Analysis of CQC Ratings of Care Home Business Performance in England: Implications for Quality Improvement

Analysis of CQC Ratings of Care Home Business Performance in England: Implications for Quality Improvement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of CQC Ratings of Care Home Business Performance in England: Implications for Quality Improvement Faith Aminaho, Chioma Onoshakpor This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6185408/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract According to the most recent data provided by the Office for National Statistics (ONS) in 2023, there are 372,035 residents in care homes in England. Many of these residents experience a low quality of life due to poor service delivered in those facilities. The Care Quality Commission (CQC) strives to regulate the health and social business in the country to promote the health and well-being of these residents in care homes. CQC measures the quality of care services delivered in different care homes in England ranging from inadequate to outstanding, depending on the performance of the care homes in the different CQC domains (safety, caring, effective, responsive, and well-led). However, care homes in England are in different regions, and care home ownership types vary from for-profit, third-sector, or public ownership types. It is therefore paramount to investigate the relationships between the quality of care and location regions, ownership types, and care home closures. This study investigatesthe relationship between location regions of care homes and the quality of care services provided and evaluates the quality of care services delivered by different care homes in various local authorities in England. This study also further investigates the relationship between care home ownership type in England and the performance of care homes. It evaluates the relationship between ownership type on the closure of care homes in England, and the relationship between quality of care services and care home closures. A descriptive design was adopted for the study, using data from the CQC database on the active care homes in England and their ratings up to August 2024. The study's findings revealed a significant relationship between the care home location region and the quality of care service in England. Notably, the exceptionally high-quality performance of the care homes in the Northeast reflects an outstanding positive impact (compared to other regions in England) in the health and social care sector. Also, there is a significant relationship between care home ownership type and quality of care service. Most care homes in England are very caring, responsive, and effective; but many do not perform very well in terms of safety and leadership. Also, the proportion of highly rated care homes within each ownership type is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type. Furthermore, there is a significant relationship between care home ownership type and care home closure. The findings of this study reveal that within each ownership type, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types. Finally, there is a significant relationship between quality of care services and care home closure. The significant number of involuntary closures due to low overall quality ratings suggest that most care homes closed involuntarily due to low performance in the CQC domains; while, the high proportion of voluntary closure of care homes with high-quality ratings, suggests that those care homes did not close due to low performance in the CQC domains. Instead, the reasons for such closures might be attributed to other factors. Recommendations for future studies were made in this study. Quality Performance Care Homes Ownership Domains Closures England Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 HIGHLIGHTS There is a significant relationship between care home location region and the quality of care services in England. There is a significant relationship between care home ownership type and the quality of care service. There is a significant relationship between care home ownership type and closures. There is a significant relationship between quality of care services and care home closure. 1. Introduction Many residents of care homes in England experience a low quality of life due to poor service delivered in those facilities (Baguma and Obeta, 2020 ; Grote et al., 2021 ; Bach-Mortensen et al., 2024 ). The quality of service is based on the perception of service users (Pérotin et al., 2013 ; Aggarwal et al., 2019 ). How a service user perceives the quality of care they receive may be influenced by the service user’s characteristics. Therefore, to evaluate the quality of service delivered by care homes, standard attributes or domains of measurement have to be established (Barron and West, 2017 ; Towers et al., 2019 ). The English health and social care regulator, the Care Quality Commission (CQC) was established in 2009, as an independent body in England to regulate health and social business in the country (Datta and Mahmood, 2012 ; Grote et al., 2021 ). The CQC measures the quality of service delivered in care homes across five domains (Barron and West, 2017 ; Allen et al., 2019 ; Allen et al., 2020 ), including safety (residents are protected from abuse and avoidable harm), effectiveness (residents receive care that achieves good outcomes and maintains the quality of life), caring (residents are treated with compassion, kindness, dignity, and respect), responsiveness (services are timely and organized to meet the needs of residents), and well-led team (leadership, management, or governance of the organization ensures it is providing high quality of care that is person-centered, encourages learning and innovation, and promotes open and fair culture). Each care home's domains are rated as outstanding, good, requires improvement, or inadequate (Barron and West, 2017 ). Although the CQC rating may be useful in ascertaining the performance of some care homes, some studies have found that the rating by the CQC may not be a good indicator of service performance (Jonker and Fisher, 2015; Allen et al., 2019 ). Moreover, some studies on the performance of care homes rated by the CQC at different inspection times show no statistically significant difference in their performance following an inspection (Allen et al., 2019 , Allen et al., 2020 ). This can be attributed to some complex factors affecting the performance of care homes which might be difficult to control. Studies have revealed the complexity of controlling price and quality of service in care homes (Forder and Allan, 2014 ; Lewis, 2022 ). The limited barrier to entry and exit of a care home business makes them compete on price, which is detrimental to the quality of service (Lewis, 2022 ). Not-for-profit care homes take in more residents at lower prices; thereby making it difficult for for-profit care homes to compete favourably without lowering their prices (Forder and Allan, 2014 ; Lewis, 2022 ). As for-profit care homes lower their prices, the quality of service is lowered to sustain the business. This leads to more involuntary closures of for-profit care homes compared to public and third-sector-funded care homes (Bach-Mortensen et al., 2024 ). Furthermore, the quality of service delivered in care homes might be impacted by the location or region of operation. Care homes located at far distances or requiring a significant amount of time for staff to get to work or potential residents find difficult to access might impact the quality of service (Mseke et al., 2024 ). Some residents may require care home to be closer to their relatives (Lewis, 2022 ). Jordan et al. ( 2004 ) conducted a study to explore the geographical accessibility of health services in urban and rural areas of the Southwest of England. Deprivation and rates of premature limiting long-term illness were raised in areas most distant from health services. They found that almost a quarter of households in the wards furthest from hospitals had no car, and the proportion of households with access to two or more cars fell in the most remote areas. Care homes where staff find it hard to commute to work might result in more staff turnover, thereby requiring the use of agency staff which costs more to maintain (Lewis, 2022 ; Wang et al., 2023 ). Moreover, using more agency staff may make care service delivery more functional instead of person-centred (Lewis, 2022 ). Orth and Cagle ( 2022 ) conducted a study to examine the locations of nursing homes with Alzheimer's special care units (ASCUs) and assess whether region and levels of rurality were associated with nursing home ASCUs. They found the odds of nursing home ASCUs were 58–69% lower in the Pacific, Middle Atlantic, and Southern regions compared to the East and North Central regions. The odds of nursing home ASCUs increased (25–47%) as rurality increased relative to nursing homes in most metropolitan areas. However, the odds of nursing home ASCUs decreased (63%) in the most rural areas. Orth and Cagle ( 2022 ) did not assess the quality of care provided in nursing homes, but the odds of nursing home ASCUs in different regions in the United States. The odds of nursing home ASCUs in any region do not reflect the quality of care service users receive in those facilities. Therefore, it is important to investigate the impact of the location of care homes on the quality of care service users receive in England. Care home ownership type might impact the quality of care service users receive. Pérotin et al. ( 2013 ) investigated how hospital ownership affects the level of quality reported by patients whose care is funded by the National Health Service (NHS) in areas other than clinical quality. They used patient experience survey data. They found that hospital ownership in and of itself does not affect the level of quality of the average patient’s reported experience. Instead, quality levels reported were completely attributable to patient characteristics, rather than to hospital ownership. The perception of the quality of care received by service users in different health and social care settings depends on their characteristics. Therefore, it is important to develop standard domains to measure the quality of care. The CQC provides quality ratings of care services based on safety, effectiveness, caring, responsiveness, and leadership. Bach-Mortensen and Montgomery ( 2019 ) conducted a study to assess care quality-related outcomes across for-profit, public, and sector organisations delivering social care services. A secondary analysis was conducted on publicly available data collected by the Care Inspectorate in Scotland. The study population are 13310 social care organisations (including nursing homes and daycare organisations). They found that public and third-sector care providers performed consistently and statistically significantly better than for-profit organisations on most outcomes. For-profit services were the most likely to be rated as high and medium risk, and the least likely to be classified as low risk. Public providers had the highest probability of being classified as low risk, and the lowest probability of having their services classified as medium and high risk, followed by third-sector providers. Public providers performed better than third-sector providers in some outcomes, but the differences were relatively low and inconsistent. Comondore et al. ( 2009 ) conducted a study to compare the quality of care in for-profit and not-for-profit nursing homes. They found that not-for-profit nursing homes delivered higher quality care than for-profit nursing homes. Similarly, Barron and West ( 2017 ) investigated if for-profit, not-for-profit, or public sector residential care and nursing homes provide better quality care. They found that for-profit facilities have lower CQC ratings than public and non-profit providers over a range of measures, including safety, effectiveness, respect, meeting needs, and leadership. The lower quality of care and the corresponding CQC ratings may be attributed to the competition on price, which is traded for quality. Therefore, in an attempt to lower the price of taking in a resident in the care or nursing homes, their revenue is reduced, leading to the delivery of a lower quality of care. Stolt et al. ( 2011 ) conducted a study on the impact of the privatisation of social services on the differences in the quality of elderly care in Sweden. They adopted a cross-sectional study to compare the quality of services in private and public elderly care. The study revealed that privatisation is significantly associated with quality differences. Private care providers emphasize service aspects rather than structural prerequisites (such as the number of employees per resident) for good care. The number of employees per resident was significantly smaller (-9%) in private elderly care; while the proportion of elderly residents taking part in the formulation of their care plan, elderly residents with a reasonable duration between the evening meal and breakfast, the elderly residents offered different food alternatives were significantly in favour of the private care providers. Therefore, considering other yardsticks for the assessment of the quality of care, private or for-profit care providers might outperform not-for-profit and third-sector providers. However, such for-profit care providers might have certain characteristics needed to gain a competitive advantage in the market. More recently, Bach-Mortensen et al., ( 2024 ) conducted a study to investigate the involuntary closures of for-profit care homes in England by the Care Quality Commission. Using data from the CQC, they found that since 2011, 816 care homes have been involuntarily closed by the CQC, out of which, 804 occurred in for-profit care homes. In other words, a few not-for-profit care homes were also involuntarily closed by the CQC, which suggests that some not-for-profit care homes are not delivering quality care to residents. Therefore, some for-profit care homes can compete favorably with not-for-profit homes. So far, no study has been conducted to investigate the impact of the location or region of care homes on their quality of service. Also, no recent study has been conducted to statistically test the association between care home ownership type (private, public, or third-sector ownership) on their performance and their likelihood for involuntary closure. Hence, the present study will investigate the impact of the location of care homes on the quality of care services provided, evaluating the performance or quality of care homes based on the different CQC set domains. This study will further investigate the impact of care home ownership type in England on the performance of care homes, using current CQC data. Finally, this study will evaluate the impact of ownership type on the closure of care homes in England by the CQC. Specifically, the objectives of this study are to determine the relationship between the location or region of care homes and their quality of care; identify local authorities that deliver high- or low-quality of care in England; compare the performance of for-profit-owned and public-/third-sector-owned care homes in England; determine the relationship between care home closures in England and their ownership types; and determine the relationship between care home closures and quality of care. 2. Theoretical Framework The theoretical framework upon which the quality of care in care homes is evaluated is based on Signalling theory. Signalling theory has been applied in health and social care research, for example in breast cancer awareness (Fletcher-Brown et al., 2018 ), and assessment of the effectiveness of regulator quality ratings for care homes (Shahzad, 2019 ). Signalling theory (ST) can be applied to describe behaviour when two parties have access to different types of information (Connelly et al., 2011 ). It comprises three key elements – the signaller, the signal, and the receiver. The signaller is an individual or organisation sending the signal; the signal is the information sent by the signaller; and the receiver refers to the intended recipient of the signal (Shahzad, 2019 ). The signalling theory was developed in Spence’s ( 1973 ) seminar paper to illustrate a situation where one firm (the signaller) conveys some important information about itself (its product or services) to another party (the receiver). Signallers are insiders who obtain information about a person, product, or firm which are normally not available to outsiders (Spence, 1973 , Shahzad, 2019 ). The information gathered by the insiders can be positive and negative, and include details specific to a product, individual or organisation, and useful for outsiders (Connelly et al., 2011 ). Once signallers or insiders have gathered the private information, the next step is to decide if the information should be conveyed to outsiders (Connelly et al., 2011 ). Hence, signals are actions that the signaller can take to convey information credibly about unobservable product quality or organisational characteristics to outsiders (receivers) with the intention of influencing some desired outcome (Rao et al., 1999 ; Taj, 2016 ). For example, warranties can be used by sellers to signal the quality of a product to potential buyers (Katz, 2007 ). The signalling theory can be applied in the care home environment. The signaller is the care home (mainly represented by the managers). Signallers can also be whistleblowers including, individual members of staff in the care home, service users, relatives of residents in the care home, agency staff, and any individual who witnesses the care home activities. The receiver of the signal sent by the signaller, in this case, is the Care Quality Commission. Care homes in England are expected to comply with regulatory requirements stipulated by the CQC and undergo unannounced site inspections by the CQC. Care homes normally do not choose what information they can pass on to or withhold from the CQC. So, both positive and negative information are disclosed to and by the CQC. The unannounced nature of inspections by the CQC makes it impossible for care home managers to sustain misleading information targeted at showing their homes in the best possible light to achieve the best possible rating. The CQC can effectively interpret and manage the signal (quality of care) it receives, and subsequently provide quality signals (quality ratings) in such a way that the initial signaller (the care home) and the general public benefit from the signalling process. In other words, the quality ratings by the CQC are made publicly available for users to understand the quality of care provided in the care home in terms of safety, effectiveness, caring, responsiveness, and leadership. 3. Methodology 3.1 Study Area This study focuses on care homes in England. England is one of the countries that make up the United Kingdom. It is the most populous country in the United Kingdom, with about 56,489,800 residents of diverse cultures and socio-economic status as of 2021 (Office for National Statistics [ONS], 2021 ). As of 2023, there are 372,035 persons living in 14,707 active care homes in England (ONS, 2023). England has nine (9) regions, London, East of England, East Midlands, West Midlands, North East, North West, South East, South West, and Yorkshire and The Humber. Based on the 2021 UK Census, East of England had a population of 6.3 million, 5.7 million in South West, 8.8 million in London, 4.9 million in the East Midlands, 9.3 million in South East, 6.0 million in the West Midlands, 7.4 million in North West, 2.6 million in North East, and 5.5 million in Yorkshire and The Humber (ONS, 2021 ). The CQC regulates the health and social care sector in each region. 3.2 Study Design This study adopted a descriptive and inferential design to ascertain the impact of care home locations and ownership types on the quality of care provided by care homes in England. This design generally interprets and describes developing trends, and draws inferences about the larger population based on sample data (Nwankwo, 2006 ). This descriptive design was successfully used in a similar study conducted by Bach-Mortensen et al. ( 2024 ) and was deemed fit to combine with inferential statistics for the present study. 3.3 Study Population The study population comprises all the active care homes in England, totalling 14,707, based on current CQC data obtained from their website on the 1st of August 2024. The care homes assist or support residents with different health and well-being conditions. 3.4 Sample Size Determination The minimum acceptable sample size was calculated using Yamane’s ( 1967 ) formula given as $$\:n=\:\frac{N}{\left[1+N{\left(P\right)}^{2}\right]}$$ where N represents the total number of active care homes in England, P is 0.05 (for a 95% confidence level), and n is the expected (or minimum) sample size. $$\:n=\:\frac{14707}{\left[1+14707{\left(0.05\right)}^{2}\right]}=390$$ The minimum acceptable sample size in this study is 390. The total number of care homes considered is 14069, 14070, 14058, 14065, 14058, and 14070 in the overall, safety, caring, effective, responsive, and well-led domains, respectively. The number of care homes is based on the overall service/population group of each care home, to avoid duplication of each care home domain. Table 1 Sample size for each domain. Domain Sample Size Overall 14069 Safety 14070 Caring 14058 Effective 14065 Responsive 14058 Well-led 14070 3.5 Data Source Three datasets were obtained for this study. Two datasets were obtained from the CQC website (CQC, 2024), while the third dataset was obtained from a study conducted by Bach-Mortensen et al. ( 2024 ). One of the datasets from the CQC website (database) contains data on active care homes in England, while the second dataset contains data on the latest ratings of care homes in England as of 1st of August 2024. The dataset from the work of Bach-Mortensen et al. ( 2024 ) includes data on care homes in England closed (voluntary and involuntary) in England between 2011 and 2023 that were not due to a provider takeover, and the active care homes in England as of 2023. Care home ownership types were categorized as third-sector, public, and for-profit. All registered charities and charitable companies were categorized as third sector; all council and NHS trust care homes were categorized as public; and all private companies, partnerships, and individual care providers without a charity number were categorized as for-profit (Bach-Mortensen et al., 2024 ). 3.6 Data Preprocessing Datasets from the CQC website were pre-processed using Python programming language. The datasets of active care homes and the latest ratings of care homes in England were merged based on the ‘Location ID’ of the care homes. Rows with unspecified location regions in the merged dataset were filled with the appropriate regions, using information from their local authorities (for example, Kingston upon Thames, Derby, Surrey, and East Riding of Yorkshire local authorities were assigned location regions respectively as London, East Midlands, Southeast, and Yorkshire and The Humber). The dataset from Bach-Mortensen et al. ( 2024 ) was already pre-processed in their work, no further preprocessing was done on the dataset. 3.7 Data Entry and Presentation The pre-processed datasets were loaded into Jupyter Notebook version 6.3.0. The data were analysed using Python programming language. The results of the analyses are presented in tables and charts. 3.8 Study Limitations This study investigated the impact of care home locations (regions) and care home ownership types on the quality of care provided by care homes in England. However, the study was faced with certain limitations. The CQC data did not consider the socio-economic status of residents in each of the care homes. Also, the data did not specify the proportion of residents in each of the care homes that were self- or state-funded. Therefore, it is difficult to determine whether the closures of the care homes were associated with care prices or funding. Furthermore, the CQC data on involuntary closure of care homes did not include ratings in the different CQC domains, only the overall ratings were considered. Therefore, it is difficult to point out the main domain that resulted in the involuntary closure of the care homes. Also, the available data may not have taken into account the overall ratings at the time of involuntary closure. Finally, time-series data analysis was not considered in the present study. Therefore, it is difficult to tell whether the quality of care in care homes improved after each CQC inspection, and what factors resulted in their improvements. 4. Results 4.1 Impact of Care Home Location Region on Quality of Care The first objective of this study is to determine the relationship between the location or region of care homes and their quality of care. Figures 2 and 3 show the number of care homes in each region in England and their quality rating in each domain (overall, safety, caring, effective, responsive, and well-led). The quality rating represents the quality of care delivered by care homes. The original quality ratings of the care homes by the CQC are categorized into high (outstanding or good) and low (requires improvement or inadequate), for better comparative analysis. The top three regions in terms of the number of care homes with high-quality ratings are South East, followed by South West and North West; while the least region in terms of the number of care homes with high-quality ratings is North East. The distribution of the number of care homes by region in overall and safety domains is similar in terms of their high-quality rating, except in the East of England and West Midlands where they swap positions (Figure 2). For the overall domain, more care homes in the Southeast region (2206 care homes) are rated ‘high’, followed by South West (1553), North West (1407), West Midlands (1187), East of England (1177), London (1080), Yorkshire and the Humber (1071), East Midlands (1059), and North East (613). For the safety domain, more care homes in the South East region (2183 care homes) are rated ‘high’, followed by South West (1533), North West (1360), West Midlands (1163), East of England (1147), London (1043), Yorkshire and the Humber (1033), East Midlands (1030), and North East (601). The distribution of the number of care homes by region in caring, effective, and responsive domains is similar in terms of their high-quality rating; while the distribution is different in the well-led domain (Figure 3). More care homes in the South East region (2576 in the caring domain, 2393 in the effective domain, and 2497 in the responsive domain) are rated ‘high’, followed by South West (1798 in the caring domain, 1656 in the effective domain, and 1739 in the responsive domain), North West (1697 in the caring domain, 1579 in the effective domain, and 1627 in the responsive domain), West Midlands (1471 in the caring domain, 1379 in the effective domain, and 1434 in the responsive domain), East of England (1440 in the caring domain, 1320 in the effective domain, and 1361 in the responsive domain), Yorkshire and the Humber (1325 in the caring domain, 1210 in the effective domain, and 1248 in the responsive domain), East Midlands (1291 in the caring domain, 1169 in the effective domain, and 1246 in the responsive domain), London (1221 in the caring domain, 1149 in the effective domain, and 1170 in the responsive domain), and North East (685 in the caring domain, 647 in the effective domain, and 665 in the responsive domain). For the well-led domain, more care homes in the South East region (2033 care homes) are rated ‘high’, followed by South West (1489), North West (1334), East of England (1083), London (1028), West Midlands (1028), Yorkshire and the Humber (1002), East Midlands (989), and North East (586). To effectively ascertain the quality of care, it is important to evaluate the proportion of care homes within each region with high-quality rating. This is based on the proportion of care homes in a particular region rated ‘high’ for each of the domains, as shown in Figure 4. The distribution of the proportion of high-quality rating of care homes within each region is different for each of the domains. For most of the domains, the Northeast has the highest proportion of high-quality ratings of care homes within the region, while the Midlands (East or West Midlands) has the lowest proportion of high-quality ratings of care homes within the region. For the overall domain, the proportion of care homes rated ‘high’ is highest within the North East (613 out of 700 care homes in the North East – 613/700), followed by London (1080/1261), South West (1553/1819), South East (2206/2683), North West (1407/1774), Yorkshire and the Humber (1071/1378), East of England (1177/1520), East Midlands (1059/1377), and West Midlands (1187/1557). For the safety domain, the proportion of care homes rated ‘high’ is highest within the North East (601/700), followed by the South West (1533/1819), London (1043/1261), South East (2183/2683), North West (1360/1774), East of England (1147/1520), Yorkshire and the Humber (1033/1379), East Midlands (1030/1377), and West Midlands (1163/1557). For the caring domain, the proportion of care homes rated ‘high’ is highest within the South West (1798/1819), followed by the North East (685/699), London (1221/1258), Yorkshire and the Humber (1325/1377), South East (2576/2678), North West (1697/1774), East of England (1440/1520), West Midlands (1471/1556), and East Midlands (1291/1377). For the effective domain, the proportion of care homes rated ‘high’ is highest within the North East (647/700), followed by the London (1149/1259), South West (1656/1819), South East (2393/2683), North West (1579/1774), West Midlands (1379/1556), Yorkshire and the Humber (1210/1377), East of England (1320/1520), and East Midlands (1169/1377). For the responsive domain, the proportion of care homes rated ‘high’ is highest within the South West (1739/1819), followed by the North East (665/700), South East (2497/2678), London (1170/1257), West Midlands (1434/1556), North West (1627/1774), Yorkshire and the Humber (1248/1377), East Midlands (1246/1377), and East of England (1361/1520). For the well-led domain, the proportion of care homes rated ‘high’ is highest within the North East (586/700), followed by the South West (1489/1819), London (1028/1261), South East (2033/2683), North West (1334/1774), Yorkshire and the Humber (1002/1379), East Midlands (989/1377), East of England (1083/1520), and West Midlands (1028/1557). 4.2 Identification of Local Authorities with High and Low Care Home Rating The second objective of this study is to identify local authorities that deliver high or low quality of care in England. It has been established that more care homes in the South East region are rated ‘high’ for the overall domain. The top 40 local authorities in England with care homes rated ‘high’ in the overall domain are shown in Figure 5. All the regions in England are represented in the list. Most care homes rated ‘high’ are in Kent (391 care homes) and Hampshire (383 care homes), both in the South East. Surprisingly, the 23rd and 40th most highly-rated local authorities (in terms of the number of care homes with a high-quality rating) are in the North East (County Durham and Sunderland). County Durham has 129 (out of 144 care homes in the local authority) care homes rated ‘high’ overall, while Sunderland has 82 (out of 83 care homes in the local authority) care homes rated ‘high’ overall. The least 40 local authorities in England with care homes rated ‘high’ in the overall domain are shown in Figure 6. All the regions in England are represented in the list. The least-rated local authority in England is the Isles of Scilly in the South West region, where the only care home in the local authority is rated ‘low’ overall. The next least-rated local authority in England is Camden in the London region, with 6 (out of 10 care homes) rated ‘high’ overall. Although the South East region has more highly-rated care homes in England, some local authorities in the region are among the least highly-rated care homes in England. They include Slough, Bracknell Forest, Reading, Portsmouth, and Windsor and Maidenhead. To effectively ascertain the quality of care in each local authority, the proportion of care homes within each local authority with a ‘high’ rating overall was evaluated. Figure 7 shows England's top 40 local authorities, based on the proportion of care homes within each local authority rated ‘high’ overall. The majority of the top local authorities are in London and North East regions. The most highly-rated local authority is Kensington and Chelsea in London (all the 11 care homes in the local authority are rated ‘high’ overall), followed by Sunderland in the North East (82 out of 83 care homes rated ‘high’ overall), South Tyneside (31/32) in the North East, Harrow (50/52) in London, and Waltham Forest (43/45) in London. Figure 8 shows the least 40 local authorities in England, based on the proportion of care homes within each local authority rated ‘high’ overall. The least-rated local authority in England is the Isles of Scilly (with no care home in the local authority rated ‘high’ overall; the only care home is rated ‘low’) in the South West, followed by Liverpool (45 out of 81 care homes rated ‘high’ overall) in the North West, Camden (6/10) in London, Halton (14/23) in the North West, and Nottingham (45/72) in the East Midlands. 4.3 Impact of Care Home Ownership Type on Quality of Care The third objective of this study is to compare the performance of for-profit-owned and public-/third-sector-owned care homes in England. Care home ownership types include for-profit, third-sector, and public. Figure 9 shows quality ratings in different domains for each of the care home ownership types. The order of the ratings is similar for each ownership type. Most care homes are rated high in the caring domain, followed by responsive, effective, overall, safe, and well-led. In other words, most care homes are very caring, responsive, and effective; while they do not perform very well in terms of safety and leadership. Figures 9 and 10 reveal that the ownership type of most of the care homes in England is for-profit, while the ownership types of the remaining care homes are third-sector and public. For the for-profit ownership type, 11544 (out of 12051) care homes are rated ‘high’ in the caring domain, 11081 (out of 12051) in the responsive domain, 10642 (out of 12058) in the effective domain, 9608 (out of 12062) in the overall domain, 9389 (out of 12063) in the safety domain, and 8934 (out of 12063) care homes are rated ‘high’ in the well-led domain. For the third-sector ownership type, 1609 (out of 1648) care homes are rated ‘high’ in the caring domain, 1572 (out of 1648) in the responsive domain, 1528 (out of 1648) in the effective domain, 1429 (out of 1648) in the overall domain, 1400 (out of 1648) in the safety domain, and 1345 (out of 1648) care homes are rated ‘high’ in the well-led domain. For the public ownership type, 351 (out of 359) care homes are rated ‘high’ in the caring domain, 334 (out of 359) in the responsive domain, 332 (out of 359) in the effective domain, 316 (out of 359) in the overall domain, 304 (out of 359) in the safety domain, and 293 (out of 359) care homes are rated ‘high’ in the well-led domain. Hence, in the overall domain, 9608 (out of 12062) care homes are rated ‘high’ for the for-profit ownership type; 1429 (out of 1648) for the third-sector ownership type; and 316 (out of 359) for the public ownership type. Therefore, within each ownership type in the overall domain, the proportion of highly-rated care homes is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type (Figure 11). 4.4 Impact of Ownership Type on Care Home Closure The fourth objective of this study is to determine the relationship between care home closures in England and their ownership types. The impact of care home ownership type on care home closure was evaluated using data from the study conducted by Bach-Mortensen et al. (2024). The data covers care home closure (involuntary and voluntary closures) in England from 2011 to 2023. Figure 12 shows the involuntary and voluntary closures of care homes for each ownership type. Most of the care homes closed are for-profit ownership type (804 involuntary closures and 6086 voluntary closures), followed by third-sector (10 involuntary closures and 1543 voluntary closures), and least for the public ownership type (2 involuntary closures and 670 voluntary closures). So, 816 care homes were closed involuntarily by the CQC, while 8299 care homes were closed voluntarily between 2011 and 2023 Table 2 shows the statistics of care homes in England closed from 2011 to 2023, and the active care homes in 2023. In 2023, there were 12581 for-profit care homes, 1746 third-sector care homes, and 402 public care homes active in England. Within each ownership type, the proportion of involuntarily closed care homes is 11.67%, while the proportion of voluntarily closed care homes is 88.33% for the for-profit ownership type; the proportion of involuntarily closed care homes is 0.64%, while the proportion of voluntarily closed care homes is 99.36% for the third-sector ownership type; and the proportion of involuntarily closed care homes is 0.30%, while the proportion of voluntarily closed care homes is 99.70% for the public ownership type. Hence, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types. However, a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types. Comparing the care home closures and the active care homes within each ownership type, the proportion of involuntarily closed care homes is 4.13%, while the proportion of voluntarily closed care homes is 31.26% for the for-profit ownership type; the proportion of involuntarily closed care homes is 0.30%, while the proportion of voluntarily closed care homes is 46.77% for the third-sector ownership type; and the proportion of involuntarily closed care homes is 0.19%, while the proportion of voluntarily closed care homes is 62.38% for the public ownership type. This result also shows that a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types. Table 2: Care homes closed from 2011 to 2023 and active care homes in 2023. Ownership Type Involuntary Closure Voluntary Closure Active Care Homes Proportion of Involuntary Closure (%) Proportion of Voluntary Closure (%) Overall Involuntary Closure (%) Overall Voluntary Closure (%) For-profit 804 6086 12581 11.67 88.33 4.13 31.26 Third-sector 10 1543 1746 0.64 99.36 0.30 46.77 Public 2 670 402 0.30 99.70 0.19 62.38 Total 816 8299 14729 100 4.5 Impact of Quality of Care on Care Home Closure The final objective of this study is to determine the relationship between care home closures and quality of care. The ratings of the care homes closed in England (based on data from the study conducted by Bach-Mortensen et al., 2024) between 2011 and 2023 are inadequate (442 involuntary closures and 814 voluntary closures), require improvement (88 involuntary closures and 992 voluntary closures), good (52 involuntary closures and 2144 voluntary closures), and outstanding (no involuntary closure and 13 voluntary closures) as shown in Figure 12. Care homes that were not rated at the time of closure were removed from the dataset. The overall quality ratings are categorised into high (outstanding or good) and low (requires improvement or inadequate), as shown in Figure 14. Figure 14 reveals that most care homes closed involuntarily (530 care homes) by the CQC had a low overall quality rating, while only a few care homes closed involuntarily (52 care homes) had a high overall quality rating. In contrast, most care homes closed voluntarily (2157 care homes) had a high overall quality rating, while fewer care homes closed voluntarily (1806 care homes) had a low overall quality rating. 4.6 Hypothesis Testing The Hypotheses in this study are tested using the Chi-Square (X 2 ) test of independence, to determine whether two categorical variables are related to each other. The tests are conducted at a significance level (a) of 0.05. In this study, the hypotheses tested include the relationship between care home location region and quality of care, the relationship between care home ownership type and quality of care, the relationship between ownership type and care home closure, and the relationship between quality of care and care home closure. 4.6.1 Relationship Between Care Home Location Region and Quality of Care Null Hypothesis (H 0 ): There is no significant relationship between care home location region and quality of care. Table 3 and Table 4 show that there is a significant relationship between care home location region and quality of care in each domain (degrees of freedom = 8, p-values < 0.05). Therefore, the null hypothesis is rejected. Table 3: Hypothesis test result of the relationship between care home location region and overall quality of care. Location Region Overall Rating Total Significance Level ( a ) Degrees of Freedom P-value Decision High Low South East 2206 477 2683 0.05 8 5.90x10 -23 Reject South West 1553 266 1819 North West 1407 367 1774 West Midlands 1187 370 1557 East of England 1177 343 1520 London 1080 181 1261 Yorkshire and The Humber 1071 307 1378 East Midlands 1059 318 1377 North East 613 87 700 Total 11353 2716 14069 Table 4: Hypothesis test results of the relationship between care home location region and quality of care in each domain. Domain Sample Size Significance Level ( a ) Degrees of Freedom X 2 P-values Decision Overall 14069 0.05 8 123.63 5.90x10 -23 Reject Safety 14070 0.05 8 132.20 9.88x10 -25 Reject Caring 14058 0.05 8 84.39 6.35x10 -15 Reject Effective 14065 0.05 8 55.09 4.25x10 -9 Reject Responsive 14058 0.05 8 69.00 7.78x10 -12 Reject Well-led 14070 0.05 8 193.79 1.30x10 -37 Reject 4.6.2 Relationship Between Care Home Ownership Type and Quality of Care H 0 : There is no significant relationship between care home ownership type and quality of care. Tables 5 and 6 show that there is a significant relationship between care home ownership type and quality of care in each domain (degrees of freedom = 2, p-value < 0.05). Therefore, the null hypothesis is rejected. Table 5: Hypothesis test result of the relationship between care home ownership type and quality of care. Ownership Type Overall Rating Total Significance Level ( a ) Degrees of Freedom P-value Decision High Low For-profit 9608 2454 12062 0.05 2 1.52x10 -13 Reject Third sector 1429 219 1648 Public 316 43 359 Total 11353 2716 14069 Table 6: Hypothesis test results of the relationship between care home ownership and quality of care in each domain. Domain Sample Size Significance Level ( a ) Degrees of Freedom X 2 P-values Decision Overall 14069 0.05 2 59.04 1.52x10 -13 Reject Safety 14070 0.05 2 51.57 6.34x10 -12 Reject Caring 14058 0.05 2 15.83 3.66x10 -4 Reject Effective 14065 0.05 2 34.03 4.08x10 -8 Reject Responsive 14058 0.05 2 24.56 4.63x10 -6 Reject Well-led 14070 0.05 2 52.55 3.88x10 -12 Reject 4.6.3 Relationship Between Ownership Type and Care Home Closure H 0 : There is no significant relationship between ownership type and care home closure. Table 7 shows that there is a significant relationship between care home ownership type and care home closure (degrees of freedom = 2, p-value < 0.05). Therefore, the null hypothesis is rejected. Table 7: Hypothesis test result of the relationship between care home ownership type and care home closure. Ownership Type Closure Total Significance Level ( a ) Degrees of Freedom P-value Decision Involuntary Voluntary For-profit 804 6086 6890 0.05 2 3.03x10 -56 Reject Third sector 10 1543 1553 Public 2 670 672 Total 816 8229 9115 4.6.4 Relationship Between Quality of Care and Care Home Closure H 0 : There is no significant relationship between quality of care and care home closure. Table 8 shows that there is a significant relationship between quality of care and care home closure (degree of freedom = 1, p-value < 0.05). Therefore, the null hypothesis is rejected. Table 8: Hypothesis test result of the relationship between quality of care and care home closure. Quality Rating Closure Total Significance Level ( a ) Degree of Freedom P-value Decision Involuntary Voluntary High 52 2157 2209 0.05 1 4.84x10 -93 Reject Low 530 1806 2336 Total 582 3963 4545 5. Discussions 5.1 Relationship Between Care Home Location Region and Quality of Care The results of this study show that there is a significant relationship between care home location region and the quality of care service in England. The top three regions in England, in terms of the number of care homes with high-quality ratings, are the South East, followed by South West and North West; while the region with the least number of care homes with high-quality ratings is the North East. However, in most of the domains, the North East has the highest proportion of high-quality ratings of care homes within the region, while the Midlands (East or West Midlands) has the lowest proportion of high-quality ratings of care homes within the region. The result suggests that even though there are fewer care homes in the North East, majority of them are rated ‘high’ in most of the domains. Furthermore, based on the proportion of care homes within each local authority rated ‘high’ overall, the majority of the top local authorities are in London and North East regions. The most highly-rated local authorities are Kensington and Chelsea in London, Sunderland in the North East, South Tyneside in the North East, Harrow in London, and Waltham Forest in London. The least-rated local authority in England is the Isles of Scilly (with no care home in the local authority rated ‘high’ overall) in the South West, followed by Liverpool in the North West, Camden in London, Halton in the North West, and Nottingham in the East Midlands. This result can be related to the study conducted by Cartagena-Farias et al. ( 2024 ) to explore the benefit of the Winter Fuel Payment scheme among eligible populations in the North/South of England. The Winter Fuel Payment enhanced the quality of life for those living in the Northern regions (compared to the Southern regions) of England. Therefore, the impact of resources and support received to promote the health and well-being of a population depends on the location region. The impact might be influenced by the characteristics of the population and the quality control measures adopted to monitor the management of resources. Although the characteristics of residents of care homes in the North East and the internal quality control measures adopted to maintain a high-quality standard of care were not considered in this study, their performance in all the CQC domains of quality care service tends to reflect an outstanding positive impact (compared to other regions in England) in the health and social care sector. 5.2 Relationship Between Care Home Ownership Type and Quality of Care There is a significant relationship between care home ownership type and quality of care service. Most care homes in England are very caring, responsive, and effective; while they do not perform very well in terms of safety and leadership. Also, the proportion of highly-rated care homes within each ownership type is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type. The findings of this study align with the results of the study conducted by Barron and West ( 2017 ). Barron and West found that for-profit facilities have lower CQC quality ratings than public and non-profit providers over a range of measures including safety, effectiveness, respect (caring), meeting needs (responsiveness), and leadership. However, for-profit care homes considered in the study (and the present study) did not separate small care home businesses from corporate for-profit care homes (unlike the study conducted by Gage et al., 2009 ). Certain classes of for-profit care homes might significantly outperform the public and third-sector care homes. Gage et al. ( 2009 ) found that quality of care was statistically associated with features of care homes and their residents. A higher probability of failing a standard was significantly associated with being a home that was a for-profit small business, was registered before 2000, accommodated publicly funded residents, and was registered to provide nursing care; while fewer failures of care standards were associated with homes that were corporate for-profit, held a specialist registration, and charged higher maximum fees. Therefore, it is important to categorise for-profit care homes into more classes, before comparing their performances with the public and third-sector care homes. 5.3 Relationship Between Care Home Ownership Type and Care Home Closure There is a significant relationship between care home ownership type and care home closure. Most care homes closed (voluntarily or involuntarily) are for-profit ownership type, followed by third-sector, and least for the public ownership type. The findings of this study reveal that within each ownership type, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types. Care homes are involuntarily closed when they consistently do not meet the CQC standards in terms of safety, caring, responsiveness, effectiveness, or leadership. The CQC can also close (involuntary closure) care homes if their activities pose an imminent risk to the health and well-being of service users. In other words, a care home rated ‘good’ overall or in a particular domain, might be closed immediately after the CQC representatives discover the care home is underperforming in the domain or other domains, and their performance poses a high risk to the health and well-being of residents (Barron and West, 2017 ; Shahzad, 2019 ; Allen et al., 2019 ; Allen et al., 2020 ; Bach-Mortensen et al., 2024 ). The decision to close care homes voluntarily is mainly internal. For instance, a care home management team can review its operations and performance internally and decide not to continue the care business. Areas the management team can review include their recruitment process and staffing level, staff training and development, access to funding, the business cash flow, access to the facility, characteristics of service users supported in the facility, management capability, or court cases due to their operations (Aggarwal et al., 2019 ; Baguma and Obeta, 2020 ; Towers et al., 2021 ; Lewis, 2022 ; Santamato et al., 2024 ). Therefore, the relatively higher proportion of voluntary closures of public and third-sector care homes, compared to for-profit care homes, might be attributed to inadequate resources or capacity to continue supporting service users in those facilities. For the for-profit care homes, the relatively higher proportion of involuntary closures, compared to the public and third-sector care homes, might be attributed to their inability to keep up with the CQC standards in any or most of the domains of performance assessment. Therefore, for-profit care homes need to adopt proper internal measures of quality control to monitor and measure their performance frequently to improve their performance and minimise involuntary closures by the CQC. 5.4 Relationship Between Quality of Care and Care Home Closure There is a significant relationship between quality of care services and care home closure. Most care homes closed involuntarily by the CQC between 2011 and 2023 had a low overall quality rating, while only a few care homes closed involuntarily had a high overall quality rating. In contrast, most care homes that closed voluntarily had a high overall quality rating, while fewer care homes that closed voluntarily had a low overall quality rating. The findings support the fact that the CQC can involuntarily close care homes if their activities pose a high risk to the health and well-being of residents (Barron and West, 2017 ; Shahzad, 2019 ; Allen et al., 2019 ; Allen et al., 2020 ; Bach-Mortensen et al., 2024 ). So, even though a care home was rated high (outstanding or good) in previous inspections, it might be abruptly closed when activities in the care home pose severe risks to the health and well-being of service users. However, the significant number of involuntary closures due to low overall quality rating suggests that most care homes closed involuntarily due to low performance in the CQC domains. Furthermore, the high proportion of voluntary closure of care homes with high-quality ratings, suggests that those care homes did not close due to low performance in the CQC domains. Instead, the reasons for such closures might be attributed to the care homes’ recruitment process and staffing level, staff training and development, access to funding, the business cash flow, access to the facility, characteristics of service users supported in the facility, management capability, or court cases due to their operations (Aggarwal et al., 2019 ; Baguma and Obeta, 2020 ; Towers et al., 2021 ; Lewis, 2022 ; Santamato et al., 2024 ). 6. Conclusions This study investigates the relationship between the location region of care homes and the quality of care services provided and evaluates the quality of care services delivered by different care homes in various local authorities in England. This study further investigates the relationship between care home ownership type in England and the performance of care homes, evaluates the relationship between ownership type on the closure of care homes in England, and the relationship between quality of care services and care home closures. A descriptive and inferential research design was adopted for the study. Chi-Square test of independence was applied to test the relationship between variables to make inferences. The conclusions of the study and recommendations are summarised as follows: The findings of the study revealed that there is a significant relationship between the care home location region and the quality of care service in England. Notably, the exceptionally high-quality performance of the care homes in the North East reflects an outstanding positive impact (compared to other regions in England) in the health and social care sector. Therefore, care homes in other regions in England should find out the strategies of the top-rated care homes in the North East that enable them to maintain high-quality care service delivery, to improve the quality of care service in their regions. There is a significant relationship between care home ownership type and quality of care service. Most care homes in England are very caring, responsive, and effective; while they do not perform very well in terms of safety and leadership. Also, the proportion of highly-rated care homes within each ownership type is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type. Therefore, the care homes should support staff by providing affordable or free training on safety, leadership, and inclusive organisational culture. The UK government should provide adequate financial support to care homes in England, to enable them to provide adequate staff training and achieve adequate staffing levels to meet the needs of service users and maintain the CQC standards. There is a significant relationship between care home ownership type and care home closure. The findings of this study reveal that within each ownership type, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types. Therefore, the relatively higher proportion of voluntary closures of public and third-sector care homes, compared to for-profit care homes, might be attributed to inadequate resources or capacity to continue supporting service users in those facilities. For the for-profit care homes, the relatively higher proportion of involuntary closures, compared to the public and third-sector care homes, might be attributed to their inability to keep up with the CQC standards in any or most of the domains of performance assessment. Therefore, for-profit care homes need to adopt proper internal measures of quality control to monitor and measure their performance frequently to improve their performance and minimise involuntary closures by the CQC. There is a significant relationship between quality of care services and care home closure. The significant number of involuntary closures due to low overall quality rating suggests that most care homes closed involuntarily due to low performance in the CQC domains. Furthermore, the high proportion of voluntary closure of care homes with high-quality ratings, suggests that those care homes did not close due to low performance in the CQC domains. Instead, the reasons for such closures might be attributed to the care homes’ recruitment process and staffing level, staff training and development, access to funding, the business cash flow, access to the facility, characteristics of service users supported in the facility, management capability, or court cases due to their operations. Therefore, care homes should continue to review their resources, capacity, and application of CQC standards to improve their quality of care services. 7. Recommendations for Future Studies Future studies should investigate the relationship between the socio-economic status of residents in care homes on the quality of care they receive. They should also consider the proportion of residents in each care home that are self- or state-funded, to determine whether closures of care homes are associated with care prices or funding. Future studies should consider using CQC data on involuntary closure of care homes that include ratings in the different CQC domains and ratings at the time of closure, instead of making recommendations only on the overall ratings and in some cases non-updated ratings. The CQC data including all domains and timely ratings will make it easier to identify the main domain that resulted in the involuntary closure of the care homes. Future studies should consider time-series data analysis to determine whether the quality of care in care homes improved after each CQC inspection, and what factors resulted in their improvements. Declarations Author credit statement Faith Aminaho: Conceptualisation, Investigation, Methodology, Data Curation, Analyses, Visualisation, and Writing. Chioma Onoshakpor: Supervision and Writing Review. Funding Declaration The authors want to acknowledge the funding A-Class Academic Consults Limited provided for this project. 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Journal of the American Medical Directors Association , 23(1), pp.150–155. https://doi.org/10.1016/j.jamda.2021.07.020 Pérotin, V., Zamora, B., Reeves, R., Bartlett, W. and Allen, P. (2013). Does hospital ownership affect patient experience? An investigation into public–private sector differences in England. Journal of Health Economics , 32(3), pp. 633–646. https://doi.org/10.1016/j.jhealeco.2013.03.003 Rao, A.R., Qu, L. and Ruekert, R.W. (1999) ‘Signaling unobservable product quality through a brand ally’, Journal of Marketing Research , 36(2), pp. 258-268. Santamato, V., Tricase, C., Faccilongo, N., Marengo, A. and Pange, J. (2024). Healthcare performance analytics based on the novel PDA methodology for assessment of efficiency and perceived quality outcomes: A machine learning approach. Expert systems with applications , 252, 124020. https://doi.org/10.1016/j.eswa.2024.124020 Shahzad, M.W. (2019). Signalling Quality: an Assessment of the Effectiveness of Regulator Quality Ratings for Care Homes . PhD Thesis, University of Leicester. pp. 1–193. Spence, M. (1973). Job Market Signaling. The Quarterly Journal of Economics , 87(3), pp. 355–374. https://doi.org/10.2307/1882010 Stolt, R., Blomqvist, P. and Winblad, U. (2011). Privatization of social services: Quality differences in Swedish elderly care. Social Science & Medicine , 72(4), pp. 560–567. https://doi.org/10.1016/j.socscimed.2010.11.012 Taj, S.A. (2016) ‘Application of signaling theory in management research: Addressing major gaps in theory’, European Management Journal, 34(4), pp. 338-348 Tingle, J. (2011). The Care Quality Commission’s end-of-year report. British Journal of Nursing , 20(16), pp. 1004–1005. https://doi.org/10.12968/bjon.2011.20.16.1004 Towers, A.-M., Smith, N., Allan, S., Vadean, F., Collins, G., Rand, S., Bostock, J., Ramsbottom, H., Forder, J., Lanza, S. and Cassell, J. (2021). Care Home Residents’ Quality of Life and Its Association with CQC Ratings and Workforce issues: the MiCareHQ mixed-methods Study. NIHR , 9(19). https://doi 10.3310/hsdr09190 Towers, A.-M., Palmer, S., Smith, N., Collins, G. and Allan, S. (2019). A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health and Quality of Life Outcomes , 17(1). https://doi.org/10.1186/s12955-019-1093-1 Wang, N., Cui, D. and Dong, Y. (2023). Study on the impact of business environment on private enterprises’ technological innovation from the perspective of transaction cost. Innovation and Green Development , 2(1), 100034. https://doi.org/10.1016/j.igd.2023.100034 Yamane, T. (1967). Statistics: An introductory analysis. 2nd edn. New York: Harper and Row. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6185408","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":427687268,"identity":"c97532d6-6311-48e3-8ad8-0ec45713b38f","order_by":0,"name":"Faith Aminaho","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBAC9gYgkQBCYBYYsOHXwnMApgXMIloLWJdEArFaGJifbni4wy6PX/Lt49c8DHbyDBJpCQS0sJndSDyTXCw5O93Mmoch2bBBIu0AXi32DAxALW3MiRtup7EZA+0EujC9gYAt7N+AWuoTN9w8BtJST4wWHpAthxM33GBjfszDcBiohYDDeJh5yoBajifO7EljY5xjcNywjedZAn4t7O3bbv5sq07sZz/G/OFNRbU8P3uaAV4tDMwIJpsEgwHBWEHT/YEU1aNgFIyCUTByAACjWz7GBvtvSwAAAABJRU5ErkJggg==","orcid":"","institution":"Robert Gordon University","correspondingAuthor":true,"prefix":"","firstName":"Faith","middleName":"","lastName":"Aminaho","suffix":""},{"id":427687269,"identity":"81d94c5e-7208-4bf6-91df-c310b3e3dbd0","order_by":1,"name":"Chioma Onoshakpor","email":"","orcid":"","institution":"Robert Gordon University","correspondingAuthor":false,"prefix":"","firstName":"Chioma","middleName":"","lastName":"Onoshakpor","suffix":""}],"badges":[],"createdAt":"2025-03-08 17:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6185408/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6185408/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78438273,"identity":"0ed072b9-9d74-4d48-800b-62323750c7fc","added_by":"auto","created_at":"2025-03-13 08:24:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35196,"visible":true,"origin":"","legend":"\u003cp\u003ePopulation of England by region based on data from the UK Census 2021 (ONS, 2021).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/21e0278da86e09acdabeed16.png"},{"id":78438739,"identity":"b1ddbc82-5d79-4814-92d8-46020122d58b","added_by":"auto","created_at":"2025-03-13 08:32:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52284,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of care homes in each region in England and their quality rating for the overall and safety domains.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/b14cf328465f9ef809971756.png"},{"id":78438271,"identity":"429d160d-ad33-4c9c-8fa4-e1edef47b6cc","added_by":"auto","created_at":"2025-03-13 08:24:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":81150,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of care homes in each region in England and their quality rating for the caring, responsive, effective, and well-led domains.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/ab4e6f1183cd4e8f6cee1518.png"},{"id":78440013,"identity":"a8368c17-47a7-4cb6-b3e5-1a96e836d545","added_by":"auto","created_at":"2025-03-13 08:40:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":128637,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of care homes within each region in England and their quality rating.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/266618a62ef96cbe50afa23d.png"},{"id":78438741,"identity":"78afdc38-a5d8-4043-bb40-dea3879fd131","added_by":"auto","created_at":"2025-03-13 08:32:08","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":106386,"visible":true,"origin":"","legend":"\u003cp\u003eForty local authorities in England with more care homes rated ‘high’ overall.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/ec547e4d85ade8ceb89e01bf.png"},{"id":78438275,"identity":"277e855c-b737-4606-aa78-09d8fd28dfb5","added_by":"auto","created_at":"2025-03-13 08:24:08","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":87612,"visible":true,"origin":"","legend":"\u003cp\u003eForty local authorities in England with fewer care homes rated ‘high’ overall.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/764766d422e4de91ce8dd9e4.png"},{"id":78438279,"identity":"f44f69c6-4f20-4d95-867d-544cb23ac1d7","added_by":"auto","created_at":"2025-03-13 08:24:08","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":92541,"visible":true,"origin":"","legend":"\u003cp\u003eTop 40 local authorities based on the proportion of care homes within each local authority rated ‘high’ overall.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/cb1b5c5aa1d01b873bcb0aaf.png"},{"id":78438742,"identity":"e1f5db70-8ecb-47aa-8097-e2882d6b8808","added_by":"auto","created_at":"2025-03-13 08:32:08","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":108428,"visible":true,"origin":"","legend":"\u003cp\u003eLeast 40 local authorities based on the proportion of care homes within each local authority rated ‘high’ overall.\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/63756c969c5328f0b0d5ad6f.png"},{"id":78438745,"identity":"67305d69-9e86-4155-bc62-fbaace53b096","added_by":"auto","created_at":"2025-03-13 08:32:08","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":53627,"visible":true,"origin":"","legend":"\u003cp\u003eEach ownership type and care home quality ratings in different domains.\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/748996197a2ab862e7c0de92.png"},{"id":78438748,"identity":"0135d76c-e860-41c0-a0dd-eb00ea8865e2","added_by":"auto","created_at":"2025-03-13 08:32:08","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":91437,"visible":true,"origin":"","legend":"\u003cp\u003eOwnership types and care home quality ratings in different domains.\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/188c3081b9b57e7129743f21.png"},{"id":78440014,"identity":"82f47e24-abc1-43f5-946a-4c1e3a04078b","added_by":"auto","created_at":"2025-03-13 08:40:08","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":29726,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of care homes with high-quality ratings within each ownership type in the overall domain.\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/67d0295c5ace15ca3648cd27.png"},{"id":78440343,"identity":"8b4326c3-00f2-49b1-8806-f60655eb5f46","added_by":"auto","created_at":"2025-03-13 08:48:08","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":31799,"visible":true,"origin":"","legend":"\u003cp\u003eInvoluntary and voluntary closures of care homes for each ownership type.\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/cf7bb51133b402a1e5f2e9b9.png"},{"id":78440018,"identity":"4a4603d7-cae3-4e59-a68b-12dee1da26aa","added_by":"auto","created_at":"2025-03-13 08:40:08","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":38413,"visible":true,"origin":"","legend":"\u003cp\u003eRatings of care homes closed in England between 2011 and 2023.\u003c/p\u003e","description":"","filename":"13.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/7891f0bac3e06bba15371641.png"},{"id":78438289,"identity":"f241ab3c-3800-4a0d-be01-7912fc59bd57","added_by":"auto","created_at":"2025-03-13 08:24:09","extension":"png","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":28666,"visible":true,"origin":"","legend":"\u003cp\u003eHigh and low ratings of care homes closed in England between 2011 and 2023.\u003c/p\u003e","description":"","filename":"14.png","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/0d832e1d36514f43ea1214c8.png"},{"id":80809880,"identity":"a4354944-8547-4e20-9eb4-9985671de197","added_by":"auto","created_at":"2025-04-17 10:08:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2511718,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6185408/v1/02ed58fe-9ee3-4bcf-909a-1ec94e542837.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAnalysis of CQC Ratings of Care Home Business Performance in England: Implications for Quality Improvement\u003c/p\u003e","fulltext":[{"header":"HIGHLIGHTS","content":"\u003cul\u003e\n \u003cli\u003eThere is a significant relationship between care home location region and the quality of care services in England.\u003c/li\u003e\n \u003cli\u003eThere is a significant relationship between care home ownership type and the quality of care service.\u003c/li\u003e\n \u003cli\u003eThere is a significant relationship between care home ownership type and closures.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThere is a significant relationship between quality of care services and care home closure.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eMany residents of care homes in England experience a low quality of life due to poor service delivered in those facilities (Baguma and Obeta, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Grote et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Bach-Mortensen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The quality of service is based on the perception of service users (P\u0026eacute;rotin et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Aggarwal et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). How a service user perceives the quality of care they receive may be influenced by the service user\u0026rsquo;s characteristics. Therefore, to evaluate the quality of service delivered by care homes, standard attributes or domains of measurement have to be established (Barron and West, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Towers et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The English health and social care regulator, the Care Quality Commission (CQC) was established in 2009, as an independent body in England to regulate health and social business in the country (Datta and Mahmood, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Grote et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe CQC measures the quality of service delivered in care homes across five domains (Barron and West, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Allen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Allen et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), including safety (residents are protected from abuse and avoidable harm), effectiveness (residents receive care that achieves good outcomes and maintains the quality of life), caring (residents are treated with compassion, kindness, dignity, and respect), responsiveness (services are timely and organized to meet the needs of residents), and well-led team (leadership, management, or governance of the organization ensures it is providing high quality of care that is person-centered, encourages learning and innovation, and promotes open and fair culture). Each care home's domains are rated as outstanding, good, requires improvement, or inadequate (Barron and West, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the CQC rating may be useful in ascertaining the performance of some care homes, some studies have found that the rating by the CQC may not be a good indicator of service performance (Jonker and Fisher, 2015; Allen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Moreover, some studies on the performance of care homes rated by the CQC at different inspection times show no statistically significant difference in their performance following an inspection (Allen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Allen et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This can be attributed to some complex factors affecting the performance of care homes which might be difficult to control.\u003c/p\u003e \u003cp\u003eStudies have revealed the complexity of controlling price and quality of service in care homes (Forder and Allan, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The limited barrier to entry and exit of a care home business makes them compete on price, which is detrimental to the quality of service (Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Not-for-profit care homes take in more residents at lower prices; thereby making it difficult for for-profit care homes to compete favourably without lowering their prices (Forder and Allan, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As for-profit care homes lower their prices, the quality of service is lowered to sustain the business. This leads to more involuntary closures of for-profit care homes compared to public and third-sector-funded care homes (Bach-Mortensen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, the quality of service delivered in care homes might be impacted by the location or region of operation. Care homes located at far distances or requiring a significant amount of time for staff to get to work or potential residents find difficult to access might impact the quality of service (Mseke et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Some residents may require care home to be closer to their relatives (Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eJordan et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) conducted a study to explore the geographical accessibility of health services in urban and rural areas of the Southwest of England. Deprivation and rates of premature limiting long-term illness were raised in areas most distant from health services. They found that almost a quarter of households in the wards furthest from hospitals had no car, and the proportion of households with access to two or more cars fell in the most remote areas. Care homes where staff find it hard to commute to work might result in more staff turnover, thereby requiring the use of agency staff which costs more to maintain (Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Moreover, using more agency staff may make care service delivery more functional instead of person-centred (Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOrth and Cagle (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) conducted a study to examine the locations of nursing homes with Alzheimer's special care units (ASCUs) and assess whether region and levels of rurality were associated with nursing home ASCUs. They found the odds of nursing home ASCUs were 58\u0026ndash;69% lower in the Pacific, Middle Atlantic, and Southern regions compared to the East and North Central regions. The odds of nursing home ASCUs increased (25\u0026ndash;47%) as rurality increased relative to nursing homes in most metropolitan areas. However, the odds of nursing home ASCUs decreased (63%) in the most rural areas. Orth and Cagle (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) did not assess the quality of care provided in nursing homes, but the odds of nursing home ASCUs in different regions in the United States. The odds of nursing home ASCUs in any region do not reflect the quality of care service users receive in those facilities. Therefore, it is important to investigate the impact of the location of care homes on the quality of care service users receive in England.\u003c/p\u003e \u003cp\u003eCare home ownership type might impact the quality of care service users receive. P\u0026eacute;rotin et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) investigated how hospital ownership affects the level of quality reported by patients whose care is funded by the National Health Service (NHS) in areas other than clinical quality. They used patient experience survey data. They found that hospital ownership in and of itself does not affect the level of quality of the average patient\u0026rsquo;s reported experience. Instead, quality levels reported were completely attributable to patient characteristics, rather than to hospital ownership. The perception of the quality of care received by service users in different health and social care settings depends on their characteristics. Therefore, it is important to develop standard domains to measure the quality of care. The CQC provides quality ratings of care services based on safety, effectiveness, caring, responsiveness, and leadership.\u003c/p\u003e \u003cp\u003eBach-Mortensen and Montgomery (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) conducted a study to assess care quality-related outcomes across for-profit, public, and sector organisations delivering social care services. A secondary analysis was conducted on publicly available data collected by the Care Inspectorate in Scotland. The study population are 13310 social care organisations (including nursing homes and daycare organisations). They found that public and third-sector care providers performed consistently and statistically significantly better than for-profit organisations on most outcomes. For-profit services were the most likely to be rated as high and medium risk, and the least likely to be classified as low risk. Public providers had the highest probability of being classified as low risk, and the lowest probability of having their services classified as medium and high risk, followed by third-sector providers. Public providers performed better than third-sector providers in some outcomes, but the differences were relatively low and inconsistent.\u003c/p\u003e \u003cp\u003eComondore et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) conducted a study to compare the quality of care in for-profit and not-for-profit nursing homes. They found that not-for-profit nursing homes delivered higher quality care than for-profit nursing homes. Similarly, Barron and West (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) investigated if for-profit, not-for-profit, or public sector residential care and nursing homes provide better quality care. They found that for-profit facilities have lower CQC ratings than public and non-profit providers over a range of measures, including safety, effectiveness, respect, meeting needs, and leadership. The lower quality of care and the corresponding CQC ratings may be attributed to the competition on price, which is traded for quality. Therefore, in an attempt to lower the price of taking in a resident in the care or nursing homes, their revenue is reduced, leading to the delivery of a lower quality of care.\u003c/p\u003e \u003cp\u003eStolt et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) conducted a study on the impact of the privatisation of social services on the differences in the quality of elderly care in Sweden. They adopted a cross-sectional study to compare the quality of services in private and public elderly care. The study revealed that privatisation is significantly associated with quality differences. Private care providers emphasize service aspects rather than structural prerequisites (such as the number of employees per resident) for good care. The number of employees per resident was significantly smaller (-9%) in private elderly care; while the proportion of elderly residents taking part in the formulation of their care plan, elderly residents with a reasonable duration between the evening meal and breakfast, the elderly residents offered different food alternatives were significantly in favour of the private care providers. Therefore, considering other yardsticks for the assessment of the quality of care, private or for-profit care providers might outperform not-for-profit and third-sector providers. However, such for-profit care providers might have certain characteristics needed to gain a competitive advantage in the market.\u003c/p\u003e \u003cp\u003eMore recently, Bach-Mortensen et al., (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) conducted a study to investigate the involuntary closures of for-profit care homes in England by the Care Quality Commission. Using data from the CQC, they found that since 2011, 816 care homes have been involuntarily closed by the CQC, out of which, 804 occurred in for-profit care homes. In other words, a few not-for-profit care homes were also involuntarily closed by the CQC, which suggests that some not-for-profit care homes are not delivering quality care to residents. Therefore, some for-profit care homes can compete favorably with not-for-profit homes.\u003c/p\u003e \u003cp\u003eSo far, no study has been conducted to investigate the impact of the location or region of care homes on their quality of service. Also, no recent study has been conducted to statistically test the association between care home ownership type (private, public, or third-sector ownership) on their performance and their likelihood for involuntary closure. Hence, the present study will investigate the impact of the location of care homes on the quality of care services provided, evaluating the performance or quality of care homes based on the different CQC set domains. This study will further investigate the impact of care home ownership type in England on the performance of care homes, using current CQC data. Finally, this study will evaluate the impact of ownership type on the closure of care homes in England by the CQC.\u003c/p\u003e \u003cp\u003eSpecifically, the objectives of this study are to determine the relationship between the location or region of care homes and their quality of care; identify local authorities that deliver high- or low-quality of care in England; compare the performance of for-profit-owned and public-/third-sector-owned care homes in England; determine the relationship between care home closures in England and their ownership types; and determine the relationship between care home closures and quality of care.\u003c/p\u003e"},{"header":"2. Theoretical Framework","content":"\u003cp\u003eThe theoretical framework upon which the quality of care in care homes is evaluated is based on Signalling theory. Signalling theory has been applied in health and social care research, for example in breast cancer awareness (Fletcher-Brown et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), and assessment of the effectiveness of regulator quality ratings for care homes (Shahzad, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Signalling theory (ST) can be applied to describe behaviour when two parties have access to different types of information (Connelly et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). It comprises three key elements \u0026ndash; the signaller, the signal, and the receiver. The signaller is an individual or organisation sending the signal; the signal is the information sent by the signaller; and the receiver refers to the intended recipient of the signal (Shahzad, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe signalling theory was developed in Spence\u0026rsquo;s (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1973\u003c/span\u003e) seminar paper to illustrate a situation where one firm (the signaller) conveys some important information about itself (its product or services) to another party (the receiver). Signallers are insiders who obtain information about a person, product, or firm which are normally not available to outsiders (Spence, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1973\u003c/span\u003e, Shahzad, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The information gathered by the insiders can be positive and negative, and include details specific to a product, individual or organisation, and useful for outsiders (Connelly et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnce signallers or insiders have gathered the private information, the next step is to decide if the information should be conveyed to outsiders (Connelly et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Hence, signals are actions that the signaller can take to convey information credibly about unobservable product quality or organisational characteristics to outsiders (receivers) with the intention of influencing some desired outcome (Rao et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Taj, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). For example, warranties can be used by sellers to signal the quality of a product to potential buyers (Katz, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe signalling theory can be applied in the care home environment. The signaller is the care home (mainly represented by the managers). Signallers can also be whistleblowers including, individual members of staff in the care home, service users, relatives of residents in the care home, agency staff, and any individual who witnesses the care home activities. The receiver of the signal sent by the signaller, in this case, is the Care Quality Commission. Care homes in England are expected to comply with regulatory requirements stipulated by the CQC and undergo unannounced site inspections by the CQC.\u003c/p\u003e \u003cp\u003eCare homes normally do not choose what information they can pass on to or withhold from the CQC. So, both positive and negative information are disclosed to and by the CQC. The unannounced nature of inspections by the CQC makes it impossible for care home managers to sustain misleading information targeted at showing their homes in the best possible light to achieve the best possible rating. The CQC can effectively interpret and manage the signal (quality of care) it receives, and subsequently provide quality signals (quality ratings) in such a way that the initial signaller (the care home) and the general public benefit from the signalling process. In other words, the quality ratings by the CQC are made publicly available for users to understand the quality of care provided in the care home in terms of safety, effectiveness, caring, responsiveness, and leadership.\u003c/p\u003e"},{"header":"3. Methodology","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study Area\u003c/h2\u003e \u003cp\u003eThis study focuses on care homes in England. England is one of the countries that make up the United Kingdom. It is the most populous country in the United Kingdom, with about 56,489,800 residents of diverse cultures and socio-economic status as of 2021 (Office for National Statistics [ONS], \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As of 2023, there are 372,035 persons living in 14,707 active care homes in England (ONS, 2023). England has nine (9) regions, London, East of England, East Midlands, West Midlands, North East, North West, South East, South West, and Yorkshire and The Humber.\u003c/p\u003e \u003cp\u003eBased on the 2021 UK Census, East of England had a population of 6.3\u0026nbsp;million, 5.7\u0026nbsp;million in South West, 8.8\u0026nbsp;million in London, 4.9\u0026nbsp;million in the East Midlands, 9.3\u0026nbsp;million in South East, 6.0\u0026nbsp;million in the West Midlands, 7.4\u0026nbsp;million in North West, 2.6\u0026nbsp;million in North East, and 5.5\u0026nbsp;million in Yorkshire and The Humber (ONS, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The CQC regulates the health and social care sector in each region.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Study Design\u003c/h2\u003e \u003cp\u003eThis study adopted a descriptive and inferential design to ascertain the impact of care home locations and ownership types on the quality of care provided by care homes in England. This design generally interprets and describes developing trends, and draws inferences about the larger population based on sample data (Nwankwo, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). This descriptive design was successfully used in a similar study conducted by Bach-Mortensen et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and was deemed fit to combine with inferential statistics for the present study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Study Population\u003c/h2\u003e \u003cp\u003eThe study population comprises all the active care homes in England, totalling 14,707, based on current CQC data obtained from their website on the 1st of August 2024. The care homes assist or support residents with different health and well-being conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Sample Size Determination\u003c/h2\u003e \u003cp\u003eThe minimum acceptable sample size was calculated using Yamane\u0026rsquo;s (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e1967\u003c/span\u003e) formula given as\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:n=\\:\\frac{N}{\\left[1+N{\\left(P\\right)}^{2}\\right]}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ewhere N represents the total number of active care homes in England, P is 0.05 (for a 95% confidence level), and n is the expected (or minimum) sample size.\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:n=\\:\\frac{14707}{\\left[1+14707{\\left(0.05\\right)}^{2}\\right]}=390$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe minimum acceptable sample size in this study is 390. The total number of care homes considered is 14069, 14070, 14058, 14065, 14058, and 14070 in the overall, safety, caring, effective, responsive, and well-led domains, respectively. The number of care homes is based on the overall service/population group of each care home, to avoid duplication of each care home domain.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample size for each domain.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSafety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponsive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell-led\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Data Source\u003c/h2\u003e \u003cp\u003eThree datasets were obtained for this study. Two datasets were obtained from the CQC website (CQC, 2024), while the third dataset was obtained from a study conducted by Bach-Mortensen et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). One of the datasets from the CQC website (database) contains data on active care homes in England, while the second dataset contains data on the latest ratings of care homes in England as of 1st of August 2024. The dataset from the work of Bach-Mortensen et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) includes data on care homes in England closed (voluntary and involuntary) in England between 2011 and 2023 that were not due to a provider takeover, and the active care homes in England as of 2023.\u003c/p\u003e \u003cp\u003eCare home ownership types were categorized as third-sector, public, and for-profit. All registered charities and charitable companies were categorized as third sector; all council and NHS trust care homes were categorized as public; and all private companies, partnerships, and individual care providers without a charity number were categorized as for-profit (Bach-Mortensen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Data Preprocessing\u003c/h2\u003e \u003cp\u003eDatasets from the CQC website were pre-processed using Python programming language. The datasets of active care homes and the latest ratings of care homes in England were merged based on the \u0026lsquo;Location ID\u0026rsquo; of the care homes. Rows with unspecified location regions in the merged dataset were filled with the appropriate regions, using information from their local authorities (for example, Kingston upon Thames, Derby, Surrey, and East Riding of Yorkshire local authorities were assigned location regions respectively as London, East Midlands, Southeast, and Yorkshire and The Humber). The dataset from Bach-Mortensen et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) was already pre-processed in their work, no further preprocessing was done on the dataset.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Data Entry and Presentation\u003c/h2\u003e \u003cp\u003eThe pre-processed datasets were loaded into Jupyter Notebook version 6.3.0. The data were analysed using Python programming language. The results of the analyses are presented in tables and charts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.8 Study Limitations\u003c/h2\u003e \u003cp\u003eThis study investigated the impact of care home locations (regions) and care home ownership types on the quality of care provided by care homes in England. However, the study was faced with certain limitations.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe CQC data did not consider the socio-economic status of residents in each of the care homes. Also, the data did not specify the proportion of residents in each of the care homes that were self- or state-funded. Therefore, it is difficult to determine whether the closures of the care homes were associated with care prices or funding.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFurthermore, the CQC data on involuntary closure of care homes did not include ratings in the different CQC domains, only the overall ratings were considered. Therefore, it is difficult to point out the main domain that resulted in the involuntary closure of the care homes. Also, the available data may not have taken into account the overall ratings at the time of involuntary closure.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFinally, time-series data analysis was not considered in the present study. Therefore, it is difficult to tell whether the quality of care in care homes improved after each CQC inspection, and what factors resulted in their improvements.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003ch2\u003e\u003cstrong\u003e4.1 Impact of Care Home Location Region on Quality of Care\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe first objective of this study is to determine the relationship between the location or region of care homes and their quality of care. Figures 2 and 3 show the number of care homes in each region in England and their quality rating in each domain (overall, safety, caring, effective, responsive, and well-led). The quality rating represents the quality of care delivered by care homes. The original quality ratings of the care homes by the CQC are categorized into high (outstanding or good) and low (requires improvement or inadequate), for better comparative analysis. The top three regions in terms of the number of care homes with high-quality ratings are South East, followed by South West and North West; while the least region in terms of the number of care homes with high-quality ratings is North East.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe distribution of the number of care homes by region in overall and safety domains is similar in terms of their high-quality rating, except in the East of England and West Midlands where they swap positions (Figure 2). For the overall domain, more care homes in the Southeast region (2206 care homes) are rated \u0026lsquo;high\u0026rsquo;, followed by South West (1553), North West (1407), West Midlands (1187), East of England (1177), London (1080), Yorkshire and the Humber (1071), East Midlands (1059), and North East (613).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the safety domain, more care homes in the South East region (2183 care homes) are rated \u0026lsquo;high\u0026rsquo;, followed by South West (1533), North West (1360), West Midlands (1163), East of England (1147), London (1043), Yorkshire and the Humber (1033), East Midlands (1030), and North East (601).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe distribution of the number of care homes by region in caring, effective, and responsive domains is similar in terms of their high-quality rating; while the distribution is different in the well-led domain (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore care homes in the South East region (2576 in the caring domain, 2393 in the effective domain, and 2497 in the responsive domain) are rated \u0026lsquo;high\u0026rsquo;, followed by South West (1798 in the caring domain, 1656 in the effective domain, and 1739 in the responsive domain), North West (1697 in the caring domain, 1579 in the effective domain, and 1627 in the responsive domain), West Midlands (1471 in the caring domain, 1379 in the effective domain, and 1434 in the responsive domain), East of England (1440 in the caring domain, 1320 in the effective domain, and 1361 in the responsive domain), Yorkshire and the Humber (1325 in the caring domain, 1210 in the effective domain, and 1248 in the responsive domain), East Midlands (1291 in the caring domain, 1169 in the effective domain, and 1246 in the responsive domain), London (1221 in the caring domain, 1149 in the effective domain, and 1170 in the responsive domain), and North East (685 in the caring domain, 647 in the effective domain, and 665 in the responsive domain). For the well-led domain, more care homes in the South East region (2033 care homes) are rated \u0026lsquo;high\u0026rsquo;, followed by South West (1489), North West (1334), East of England (1083), London (1028), West Midlands (1028), Yorkshire and the Humber (1002), East Midlands (989), and North East (586).\u003c/p\u003e\n\u003cp\u003eTo effectively ascertain the quality of care, it is important to evaluate the proportion of care homes within each region with high-quality rating. This is based on the proportion of care homes in a particular region rated \u0026lsquo;high\u0026rsquo; for each of the domains, as shown in Figure 4. The distribution of the proportion of high-quality rating of care homes within each region is different for each of the domains. For most of the domains, the Northeast has the highest proportion of high-quality ratings of care homes within the region, while the Midlands (East or West Midlands) has the lowest proportion of high-quality ratings of care homes within the region.\u003c/p\u003e\n\u003cp\u003eFor the overall domain, the proportion of care homes rated \u0026lsquo;high\u0026rsquo; is highest within the North East (613 out of 700 care homes in the North East \u0026ndash; 613/700), followed by London (1080/1261), South West (1553/1819), South East (2206/2683), North West (1407/1774), Yorkshire and the Humber (1071/1378), East of England (1177/1520), East Midlands (1059/1377), and West Midlands (1187/1557). For the safety domain, the proportion of care homes rated \u0026lsquo;high\u0026rsquo; is highest within the North East (601/700), followed by the South West (1533/1819), London (1043/1261), South East (2183/2683), North West (1360/1774), East of England (1147/1520), Yorkshire and the Humber (1033/1379), East Midlands (1030/1377), and West Midlands (1163/1557).\u003c/p\u003e\n\u003cp\u003eFor the caring domain, the proportion of care homes rated \u0026lsquo;high\u0026rsquo; is highest within the South West (1798/1819), followed by the North East (685/699), London (1221/1258), Yorkshire and the Humber (1325/1377), South East (2576/2678), North West (1697/1774), East of England (1440/1520), West Midlands (1471/1556), and East Midlands (1291/1377). For the effective domain, the proportion of care homes rated \u0026lsquo;high\u0026rsquo; is highest within the North East (647/700), followed by the London (1149/1259), South West (1656/1819), South East (2393/2683), North West (1579/1774), West Midlands (1379/1556), Yorkshire and the Humber (1210/1377), East of England (1320/1520), and East Midlands (1169/1377).\u003c/p\u003e\n\u003cp\u003eFor the responsive domain, the proportion of care homes rated \u0026lsquo;high\u0026rsquo; is highest within the South West (1739/1819), followed by the North East (665/700), South East (2497/2678), London (1170/1257), West Midlands (1434/1556), North West (1627/1774), Yorkshire and the Humber (1248/1377), East Midlands (1246/1377), and East of England (1361/1520). For the well-led domain, the proportion of care homes rated \u0026lsquo;high\u0026rsquo; is highest within the North East (586/700), followed by the South West (1489/1819), London (1028/1261), South East (2033/2683), North West (1334/1774), Yorkshire and the Humber (1002/1379), East Midlands (989/1377), East of England (1083/1520), and West Midlands (1028/1557).\u003c/p\u003e\n\u003ch2 id=\"_Toc192530998\"\u003e\u003cstrong\u003e4.2 Identification of Local Authorities with High and Low Care Home Rating\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe second objective of this study is to identify local authorities that deliver high or low quality of care in England. It has been established that more care homes in the South East region are rated \u0026lsquo;high\u0026rsquo; for the overall domain. The top 40 local authorities in England with care homes rated \u0026lsquo;high\u0026rsquo; in the overall domain are shown in Figure 5. All the regions in England are represented in the list.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost care homes rated \u0026lsquo;high\u0026rsquo; are in Kent (391 care homes) and Hampshire (383 care homes), both in the South East. Surprisingly, the 23rd and 40th most highly-rated local authorities (in terms of the number of care homes with a high-quality rating) are in the North East (County Durham and Sunderland). County Durham has 129 \u0026nbsp;(out of 144 care homes in the local authority) care homes rated \u0026lsquo;high\u0026rsquo; overall, while Sunderland has 82 \u0026nbsp;(out of 83 care homes in the local authority) care homes rated \u0026lsquo;high\u0026rsquo; overall.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe least 40 local authorities in England with care homes rated \u0026lsquo;high\u0026rsquo; in the overall domain are shown in Figure 6. All the regions in England are represented in the list. The least-rated local authority in England is the Isles of Scilly in the South West region, where the only care home in the local authority is rated \u0026lsquo;low\u0026rsquo; overall.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe next least-rated local authority in England is Camden in the London region, with 6 (out of 10 care homes) rated \u0026lsquo;high\u0026rsquo; overall. Although the South East region has more highly-rated care homes in England, some local authorities in the region are among the least highly-rated care homes in England. They include Slough, Bracknell Forest, Reading, Portsmouth, and Windsor and Maidenhead.\u003c/p\u003e\n\u003cp\u003eTo effectively ascertain the quality of care in each local authority, the proportion of care homes within each local authority with a \u0026lsquo;high\u0026rsquo; rating overall was evaluated. Figure 7 shows England\u0026apos;s top 40 local authorities, based on the proportion of care homes within each local authority rated \u0026lsquo;high\u0026rsquo; overall.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of the top local authorities are in London and North East regions. The most highly-rated local authority is Kensington and Chelsea in London (all the 11 care homes in the local authority are rated \u0026lsquo;high\u0026rsquo; overall), followed by Sunderland in the North East (82 out of 83 care homes rated \u0026lsquo;high\u0026rsquo; overall), South Tyneside (31/32) in the North East, Harrow (50/52) in London, and Waltham Forest (43/45) in London.\u003c/p\u003e\n\u003cp\u003eFigure 8 shows the least 40 local authorities in England, based on the proportion of care homes within each local authority rated \u0026lsquo;high\u0026rsquo; overall.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe least-rated local authority in England is the Isles of Scilly (with no care home in the local authority rated \u0026lsquo;high\u0026rsquo; overall; the only care home is rated \u0026lsquo;low\u0026rsquo;) in the South West, followed by Liverpool (45 out of 81 care homes rated \u0026lsquo;high\u0026rsquo; overall) in the North West, Camden (6/10) in London, Halton (14/23) in the North West, and Nottingham (45/72) in the East Midlands.\u003c/p\u003e\n\u003ch2 id=\"_Toc192530999\"\u003e\u003cstrong\u003e4.3 Impact of Care Home Ownership Type on Quality of Care\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe third objective of this study is to compare the performance of for-profit-owned and public-/third-sector-owned care homes in England. Care home ownership types include for-profit, third-sector, and public. Figure 9 shows quality ratings in different domains for each of the care home ownership types. The order of the ratings is similar for each ownership type. Most care homes are rated high in the caring domain, followed by responsive, effective, overall, safe, and well-led. In other words, most care homes are very caring, responsive, and effective; while they do not perform very well in terms of safety and leadership. Figures 9 and 10 reveal that the ownership type of most of the care homes in England is for-profit, while the ownership types of the remaining care homes are third-sector and public.\u003c/p\u003e\n\u003cp\u003eFor the for-profit ownership type, 11544 (out of 12051) care homes are rated \u0026lsquo;high\u0026rsquo; in the caring domain, 11081 (out of 12051) in the responsive domain, 10642 (out of 12058) in the effective domain, 9608 (out of 12062) in the overall domain, 9389 (out of 12063) in the safety domain, and 8934 (out of 12063) care homes are rated \u0026lsquo;high\u0026rsquo; in the well-led domain. For the third-sector ownership type, 1609 (out of 1648) care homes are rated \u0026lsquo;high\u0026rsquo; in the caring domain, 1572 (out of 1648) in the responsive domain, 1528 (out of 1648) in the effective domain, 1429 (out of 1648) in the overall domain, 1400 (out of 1648) in the safety domain, and 1345 (out of 1648) care homes are rated \u0026lsquo;high\u0026rsquo; in the well-led domain. For the public ownership type, 351 (out of 359) care homes are rated \u0026lsquo;high\u0026rsquo; in the caring domain, 334 (out of 359) in the responsive domain, 332 (out of 359) in the effective domain, 316 (out of 359) in the overall domain, 304 (out of 359) in the safety domain, and 293 (out of 359) care homes are rated \u0026lsquo;high\u0026rsquo; in the well-led domain.\u003c/p\u003e\n\u003cp\u003eHence, in the overall domain, 9608 (out of 12062) care homes are rated \u0026lsquo;high\u0026rsquo; for the for-profit ownership type; 1429 (out of 1648) for the third-sector ownership type; and 316 (out of 359) for the public ownership type. Therefore, within each ownership type in the overall domain, the proportion of highly-rated care homes is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type (Figure 11).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e4.4 Impact of Ownership Type on Care Home Closure\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe fourth objective of this study is to determine the relationship between care home closures in England and their ownership types. The impact of care home ownership type on care home closure was evaluated using data from the study conducted by Bach-Mortensen et al. (2024). The data covers care home closure (involuntary and voluntary closures) in England from 2011 to 2023. Figure 12 shows the involuntary and voluntary closures of care homes for each ownership type. Most of the care homes closed are for-profit ownership type (804 involuntary closures and 6086 voluntary closures), followed by third-sector (10 involuntary closures and 1543 voluntary closures), and least for the public ownership type (2 involuntary closures and 670 voluntary closures). So, 816 care homes were closed involuntarily by the CQC, while 8299 care homes were closed voluntarily between 2011 and 2023\u003c/p\u003e\n\u003cp\u003eTable 2 shows the statistics of care homes in England closed from 2011 to 2023, and the active care homes in 2023. In 2023, there were 12581 for-profit care homes, 1746 third-sector care homes, and 402 public care homes active in England. Within each ownership type, the proportion of involuntarily closed care homes is 11.67%, while the proportion of voluntarily closed care homes is 88.33% for the for-profit ownership type; the proportion of involuntarily closed care homes is 0.64%, while the proportion of voluntarily closed care homes is 99.36% for the third-sector ownership type; and the proportion of involuntarily closed care homes is 0.30%, while the proportion of voluntarily closed care homes is 99.70% for the public ownership type. Hence, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types. However, a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComparing the care home closures and the active care homes within each ownership type, the proportion of involuntarily closed care homes is 4.13%, while the proportion of voluntarily closed care homes is 31.26% for the for-profit ownership type; the proportion of involuntarily closed care homes is 0.30%, while the proportion of voluntarily closed care homes is 46.77% for the third-sector ownership type; and the proportion of involuntarily closed care homes is 0.19%, while the proportion of voluntarily closed care homes is 62.38% for the public ownership type. This result also shows that a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types.\u003c/p\u003e\n\u003cp\u003eTable 2: Care homes closed from 2011 to 2023 and active care homes in 2023.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"566\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOwnership\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eType\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInvoluntary Closure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVoluntary Closure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive Care Homes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion of Involuntary Closure (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion of Voluntary Closure (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Involuntary Closure (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Voluntary Closure (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eFor-profit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e804\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e6086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e88.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e31.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eThird-sector\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1543\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e99.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e46.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e402\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e99.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e62.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e816\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8299\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14729\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e100\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc192531001\"\u003e\u003cstrong\u003e4.5 Impact of Quality of Care on Care Home Closure\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe final objective of this study is to determine the relationship between care home closures and quality of care. The ratings of the care homes closed in England (based on data from the study conducted by Bach-Mortensen et al., 2024) between 2011 and 2023 are inadequate (442 involuntary closures and 814 voluntary closures), require improvement (88 involuntary closures and 992 voluntary closures), good (52 involuntary closures and 2144 voluntary closures), and outstanding (no involuntary closure and 13 voluntary closures) as shown in Figure 12. Care homes that were not rated at the time of closure were removed from the dataset.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe overall quality ratings are categorised into high (outstanding or good) and low (requires improvement or inadequate), as shown in Figure 14. \u0026nbsp;Figure 14 reveals that most care homes closed involuntarily (530 care homes) by the CQC had a low overall quality rating, while only a few care homes closed involuntarily (52 care homes) had a high overall quality rating. In contrast, most care homes closed voluntarily (2157 care homes) had a high overall quality rating, while fewer care homes closed voluntarily (1806 care homes) had a low overall quality rating.\u003c/p\u003e\n\u003ch2 id=\"_Toc192531002\"\u003e\u003cstrong\u003e4.6 Hypothesis Testing\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe Hypotheses in this study are tested using the Chi-Square (X\u003csup\u003e2\u003c/sup\u003e) test of independence, to determine whether two categorical variables are related to each other. The tests are conducted at a significance level (a) of 0.05. In this study, the hypotheses tested include the relationship between care home location region and quality of care, the relationship between care home ownership type and quality of care, the relationship between ownership type and care home closure, and the relationship between quality of care and care home closure.\u003c/p\u003e\n\u003ch3 id=\"_Toc192531003\"\u003e\u003cstrong\u003e4.6.1 Relationship Between Care Home Location Region and Quality of Care\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNull Hypothesis (H\u003csub\u003e0\u003c/sub\u003e): There is no significant relationship between care home location region and quality of care.\u003c/p\u003e\n\u003cp\u003eTable 3 and Table 4 show that there is a significant relationship between care home location region and quality of care in each domain (degrees of freedom = 8, p-values \u0026lt; 0.05). Therefore, the null hypothesis is rejected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3: Hypothesis test result of the relationship between care home location region and overall quality of care.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation Region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Rating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance Level (\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegrees of Freedom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSouth East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e477\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"10\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"10\" style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"10\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5.90x10\u003csup\u003e-23\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"10\" style=\"width: 57px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSouth West\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1553\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1819\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNorth West\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1407\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e367\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eWest Midlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e370\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1557\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEast of England\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1520\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eLondon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eYorkshire and The Humber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1378\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEast Midlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1059\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1377\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNorth East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e613\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e700\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e11353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e14069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable 4: Hypothesis test results of the relationship between care home location region and quality of care in each domain.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance Level (\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegrees of Freedom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-values\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e123.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5.90x10\u003csup\u003e-23\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eSafety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e132.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e9.88x10\u003csup\u003e-25\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eCaring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e84.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6.35x10\u003csup\u003e-15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eEffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e55.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4.25x10\u003csup\u003e-9\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eResponsive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e69.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7.78x10\u003csup\u003e-12\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eWell-led\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e193.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.30x10\u003csup\u003e-37\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch3 id=\"_Toc192531004\"\u003e\u003cstrong\u003e4.6.2 Relationship Between Care Home Ownership Type and Quality of Care\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eH\u003csub\u003e0\u003c/sub\u003e: There is no significant relationship between care home ownership type and quality of care.\u003c/p\u003e\n\u003cp\u003eTables 5 and 6 show that there is a significant relationship between care home ownership type and quality of care in each domain (degrees of freedom = 2, p-value \u0026lt; 0.05). Therefore, the null hypothesis is rejected.\u003c/p\u003e\n\u003cp\u003eTable 5: Hypothesis test result of the relationship between care home ownership type and quality of care.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOwnership Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Rating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance Level (\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegrees of Freedom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eFor-profit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e9608\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e2454\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.52x10\u003csup\u003e-13\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 57px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eThird sector\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1429\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1648\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e359\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e11353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e2716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e14069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 6: Hypothesis test results of the relationship between care home ownership and quality of care in each domain.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance Level (\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegrees of Freedom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-values\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e59.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.52x10\u003csup\u003e-13\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eSafety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e51.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6.34x10\u003csup\u003e-12\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eCaring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3.66x10\u003csup\u003e-4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eEffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e34.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4.08x10\u003csup\u003e-8\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eResponsive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e24.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4.63x10\u003csup\u003e-6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eWell-led\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e52.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3.88x10\u003csup\u003e-12\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3 id=\"_Toc192531005\"\u003e\u003cstrong\u003e4.6.3 Relationship Between Ownership Type and Care Home Closure\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eH\u003csub\u003e0\u003c/sub\u003e: There is no significant relationship between ownership type and care home closure.\u003c/p\u003e\n\u003cp\u003eTable 7 shows that there is a significant relationship between care home ownership type and care home closure (degrees of freedom = 2, p-value \u0026lt; 0.05). Therefore, the null hypothesis is rejected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 7: Hypothesis test result of the relationship between care home ownership type and care home closure.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOwnership Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClosure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance Level (\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegrees of Freedom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInvoluntary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVoluntary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eFor-profit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e804\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e6890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3.03x10\u003csup\u003e-56\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 57px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eThird sector\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1543\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e672\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e816\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e9115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3 id=\"_Toc192531006\"\u003e\u003cstrong\u003e4.6.4 Relationship Between Quality of Care and Care Home Closure\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eH\u003csub\u003e0\u003c/sub\u003e: There is no significant relationship between quality of care and care home closure.\u003c/p\u003e\n\u003cp\u003eTable 8 shows that there is a significant relationship between quality of care and care home closure (degree of freedom = 1, p-value \u0026lt; 0.05). Therefore, the null hypothesis is rejected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 8: Hypothesis test result of the relationship between quality of care and care home closure.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eQuality Rating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClosure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance Level (\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree of Freedom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInvoluntary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVoluntary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4.84x10\u003csup\u003e-93\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 57px;\"\u003e\n \u003cp\u003eReject\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e530\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2336\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3963\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4545\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"5. Discussions","content":"\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Relationship Between Care Home Location Region and Quality of Care\u003c/h2\u003e \u003cp\u003eThe results of this study show that there is a significant relationship between care home location region and the quality of care service in England. The top three regions in England, in terms of the number of care homes with high-quality ratings, are the South East, followed by South West and North West; while the region with the least number of care homes with high-quality ratings is the North East. However, in most of the domains, the North East has the highest proportion of high-quality ratings of care homes within the region, while the Midlands (East or West Midlands) has the lowest proportion of high-quality ratings of care homes within the region. The result suggests that even though there are fewer care homes in the North East, majority of them are rated \u0026lsquo;high\u0026rsquo; in most of the domains.\u003c/p\u003e \u003cp\u003eFurthermore, based on the proportion of care homes within each local authority rated \u0026lsquo;high\u0026rsquo; overall, the majority of the top local authorities are in London and North East regions. The most highly-rated local authorities are Kensington and Chelsea in London, Sunderland in the North East, South Tyneside in the North East, Harrow in London, and Waltham Forest in London. The least-rated local authority in England is the Isles of Scilly (with no care home in the local authority rated \u0026lsquo;high\u0026rsquo; overall) in the South West, followed by Liverpool in the North West, Camden in London, Halton in the North West, and Nottingham in the East Midlands.\u003c/p\u003e \u003cp\u003eThis result can be related to the study conducted by Cartagena-Farias et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) to explore the benefit of the Winter Fuel Payment scheme among eligible populations in the North/South of England. The Winter Fuel Payment enhanced the quality of life for those living in the Northern regions (compared to the Southern regions) of England. Therefore, the impact of resources and support received to promote the health and well-being of a population depends on the location region. The impact might be influenced by the characteristics of the population and the quality control measures adopted to monitor the management of resources. Although the characteristics of residents of care homes in the North East and the internal quality control measures adopted to maintain a high-quality standard of care were not considered in this study, their performance in all the CQC domains of quality care service tends to reflect an outstanding positive impact (compared to other regions in England) in the health and social care sector.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Relationship Between Care Home Ownership Type and Quality of Care\u003c/h2\u003e \u003cp\u003eThere is a significant relationship between care home ownership type and quality of care service. Most care homes in England are very caring, responsive, and effective; while they do not perform very well in terms of safety and leadership. Also, the proportion of highly-rated care homes within each ownership type is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type.\u003c/p\u003e \u003cp\u003eThe findings of this study align with the results of the study conducted by Barron and West (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Barron and West found that for-profit facilities have lower CQC quality ratings than public and non-profit providers over a range of measures including safety, effectiveness, respect (caring), meeting needs (responsiveness), and leadership. However, for-profit care homes considered in the study (and the present study) did not separate small care home businesses from corporate for-profit care homes (unlike the study conducted by Gage et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Certain classes of for-profit care homes might significantly outperform the public and third-sector care homes.\u003c/p\u003e \u003cp\u003eGage et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) found that quality of care was statistically associated with features of care homes and their residents. A higher probability of failing a standard was significantly associated with being a home that was a for-profit small business, was registered before 2000, accommodated publicly funded residents, and was registered to provide nursing care; while fewer failures of care standards were associated with homes that were corporate for-profit, held a specialist registration, and charged higher maximum fees. Therefore, it is important to categorise for-profit care homes into more classes, before comparing their performances with the public and third-sector care homes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e5.3 Relationship Between Care Home Ownership Type and Care Home Closure\u003c/h2\u003e \u003cp\u003eThere is a significant relationship between care home ownership type and care home closure. Most care homes closed (voluntarily or involuntarily) are for-profit ownership type, followed by third-sector, and least for the public ownership type. The findings of this study reveal that within each ownership type, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types.\u003c/p\u003e \u003cp\u003eCare homes are involuntarily closed when they consistently do not meet the CQC standards in terms of safety, caring, responsiveness, effectiveness, or leadership. The CQC can also close (involuntary closure) care homes if their activities pose an imminent risk to the health and well-being of service users. In other words, a care home rated \u0026lsquo;good\u0026rsquo; overall or in a particular domain, might be closed immediately after the CQC representatives discover the care home is underperforming in the domain or other domains, and their performance poses a high risk to the health and well-being of residents (Barron and West, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Shahzad, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Allen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Allen et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Bach-Mortensen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The decision to close care homes voluntarily is mainly internal. For instance, a care home management team can review its operations and performance internally and decide not to continue the care business. Areas the management team can review include their recruitment process and staffing level, staff training and development, access to funding, the business cash flow, access to the facility, characteristics of service users supported in the facility, management capability, or court cases due to their operations (Aggarwal et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Baguma and Obeta, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Towers et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Santamato et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, the relatively higher proportion of voluntary closures of public and third-sector care homes, compared to for-profit care homes, might be attributed to inadequate resources or capacity to continue supporting service users in those facilities. For the for-profit care homes, the relatively higher proportion of involuntary closures, compared to the public and third-sector care homes, might be attributed to their inability to keep up with the CQC standards in any or most of the domains of performance assessment. Therefore, for-profit care homes need to adopt proper internal measures of quality control to monitor and measure their performance frequently to improve their performance and minimise involuntary closures by the CQC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e5.4 Relationship Between Quality of Care and Care Home Closure\u003c/h2\u003e \u003cp\u003eThere is a significant relationship between quality of care services and care home closure. Most care homes closed involuntarily by the CQC between 2011 and 2023 had a low overall quality rating, while only a few care homes closed involuntarily had a high overall quality rating. In contrast, most care homes that closed voluntarily had a high overall quality rating, while fewer care homes that closed voluntarily had a low overall quality rating.\u003c/p\u003e \u003cp\u003eThe findings support the fact that the CQC can involuntarily close care homes if their activities pose a high risk to the health and well-being of residents (Barron and West, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Shahzad, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Allen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Allen et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Bach-Mortensen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). So, even though a care home was rated high (outstanding or good) in previous inspections, it might be abruptly closed when activities in the care home pose severe risks to the health and well-being of service users. However, the significant number of involuntary closures due to low overall quality rating suggests that most care homes closed involuntarily due to low performance in the CQC domains.\u003c/p\u003e \u003cp\u003eFurthermore, the high proportion of voluntary closure of care homes with high-quality ratings, suggests that those care homes did not close due to low performance in the CQC domains. Instead, the reasons for such closures might be attributed to the care homes\u0026rsquo; recruitment process and staffing level, staff training and development, access to funding, the business cash flow, access to the facility, characteristics of service users supported in the facility, management capability, or court cases due to their operations (Aggarwal et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Baguma and Obeta, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Towers et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lewis, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Santamato et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eThis study investigates the relationship between the location region of care homes and the quality of care services provided and evaluates the quality of care services delivered by different care homes in various local authorities in England. This study further investigates the relationship between care home ownership type in England and the performance of care homes, evaluates the relationship between ownership type on the closure of care homes in England, and the relationship between quality of care services and care home closures. A descriptive and inferential research design was adopted for the study. Chi-Square test of independence was applied to test the relationship between variables to make inferences. The conclusions of the study and recommendations are summarised as follows:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe findings of the study revealed that there is a significant relationship between the care home location region and the quality of care service in England. Notably, the exceptionally high-quality performance of the care homes in the North East reflects an outstanding positive impact (compared to other regions in England) in the health and social care sector. Therefore, care homes in other regions in England should find out the strategies of the top-rated care homes in the North East that enable them to maintain high-quality care service delivery, to improve the quality of care service in their regions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThere is a significant relationship between care home ownership type and quality of care service. Most care homes in England are very caring, responsive, and effective; while they do not perform very well in terms of safety and leadership. Also, the proportion of highly-rated care homes within each ownership type is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type. Therefore, the care homes should support staff by providing affordable or free training on safety, leadership, and inclusive organisational culture. The UK government should provide adequate financial support to care homes in England, to enable them to provide adequate staff training and achieve adequate staffing levels to meet the needs of service users and maintain the CQC standards.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThere is a significant relationship between care home ownership type and care home closure. The findings of this study reveal that within each ownership type, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types. Therefore, the relatively higher proportion of voluntary closures of public and third-sector care homes, compared to for-profit care homes, might be attributed to inadequate resources or capacity to continue supporting service users in those facilities. For the for-profit care homes, the relatively higher proportion of involuntary closures, compared to the public and third-sector care homes, might be attributed to their inability to keep up with the CQC standards in any or most of the domains of performance assessment. Therefore, for-profit care homes need to adopt proper internal measures of quality control to monitor and measure their performance frequently to improve their performance and minimise involuntary closures by the CQC.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThere is a significant relationship between quality of care services and care home closure. The significant number of involuntary closures due to low overall quality rating suggests that most care homes closed involuntarily due to low performance in the CQC domains. Furthermore, the high proportion of voluntary closure of care homes with high-quality ratings, suggests that those care homes did not close due to low performance in the CQC domains. Instead, the reasons for such closures might be attributed to the care homes’ recruitment process and staffing level, staff training and development, access to funding, the business cash flow, access to the facility, characteristics of service users supported in the facility, management capability, or court cases due to their operations. Therefore, care homes should continue to review their resources, capacity, and application of CQC standards to improve their quality of care services.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e "},{"header":"7. Recommendations for Future Studies","content":"\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFuture studies should investigate the relationship between the socio-economic status of residents in care homes on the quality of care they receive. They should also consider the proportion of residents in each care home that are self- or state-funded, to determine whether closures of care homes are associated with care prices or funding.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFuture studies should consider using CQC data on involuntary closure of care homes that include ratings in the different CQC domains and ratings at the time of closure, instead of making recommendations only on the overall ratings and in some cases non-updated ratings. The CQC data including all domains and timely ratings will make it easier to identify the main domain that resulted in the involuntary closure of the care homes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFuture studies should consider time-series data analysis to determine whether the quality of care in care homes improved after each CQC inspection, and what factors resulted in their improvements.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor credit statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFaith Aminaho:\u0026nbsp;\u003c/strong\u003eConceptualisation, Investigation, Methodology, Data Curation, Analyses, Visualisation, and Writing. \u003cstrong\u003eChioma Onoshakpor:\u0026nbsp;\u003c/strong\u003eSupervision and Writing Review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors want to acknowledge the funding A-Class Academic Consults Limited provided for this project.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be made available on request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAcar, A.Z. and Acar, P. 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Statistics: An introductory analysis. 2nd edn. New York: Harper and Row.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Quality, Performance, Care Homes, Ownership, Domains, Closures, England","lastPublishedDoi":"10.21203/rs.3.rs-6185408/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6185408/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAccording to the most recent data provided by the Office for National Statistics (ONS) in 2023, there are 372,035 residents in care homes in England. Many of these residents experience a low quality of life due to poor service delivered in those facilities. The Care Quality Commission (CQC) strives to regulate the health and social business in the country to promote the health and well-being of these residents in care homes. CQC measures the quality of care services delivered in different care homes in England ranging from inadequate to outstanding, depending on the performance of the care homes in the different CQC domains (safety, caring, effective, responsive, and well-led). However, care homes in England are in different regions, and care home ownership types vary from for-profit, third-sector, or public ownership types. It is therefore paramount to investigate the relationships between the quality of care and location regions, ownership types, and care home closures. This study investigatesthe relationship between location regions of care homes and the quality of care services provided and evaluates the quality of care services delivered by different care homes in various local authorities in England. This study also further investigates the relationship between care home ownership type in England and the performance of care homes. It evaluates the relationship between ownership type on the closure of care homes in England, and the relationship between quality of care services and care home closures. A descriptive design was adopted for the study, using data from the CQC database on the active care homes in England and their ratings up to August 2024. The study's findings revealed a significant relationship between the care home location region and the quality of care service in England. Notably, the exceptionally high-quality performance of the care homes in the Northeast reflects an outstanding positive impact (compared to other regions in England) in the health and social care sector. Also, there is a significant relationship between care home ownership type and quality of care service. Most care homes in England are very caring, responsive, and effective; but many do not perform very well in terms of safety and leadership. Also, the proportion of highly rated care homes within each ownership type is highest for the public ownership type, followed by the third-sector, and lowest for the for-profit ownership type. Furthermore, there is a significant relationship between care home ownership type and care home closure. The findings of this study reveal that within each ownership type, a higher proportion of care homes are closed involuntarily by the CQC for the for-profit ownership type, compared to the third-sector and public ownership types; and a higher proportion of care homes are closed voluntarily for the public ownership type, followed by the third-sector and for-profit ownership types. Finally, there is a significant relationship between quality of care services and care home closure. The significant number of involuntary closures due to low overall quality ratings suggest that most care homes closed involuntarily due to low performance in the CQC domains; while, the high proportion of voluntary closure of care homes with high-quality ratings, suggests that those care homes did not close due to low performance in the CQC domains. Instead, the reasons for such closures might be attributed to other factors. Recommendations for future studies were made in this study.\u003c/p\u003e","manuscriptTitle":"Analysis of CQC Ratings of Care Home Business Performance in England: Implications for Quality Improvement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-13 08:24:03","doi":"10.21203/rs.3.rs-6185408/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4dd19a08-53bd-4115-b275-41049de18dc0","owner":[],"postedDate":"March 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-17T10:08:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-13 08:24:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6185408","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6185408","identity":"rs-6185408","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}