Resident funding and care home quality: a retrospective observational analysis of the impact of the two-tier care system in England.

BACKGROUND Adult social care in England operates in a two-tier system of self-funded and state-funded residents. It is unclear, however, whether resident funding source impacts care home quality. METHODS We conducted a nationwide retrospective observational analysis of care homes in England (n = 28 239 Provider Information Return entries for 14 444 care homes, representing ~367 653 residents), 2021-23, to examine the relationship between resident funding (self- or state-funded) and care home quality (inspection ratings by the industry regulator). We linked data from the Care Quality Commission's Provider Information Return to inspection ratings, area deprivation, and care home and resident characteristics. We modelled a series of logistic regressions, incorporating interaction terms to investigate the interrelationships between ownership (for-profit, third sector, public) and area deprivation. FINDINGS Care homes with more self-funded residents were more likely to have better inspection ratings [odds ratio for each percentage of self-funded residents: 1.01, 95% confidence interval (CI) 1.008-1.012, P < .001]. The effect of self-funded residents on care quality was largest amongst for-profit homes and not statistically significant for third sector and public homes. For homes without self-funders, third sector and public providers were 14.0 (95% CI: 10.1-17.8, P < .001) and 6.9 (95% CI: 4.1-9.7, P < .001) percentage points more likely to be rated higher than for-profit homes. CONCLUSIONS The quality of for-profit care homes is strongly influenced by the proportion of self-funded residents, whilst third and public sector homes provide consistent care regardless of resident funding source. This strongly impacts care equity for residents nationwide, as the concentration of self-funders is largely determined by area wealth.