Deciding to put a loved one into a care home is no easy task - it is both a considerable emotional and financial strain with fees costing around £3,000 a month.

Yet despite the costs, around a quarter of care homes in Kent are rated as requiring improvement, according to the Care and Quality Commission (CQC).

The CQC conducts regular reports assessing standards - in a similar role to that of Ofsted in education.

The big question is just why are standards apparently slipping?

Northfleet care home Dene Holm saw its previous 'good' rating downgraded to 'inadequate' in September. The report said: “We were concerned to find managers had no oversight of the home. Risks to people’s safety, such as falls or choking risks, weren’t being well managed.

“Staff told us they didn’t feel supported and were short staffed. Yet, despite this, they were doing their best to provide the best care they could."

In July, CQC inspectors visited Barnes Lodge in Tonbridge, after concerns were raised relating to the safeguarding of vulnerable adults and staffing.

Some living at the care home, said the report, were left with "long and dirty" fingernails and clothes, as well as unexplained bruises that were not being investigated.

It found there were too few staff and many that were on shift at the time were from an agency.

As a result of the inspection the overall rating for the service fell from 'good' to 'inadequate' and the home placed into special measures.

In September, Canterbury House Care Home in Faversham, was given a rating of 'requires improvement' - having previously been rated 'good'.

In the report, the regulator noted: “Accidents and incidents had been recorded and analysed but action taken had not been effective in mitigating risks.”

Once again, inspectors complained the facility was understaffed and that some staff members had no experience working in care.

In December, comments made by staff to the CQC during a recent visit to Rogers House in Wigmore, Gillingham described working conditions as "horrible" and the "worst" they "had ever known it".

Previously judged 'good' it was downgraded to 'inadequate' and plunged into special measures.

It prompted the site's management, Rapport Housing and Care, chief executive Leon Steer to say: "We have been working with the CQC and our consultants on the improvements we need to make within our homes and are confident we are making progress.

"Prior to the Covid-19 pandemic and subsequent staffing crisis within the care sector, all of our homes held ‘good’ ratings, and we are working hard to restore these."

Staffing, for the eagle-eyed, is a recurring theme - or, at least, the lack of.

Care home are a key part of the social care network.

It is a sector which has rarely fallen out of the headlines in recent years due to a lack of funding from central government and an ever expanding remit due to the squeeze on the NHS and people living longer.

It is estimated close to half a million people in the UK live in residential care homes - and the role they fulfil has changed dramatically over the last 30 years.

Explains Nadra Ahmed, chair of the National Care Association which represents independent social care providers, as well as a Kent Ambassador explained: "There are two key reasons care homes are facing challenges at the moment.

"One of them is staffing and the other is funding. They are the key to the success of the service.

"If we don't have the workforce, you can give us all the money in the world, we won't be able to deliver.

"We have seen an erosion of the workforce when we actually need to see more people working in social care.

"Part of that will be to do with Covid, part of that to do with pay scales. Especially as we have a much more aggressive retail market.

"But what we have to be clear about is the underfunding of social care by successive governments. Any resilience in the sector has been eroded completely."

'The shrinking workforce is not because more people are leaving – it is because fewer people are starting...'

Oonagh Smyth is CEO of Skills for Care, a charity supporting social care workers. She explains: "We have been predicting the need for workforce growth for many years.

"In the past, we saw demand for care roles increasing as we needed more capacity to meet need, but we also saw the workforce grow too - we were recruiting more people but still not enough. But this year, for the first time, we still saw demand increasing, but the total workforce shrinking.

"So, it has been both a predictable trend that we have seen over 10 years, and a dramatic response to the current labour market conditions. The shrinking workforce is not because more people are leaving – it is because fewer people are starting - a 17% reduction in new starters across adult social care since 2018/19.

“The current vacancy rate in care homes with nursing is 8.8% while for care homes without nursing this is 7.7%. This compares to 5.4% and 4.5% in 2020/21."

Mrs Ahmed, who received a CBE in the New Year's Honours List for her work in social care - adding to an OBE received in 2006 - spent many years operating such facilities, leaving in the late 1990s.

She adds: "When I was running care homes, they were what were known as the 'cream tea society'. They didn't want to live alone; they walked into my care home, we provided them with food, supported them with personal hygiene, they walked in the grounds and walked or drove into town. As soon as their health started to fail, they would go to a nursing facility.

"Now, we have a completely different situation. Now everyone's welcome. Those with dementia diagnoses, mental health problems, and of course all of that needs people to be supported by a more highly skilled staff group but also greater numbers."

And it is that added pressure which is going often unnoticed, and frequently drowned out by concerns for the NHS.

Adds Mrs Ahmed: "The difference now to when I stopped operating care homes in the 1990s, is that people are living longer, but doing so with complex health care conditions. The NHS is failing.

'People are living longer, but doing so with complex health care conditions...'

"So I do think care homes have got progressively worse because the expectation is that the NHS will do less and social care will do more.

"We don't have the infrastructure of primary care services - we don't have mental health services that are up speed, no physiotherapists, there's a shortage in a number of things."

With minimum wage entry requirements and complex health needs involved, it is perhaps little wonder the care home sector is struggling. Jobs in the profession are routinely under-appreciated.

Explains Skills for Care's Oonagh Smyth: “The current average pay rate for a care worker in a care home with nursing is £20,500 in local authorities and £18,200 among independent providers. For care only homes these figures are £20,300 and £18,100.

“We need to think about how we recruit people who haven’t typically been attracted to care – for example men who only make up 18% of the workforce. In a sector that is always going to be needed, we should be talking more positively about social care as a job for which there is always a need.

“The most immediate fixes must be focused on helping social care compete with other sectors. That means reviewing pay and terms and conditions, and talking more about the rewarding career opportunities that social care offers.”

However, for many the equation of sky-high costs and low staff wage will sit uncomfortably.

Mrs Ahmed estimates, "kindly", residential care home rates of £700 a week. It's a cost which works out to be around £4 an hour for caring for those with health conditions ranging from dementia to stroke recovery or, simply, old age.

Those costs, however, can vary considerably between providers. Some backed by big investment companies will seek a return on investment and can charge up to £1,400 a week.

However, for those with smaller price-tags, the pressures they are facing are weighing heavily on them.

From small providers struggling with increases to mortgage costs to soaring energy bills, the staffing crisis is just another huge hurdle they need to find a way to get over.

In addition, local authorities - which pay towards those with little or no capital to afford the bills - have been squeezed to the extent they can only just afford a 2% rise in contributions year-on-year. A mere drop in the ocean.

Adds Mrs Ahmed: "A provider has to find that money. And then add on to the fact they are looking after people with very complex needs, so their staffing levels may need to rise. So where once you needed a ratio of one staff member to eight patients, you might need one to six.

'A hospital bed costs £2,500 a week. In a care home, we're only willing to pay, say, £700...'

"A hospital bed costs £2,500 a week. In a care home, we're only willing to pay, say, £700. We're paying that level for someone whose condition hasn't changed, they've come out of an acute setting but they need care and support.

"They can't safely be looked after in their own homes."

What sort of effect does a shortage of staff have?

Helen Wildbore, director of the Relatives & Residents Association, the national charity for older people in care and their families, says: "The fact that half of all residential care homes in England inspected last year were rated inadequate or requiring improvement confirms the very worst fears of people and families who place their trust in care services for the most personal and intimate support.

"These fears include neglect, abuse and the loss of autonomy and liberty. But many also fear more subtle erosions of dignity, in the form of 'everyday' breaches of rights that don’t tend to make the headlines: being dressed in someone else’s clothes, or left without hearing aids or dentures.

'I'm an optimist - I think someone will have that lightbulb moment at some point and changes will, eventually, be made...'

"These seemingly small acts have a huge impact on wellbeing, and can quickly leave people feeling dehumanised."

Nadra Ahmed admits there is no "silver bullet" to solve the problem and instead says "root and branch reform" is the only way forward.

She concludes: "We contribute £55 billion into the economy, we employ more in social care than the NHS, and we look after more people than the NHS on a given day. So it is a sector in its own right and it needs to be acknowledged and recognised as such.

"I will continue to fight for it. I'm an optimist - I think someone will have that lightbulb moment at some point and changes will, eventually, be made."

For the sake of all us, we can only hope that comes true.