The Key Challenges Facing Adult Social Care in Medway

Medway has a substantial adult social care market, but its central challenge is not simply finding enough providers.

The harder problem is matching an ageing population and increasingly complex needs with the right type of capacity, a sustainable workforce, affordable fees and services that can support people at the point they actually need care.

That distinction is visible throughout the current evidence.

Medway Council describes mainstream residential provision as relatively robust, yet continues to identify shortages in high-frailty nursing, dementia residential and nursing care, functional mental health provision, planned nursing respite, specialist care for people under 65 and support for people with multiple complex needs.

Homecare presents almost the reverse picture. The commissioned market is sizeable and there is strong provider interest, but quality, workforce stability and the economics of delivering reliable care remain important pressures.

The council is also trying to prevent or delay avoidable escalation into long-term care, increase independence and improve hospital flow. That means demographic growth cannot simply be translated into an equivalent increase in conventional residential placements.

For providers considering Medway, the strongest market opportunities sit inside these tensions.

The companion adult social care market report sets out capacity, demand and headline market structure in more detail.

At a glance

Rising demand

9,265 requests from new clients in 2024/25, up across working-age and older adults

Ageing

People aged 80+ needing help with self-care or domestic tasks projected to rise materially by 2040

Dementia

Substantial projected growth; commissioners identify specialist shortages

Residential and nursing

Mainstream residential relatively robust; complex nursing and dementia remain priorities

Homecare

12 framework providers; 104 organisations registered for community-based adult social care locally

Quality

April 2026: five of 12 framework homecare providers rated Requires Improvement; four not yet rated

Workforce

Recruitment, retention and skills remain threats to sustainability

Commissioning

Care-home recommissioning; supported living and short-term assessment arrangements changing

Strategic direction

Prevention, reablement, independence and reduced avoidable escalation

These pressures interact. A service can be in high demand and still be difficult to deliver sustainably.

1. Demand is increasing, but most requests do not become long-term packages

Medway received 9,265 requests for adult social care support from new clients in 2024/25.

Of these, 6,275 related to people aged 65 and over, compared with 4,846 in 2022/23. Requests from adults aged 18 to 64 also increased, from 2,777 to 2,980 over the same period.

1. Age 18 to 64

   2,980

2. Age 65 and over

   6,275

That is a clear demand signal.

It is not, however, a direct measure of the provider market.

Medway reports that 46% of requests resulted in information, advice, signposting or no subsequent service. Only 6% resulted in a long-term service such as homecare or residential care.

• 46%Advice, signposting or no subsequent service
• 6%Long-term service such as homecare or residential care

Shares of 9,265 requests from new clients. Medway Council, 2024/25.

This distinction is fundamental for a provider assessing the area.

A rising number of people contacting adult social care can increase pressure on the system without producing an equivalent increase in commissioned care hours or placements.

The route can include:

• advice and signposting
• equipment and adaptations
• preventative support
• reablement
• support from family or community networks
• short-term services
• direct payments
• long-term commissioned care.

Medway's own strategic direction increasingly emphasises early intervention and independence.

The commercial question is therefore not simply how many people need help.

It is which needs continue through the system into a form of support that a particular provider can deliver.

2. Population ageing is increasing complexity, not just volume

Medway is ageing.

The 2021 Census recorded 279,730 residents, with approximately 17% aged 65 and over. Between 2011 and 2021, the population aged 65 and above increased by 24%.

The implications become more significant when looking at the oldest age groups and functional need.

Medway's adult care evidence projects substantial increases by 2040 in the number of people aged over 80 who need help with at least one self-care or domestic task. CQC cited projections of a 43% increase among women and 53% among men.

1. Women

   +43%

2. Men

   +53%

Projections cited by CQC.

Ageing also increases the prevalence of conditions that make care more complex.

These include:

• dementia
• frailty
• falls
• multimorbidity
• mobility limitations
• sensory impairment
• increasing dependence with activities of daily living.

For providers, this changes what "capacity" means.

A registered bed is not necessarily a suitable bed.

A care worker with availability is not necessarily equipped to support a person whose needs require specialist competencies, double-handed care, behavioural support or nursing oversight.

The more useful measure of future capacity is therefore capability.

Medway may have enough providers in a broad registration category while still having too little provision for the people commissioners find hardest to support.

3. Dementia and high-frailty nursing remain structural gaps

One of Medway's clearest challenges is specialist accommodation-based care.

The council's current Market Position Statement identifies shortages in:

• high-frailty and nursing care
• residential dementia care
• dementia nursing
• provision for people with dementia alongside functional mental-health needs
• long-term planned nursing respite
• specialist care for people under 65

Its commissioning intentions for 2026 to 2028 reinforce the same priorities.

The council wants more dementia nursing, physical-disability nursing, working-age adult mental-health provision, working-age dementia provision and services for people with multiple complex needs.

This is important because it shows continuity between older market evidence and current commissioning action.

The gap has not simply been inferred from demographic projections. It is visible in the types of placements the council says remain difficult to source.

CQC's January 2025 assessment also found gaps in nursing and residential beds, particularly for people with complex needs and young people transitioning from children's services.

At the time of CQC's evidence collection, average waits were 36.25 days for residential placements and 31.3 days for nursing placements. Some people remained in hospital after they were medically fit for discharge because suitable capacity was unavailable.

1. Residential36.25 days
2. Nursing31.3 days

2840

CQC Medway local authority assessment.

The challenge is therefore specific.

Medway does not simply need more care-home beds. It needs beds capable of accepting higher-acuity residents safely and sustainably.

4. The council is intervening directly in the capacity problem

Medway's proposed council-owned care development is one of the strongest indicators of the seriousness of the specialist-capacity issue.

A full planning application was submitted in July 2026 for an 80-bed care home. Current proposals include 40 specialist nursing residential dementia beds and 40 beds associated with discharge-to-assess provision, alongside Adult Social Care Units.

• 40Specialist nursing residential dementia beds
• 40Discharge-to-assess beds

This has two implications for independent providers.

First, it confirms that commissioners consider specialist dementia and discharge capacity a material problem.

Second, it means the future supply picture is changing.

A provider assessing Medway cannot simply take today's shortage and assume it will remain unchanged for the life of a new development.

Future capacity needs to account for:

• the council's proposed care home
• recommissioning of existing frameworks
• additional block contracts
• new independent developments
• changes in hospital discharge pathways
• increased use of prevention and reablement.

A genuine gap today can still be a poor investment if several hundred additional places are already in the pipeline.

The correct analysis is demand minus suitable current and planned capacity.

5. Hospital discharge exposes weaknesses elsewhere in the market

Adult social care capacity and hospital flow are closely linked.

CQC found that Medway had experienced discharge delays because appropriate services were not always available. During the evidence period, the shortest cited delay was four days and the longest was 119 days.

1. Shortest cited delay

   4 days

2. Longest cited delay

   119 days

CQC evidence period.

The council had also identified a shortfall in step-down capacity and was using additional beds to address winter pressure.

This matters commercially because hospital discharge can create visible demand without necessarily translating into straightforward long-term placements.

A person leaving hospital may need:

• short-term assessment
• reablement
• rehabilitation
• intensive homecare
• equipment
• temporary residential support
• permanent residential or nursing care.

Medway's commissioning model is increasingly designed to move people through these stages rather than defaulting directly to long-term care.

Its proposed new facility includes discharge-to-assess capacity, and the current short-term assessment bed contract ends in March 2027, with market engagement planned before future commissioning arrangements are settled.

For providers, discharge can therefore represent an opportunity, but it is a distinct operating model.

Services need to accept people promptly, work across health and social care, manage changing needs and support onward movement.

A conventional long-stay care model cannot simply assume it is interchangeable with step-down or assessment provision.

6. Homecare has capacity, but sustainability and quality are different questions

Medway's homecare market illustrates why provider numbers can be misleading.

The Support to Live at Home contract covers approximately 1,250 people and around 495,000 hours of care and support each year.

1,250

People on homecare and extra care

495,000

Hours of care and support each year

Medway Council Market Position Statement.

• 104Organisations registered for community-based adult social care
• 12Providers on the homecare framework from April 2024

Twelve providers were appointed to the homecare framework beginning in April 2024. More than 100 providers expressed interest during recommissioning, and the council reported 104 organisations registered with CQC to provide community-based adult social care in Medway.

That is not evidence of a thin market.

CQC's assessment found an average wait of one day for a homecare package during its evidence period and reported no domiciliary-care waiting list.

Yet the same assessment also recorded concerns about reduced budgets, staffing levels, increasing care costs and long-term market sustainability.

These findings are not contradictory.

A market can have enough providers to absorb packages today while still facing pressure on:

• recruitment
• retention
• travel time
• hourly rates
• package density
• management capacity
• quality
• profitability.

For a new domiciliary-care agency, the challenge is therefore not simply obtaining CQC registration.

It is finding a route into a market where commissioned provision is already structured and where many organisations have shown interest in the available work.

Private-pay, direct-payment and specialist routes may therefore be more relevant to some entrants than assuming immediate access to council-funded volume.

7. Quality remains a material market challenge

Capacity without quality does not solve Medway's problem.

The council's April 2026 Market Position Statement data showed a mixed quality picture among community-based providers.

Of the 12 homecare providers on the commissioned framework:

• 5Requires Improvement
• 4Not yet rated
• 3Good

Across all community-based provider locations in Medway, the council reported a higher proportion rated Requires Improvement and a lower proportion rated Good than the South East comparison, while also noting that a large number had not yet been rated.

The council is responding through contract monitoring, quality assurance and provider support.

Its Quality Assurance Team now describes a continuous, intelligence-led and risk-based model covering residential care, nursing, supported living, domiciliary care, day opportunities and respite.

For a new provider, this raises the standard of the opportunity.

Entering a market with quality pressure is not simply an invitation to open another service. A credible entrant needs to demonstrate that its governance, registered management, workforce and operational controls can deliver reliably.

Quality can also affect market capacity.

CQC's earlier assessment recorded commissioning suspensions, restrictions and contract termination associated with quality concerns and other risks. It also recorded packages being handed back as people's needs increased.

A nominal provider count can therefore overstate usable capacity if some services cannot accept complex referrals, are restricted from new admissions or cannot maintain quality at higher acuity.

8. Workforce is one of the constraints behind the capacity gap

Medway identifies workforce as one of the principal factors affecting its adult social care market.

The challenge is not simply the total number of care workers.

Different gaps require different capabilities.

High-frailty nursing requires registered nurses and staff confident with significant physical dependency.

Dementia services require competencies around communication, distress, risk, nutrition, mobility and changing cognition.

Supported living for people with complex needs can require specialist autism, learning-disability, mental-health or behavioural-support experience.

Homecare depends on enough staff being available in the right places and at the right times.

CQC's 2025 assessment found that workforce recruitment and retention were significant challenges to market stability. Providers also gave mixed feedback about the support available to address recruitment and training.

The regulator recorded reductions in staffing within residential and nursing homes and noted that packages had been handed back across nursing, residential, supported living and homecare settings.

This reveals an important commercial problem.

The services with the clearest unmet demand can also be the hardest to staff.

A new provider cannot treat recruitment as a post-registration task.

Before launch, it needs a credible view of:

• local wage expectations
• registered-manager availability
• nurse recruitment where relevant
• sponsorship dependence
• training requirements
• travel and shift patterns
• supervision capacity
• agency exposure
• staff turnover.

A service that cannot recruit the required workforce does not add effective capacity, regardless of how strong the demand case appears.

9. Increasing complexity can make existing provision unsuitable

One of the reasons specialist gaps persist is that people's needs can outgrow the service originally designed for them.

CQC recorded that four nursing homes had handed back packages during the preceding 12 months because people's support needs had increased. Seven residential packages, five supported-living packages and three homecare packages had also been handed back.

1. Nursing homes

   4

2. Residential packages

   7

3. Supported-living packages

   5

4. Homecare packages

   3

CQC evidence for the preceding 12 months.

This is a critical market signal.

It suggests the challenge is not always finding an initial placement.

It can be maintaining that placement as needs intensify.

For providers, this raises difficult strategic choices.

A service can specialise at a defined level of need and transfer people when their requirements exceed that level.

Or it can invest in the staffing, environment, training and governance required to support people through greater complexity.

Neither approach is automatically wrong.

But a provider needs to know which model it is operating.

The commercial risk appears when a service prices and staffs for moderate needs while gradually accepting residents or packages requiring substantially more intensive support.

That can erode margins, increase workforce pressure and eventually make the placement unsustainable.

10. Supported living is expanding, but complexity still determines viability

Supported living is an important part of Medway's strategy for working-age adults.

As of April 2026, the council reported 384 people receiving supported-living services.

The commissioning structure recognises different levels of need, including lower-needs provision, higher-needs support and specialist support.

This is strategically consistent with the wider aim of helping people live as independently as possible.

But supported living should not be treated as a single market.

The needs of a person requiring several hours of weekly support are fundamentally different from somebody requiring 24-hour staffing, waking nights, one-to-one or two-to-one support, specialist behavioural input or extensive physical assistance.

CQC's assessment identified a particular shortfall for some people with mild learning disabilities or autism who required around 30 hours of support per week, as well as average waiting times of 33.5 days for mental-health supported living and 39.5 days for learning-disability supported living during its evidence period.

1. Mental health33.5 days
2. Learning disability39.5 days

3045

Commissioning arrangements are also changing.

Medway's supported-living DPS has been organised around lower, higher and specialist need, and the council's current commissioning programme is reviewing future arrangements around the end of the existing contract term.

For prospective providers, the lesson is to define the cohort first.

"Supported living in Medway" is too broad to constitute a business case.

11. Respite remains difficult to provide sustainably

Medway continues to identify a lack of long-term planned nursing respite.

This is a significant need for families and unpaid carers, but it is also a commercially difficult form of provision.

Respite demand can be uneven.

A provider may need to preserve capacity for short stays while permanent placements offer greater occupancy certainty.

People requiring nursing respite may also have complex individual needs, making rapid admissions more difficult.

CQC found during its assessment that respite beds could become occupied by people waiting for permanent residential or nursing provision.

That illustrates how one capacity shortage can consume another.

If permanent nursing beds are unavailable, short-term capacity can stop functioning as short-term capacity.

The result is a system-level bottleneck.

For a provider, respite can represent a genuine gap, but the operating model needs to account for utilisation risk, admissions complexity and the commissioning mechanism.

Unmet need alone does not guarantee a sustainable standalone respite business.

12. Financial pressure affects both the council and providers

Adult social care is expensive, and Medway is operating within significant financial constraints.

CQC reported that the council's adult social care spend in 2023/24 exceeded its original estimate. The council's current commissioning material also explicitly identifies long-term funding uncertainty as a major market factor.

Providers face their own cost pressures.

For 2026/27, Medway's published weekly band rates are £824 for standard residential, £875 for dementia residential, £1,030 for standard nursing and £1,081.50 for dementia nursing.

1. Standard residential£824
2. Dementia residential£875
3. Standard nursing£1,030
4. Dementia nursing£1,081.50

8001150

Those rates provide a useful benchmark, but they do not by themselves establish whether a service is viable.

The true cost depends on:

• staffing intensity
• wage levels
• pension and National Insurance
• agency use
• food and utilities
• property costs
• insurance
• equipment
• training
• management
• compliance
• maintenance
• financing.

The most difficult placements are often the most expensive to support.

This creates a recurring tension between social need and economically sustainable demand.

A shortage of complex nursing provision may be very real. But if the cost of safely delivering that provision exceeds the fee available, the shortage can persist despite obvious demand.

Medway says it is considering greater use of block contracts where managing supply and cost is particularly difficult.

That is commercially significant because block purchasing can offer providers greater volume certainty while giving commissioners more control over capacity and cost.

13. Assessment and review pressures can delay the route from need to service

Provider capacity is only one part of the care pathway.

CQC's assessment found waiting lists across Care Act assessments, learning-disability assessments, occupational therapy, safeguarding, DoLS and financial assessments.

The average Care Act assessment wait reported during the evidence period was 15 days, while annual reviews averaged 145 days.

Financial assessments were particularly delayed, with a median wait of 181 days during the period reviewed.

1. Care Act assessment, average

   15 days

2. Annual reviews, average

   145 days

3. Financial assessment, median

   181 days

The council had already begun measures to address these pressures, including recruitment, restructuring and a "Waiting Well" approach for people waiting more than 28 days.

For providers, these figures need careful interpretation.

A waiting list for an assessment is not equivalent to a waiting list for a provider.

Likewise, a person may have eligible needs but still require funding decisions, brokerage, property arrangements or family decisions before a package begins.

Commercial forecasts should therefore distinguish between:

1. Underlying need
2. Assessed eligible need
3. Commissioned demand
4. Actual referrals
5. Accepted packages
6. Occupied beds or delivered hours

Failing to separate these stages can make a market appear larger and faster-moving than it really is.

14. Unpaid carers are part of Medway's capacity system

A substantial amount of care in Medway is delivered outside the formal provider market by relatives and other unpaid carers.

This affects formal demand in two directions.

Where unpaid care is sustainable, it can reduce or delay the requirement for commissioned support.

Where it breaks down, demand can escalate quickly.

CQC found mixed experiences around carers assessments and identified the carers offer as an area requiring improvement. Some carers had waited substantially longer than the intended timescale, although there was no waiting list for the commissioned carers support service itself.

Respite, flexible home support and preventative services therefore play a wider role than their immediate service volume suggests.

They can help sustain an unpaid caring arrangement and delay a crisis that would otherwise require a more intensive package.

For providers, this creates opportunities around flexible and preventative support, but it also reinforces the importance of understanding who actually purchases the service.

Need experienced by an unpaid carer does not automatically translate into a council-funded package.

15. Prevention and reablement deliberately change the shape of demand

Medway's current Adult Social Care Strategy places increasing emphasis on helping people remain independent and intervening before needs escalate.

The council's commissioned services already include intermediate care and reablement, community equipment, homecare, extra care, supported living and voluntary-sector support.

Community equipment volumes are substantial. Medway reports 37,623 items issued to 5,927 clients between April 2025 and March 2026.

37,623

Items issued

to

5,927

Clients

This matters because successful prevention changes the provider market.

Equipment, adaptations, reablement and community support can delay or reduce the need for long-term homecare or residential admission.

At the same time, they can create demand for different services.

The market therefore does not simply expand in a straight line as the population ages.

Some demand shifts from institutional care towards:

• equipment
• technology
• short-term enablement
• community support
• extra care
• supported living
• more complex care delivered at home.

Providers need to understand where their model sits within this pathway.

A business based on lower-acuity long-term support may face different strategic pressures from one designed for people whose needs remain intensive after preventative options have been exhausted.

16. Commissioning is changing across several parts of the market

Medway is entering an active period of recommissioning.

The council is:

• recommissioning residential and nursing care arrangements
• considering greater use of block contracts
• reviewing supported-living arrangements
• preparing future commissioning for short-term assessment beds
• planning engagement ahead of the next homecare cycle
• reviewing extra-care arrangements.

For established providers, this creates a need to track procurement and specification changes.

For new providers, it creates potential entry points.

But procurement opportunity and market opportunity are not the same thing.

Winning a place on a framework or DPS does not guarantee referrals.

Providers still need to understand:

• how packages are allocated
• which needs are difficult to source
• likely fee levels
• quality thresholds
• geographical requirements
• contractual KPIs
• expected response times
• whether sufficient volume is realistically available.

The strongest business case combines commissioning access with a specific unmet need.

17. Partnership working is improving, but provider relationships have been mixed

CQC scored Medway relatively positively for partnerships and communities, highlighting collaboration across health, social care, housing, voluntary organisations and other agencies.

There were examples of integrated work around hospital admission prevention, falls, carers and people experiencing multiple disadvantage.

However, provider feedback was mixed.

Some providers described positive forums and support, while others reported difficulties communicating with locality teams or felt insufficiently involved in market shaping.

This matters because adult social care increasingly depends on providers operating as part of a wider system.

Complex services may need to work with:

• social workers
• brokerage
• hospital discharge teams
• community health
• mental-health services
• occupational therapists
• equipment services
• housing
• voluntary organisations
• families and carers.

A provider that treats its service as an isolated transaction can struggle in a market where commissioning increasingly expects collaboration, timely admissions and shared responsibility for system flow.

What do these challenges mean for a new provider?

Medway has genuine adult social care demand, and the evidence identifies real gaps.

But those gaps are selective.

The strongest current signals concern:

1. Complex nursing and high frailty

   Capacity remains difficult to source and commissioners explicitly want more provision.

2. Dementia

   Both residential and nursing dementia are current priorities, although planned council capacity needs to be included in future supply analysis.

3. Specialist working-age provision

   Mental health, physical-disability nursing, working-age dementia and multiple complex needs are all identified commissioning priorities.

4. Supported living for defined cohorts

   There are identifiable gaps, but the market needs to be analysed by level and type of support rather than as one category.

5. Respite and short-term capacity

   The need is real, but utilisation and operating economics can be difficult.

6. High-quality community support

   Homecare has substantial existing supply, so a new entrant needs a clearer differentiator than simply being another registered agency.

The weaker proposition is to treat rising demand as proof that any care service will succeed.

Medway's evidence shows why that is unsafe.

A service can face strong underlying need and still fail because:

• the wrong capacity is being created
• staffing is unavailable
• fees do not cover delivery costs
• commissioning access is limited
• competing capacity is already planned
• quality cannot be sustained
• referrals do not convert into viable utilisation

The central challenge for Medway

Medway's adult social care problem is not primarily a shortage of organisations.

It is the alignment of the right capability with increasingly complex need.

The area has a large provider market. It also has people waiting for specialist placements, providers handing back packages as needs intensify, pressure on hospital discharge, quality variation and persistent workforce and funding constraints.

At the same time, the council is deliberately investing in prevention, reablement and independence so that long-term care is used more selectively.

For a provider, this produces a market that rewards specificity.

The strongest proposition is likely to start with a clearly defined problem:

a dementia nursing placement that is difficult to source, a working-age adult whose needs do not fit existing provision, a sustainable specialist supported-living model, or community support that prevents escalation into more intensive care.

The service model, workforce, property, pricing and registration can then be built around that need.

That is a much stronger basis for entering Medway than the general assumption that an ageing population must simply require more care.