
26.8% 26.3% 28.5% 37.3% 20.6%26.2% 25.9% 27.3% 37.1% 20.4%
ALL CARE NURSING CARE PERSONAL CARE
CARE TYPE FUNDING TYPE
PRIVATE-PAY LA
2019/20 FY Q2 2020
25%
26%
27%
28%
29%
30%
31%
32%
33%
20
19/2
02
018
/19
20
17/1
82
016
/17
20
15/1
62
014
/15
20
13/1
42
012
/13
20
11/1
22
010
/11
20
09
/10
20
08
/09
40% or more 30%-40%
20%-30% 10%-20% 0%-10% Loss making
11%
21%
30%
22%
11%5%
FIG 16 | EBITDARM as % of income, by region and care type 2019/20
FIG 17 | EBITDARM margins, 2019/20 financial year vs Q2 2020
FIG 14 | EBITDARM as % of income, since 2008/09
FIG 15 | Distribution of EBITDARM margins, 2019/20
P R O F I T A B I L I T Y
s shown in Figure 14, profitability
has been on a downward trajectory
over the last decade. The 2019/20
financial year was no different with
average EBITDARM margins declining
to 26.8%. Despite the broad story, there
is a huge amount of variation within the
market. As illustrated by Figure 15, a
third of group-owned care homes traded
at EBITDARM margins in excess of 30%
in 2019/20, while only 5% made a loss.
In most regions, profit margins are
higher across the personal care sector,
as shown in Figure 16. High staff costs
are weighing on margins in the nursing
care segment of the market, which is
challenged to deliver 24/7 nursing care
to residents. The South East, London,
Wales and Scotland are the only
exceptions to this trend. A larger
private-pay market, supported by
higher fees, has helped to raise
profitability in the South East, while
occupancy rates well in excess of 90%
are supporting earnings in the Scottish
and Welsh nursing segments.
Summarising the financial impact of Covid-19
As shown in Figure 17, EBITDARM
margins have seen little decline so
far, falling by only 0.6% in the second
quarter of 2020. Limited declines are
also consistent across care types and
funding models. A lot of this must
be credited to care operators and the
social care workforce who have rallied
to protect residents, support the
wider healthcare system, and made
significant personal sacrifices in
the process.
Fee uplifts in the new financial year
and additional government support
have also helped to support trading
performance across the sector. The
Care operators have demonstrated an ability to limit the human and financial impact of the virus so far
Source: Knight Frank Source: Knight Frank
A
C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0 C A R E H O M E S T R A D I N G P E R F O R M A N C E 2 0 2 0
1 0 1 1
Source: Knight Frank
Source: Knight Frank
Knight Frank Research provides strategic advice, consultancy services and forecasting to a wide range of clients worldwide including developers, investors, funding organisations, corporate institutions and the public sector. All our clients recognise the need for expert independent advice customised to their specific needs. Important Notice: © Knight Frank LLP 2020 This report is published for general information only and not to be relied upon in any way. Although high standards have been used in the preparation of the information, analysis, views and projections presented in this report, no responsibility or liability whatsoever can be accepted by Knight Frank LLP for any loss or damage resultant from any use of, reliance on or reference to the contents of this document. As a general report, this material does not necessarily represent the view of Knight Frank LLP in relation to particular properties or projects. Reproduction of this report in whole or in part is not allowed without prior written approval of Knight Frank LLP to the form and content within which it appears. Knight Frank LLP is a limited liability partnership registered in England with registered number OC305934. Our registered office is 55 Baker Street, London, W1U 8AN, where you may look at a list of members’ names.
Knight Frank Research Reports are available atknightfrank.com/research
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Healthcare
Julian Evans FRICS
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Patrick Evans MRICS
Head of Corporate Valuations
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Head of Commercial Valuations
+44 20 7861 1563
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Front Cover: Graysford Hall, Leicester, Sanders Senior Living
Footnotes:(1) 1,973 Covid-19 deaths were registered with the National Records of Scotland (NRC) between 22nd March and 27th September 2020.
(2) Our survey is based on PHE definition of PPE, including disposable gloves, fluid-repellent masks, and eye protection. Please note additional costs may have been incurred through the purchase of cleaning products, hand sanitiser and tempera-ture checking instruments.
F O R W A R D V I E W
This year’s trading performance
survey has made two things even
clearer to me. Firstly, this crisis has
demonstrated the resilience and
capability of our residential care
sector. Undoubtedly, the pandemic
has tested and will continue to
test operators financially well into
next year, but it’s critical that we
continue to champion the incredible
performance of care home operators
and their workforces during the
pandemic. While the British media
has at times conveyed a hysterical
image of care homes, an occupancy
loss of only 8.5% across a sector that
deals in caring for the most vulnerable
demographic in society is an incredible
feat, and testament to operators.
Looking forward, group operators are
now in a much stronger position, and
for a whole host of reasons.
Secondly, the crisis has demonstrated
the huge importance of reliable, real-
time data across the broader healthcare
sector and within residential care. This
is something we certainly recognise
as advisors, but the willingness of
many providers to contribute in our
surveys confirms that you do too. I’d
like to thank all the operators that
have once again submitted their
data for the purposes of our annual
Trading Performance Review. In
particular, I would like to thank those
operators that have participated in
our weekly occupancy and mortality
tracking since March 2020. Thanks
to you, our datasets have provided
valuable intelligence to the market
in 2020 and creating better and more
usable healthcare data will form a key
part of our strategy for 2021.
Julian Evans FRICS
Head of Healthcare