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Nick Bruce

Why Small is Beautiful

Dr Nick Bruce is the founder and non-executive chairman of Nightingale Retirement Care Ltd, and holds a Doctorate in Business Administration from the University of Liverpool.

Within long-term care, academmic research is challenging the dominance of large providers and underlining why small is beautiful. The CQC agrees (Ref. 3).

Despite the prevailing industry trend for larger care companies and franchises, there’s compelling academic evidence that smaller providers are often significantly better at enhancing client satisfaction and overall welfare (Ref. 1, 5). This isn’t merely a matter of funding or the constraints of high demand versus limited budgets. For Nightingales, it’s about focus and fundamentally rethinking the value and recognition of those at the heart of care provision – our employees (Ref. 4, 6).

The conventional funding model for care is a blend of public and private sources, intricately linked to the type of care and the individual’s financial capacity. Many providers attempt to straddle this divide, securing large block contracts with local and health authorities while simultaneously courting private clients, who typically have longer visits and contribute higher fees. This dual approach, however, creates a set of challenges that can leave their private clients feeling undervalued and overlooked.

One significant issue is the prioritisation of clients. When a substantial portion of a provider’s business hinges on one funding source, private clients typically become secondary. This often results in irregular and unpredictable care schedules, and a revolving door of caregivers whom they have not seen before. The lack of consistency not only leads to stress and discomfort through having strangers in their home, but also the additional stress and uncertainty of not knowing when and if their needs will be met, particularly when timely support is crucial (Ref. 5).

Another critical challenge is staff recruitment and retention. State-funded visits, constrained by tight budgets, are often brief and transactional, offering little room for caregivers and clients to establish meaningful connections (Ref. 5). This model leads to high staff turnover, and providers, grappling with recruitment challenges, frequently resort to hiring from abroad or overusing agency staff (Ref. 2). This can further strain client satisfaction due to potential cultural and communication barriers.

Our approach, centred on remaining a small-scale, private client-focused entity, adeptly navigates these challenges. Our bespoke approach to care not only ensures a more personalised and consistent care experience but also leads to a deeper sense of community and connection between clients and caregivers (Ref. 2, 5). Further, by embracing employee ownership, we empower our staff, enhancing their job satisfaction and commitment, which in turn positively impacts the quality of care provided – each of them think and act like owners (Ref. 1, 6).

Flexibility is still a part of our model, accommodating unforeseen client needs or staff availability. However, our clients predominantly enjoy the stability of knowing who their caregiver will be, the assurance of punctuality, and the comfort of familiar faces (Ref. 5). This level of personalisation and consistency in care is not just a differentiator; it’s a game-changer in terms of client satisfaction and health outcomes.

Our approach doesn’t just meet the standard; it redefines it, placing client welfare and employee value at the forefront of long-term care.




  1. Bhattacharyya et al (2022) – Self-reported satisfaction of older adult residents in nursing homes: Development of a conceptual framework.
  2. Holder et al (2012) – Forced relocation between nursing homes: residents’ health outcomes and potential moderators.
  3. CQC (2017) – The state of adult social care 2014-2017- Findings from CQC’s initial programme of comprehensive inspections in adult social care.
  4. Kane et al (2007) – Resident outcomes in small-house nursing homes: A longitudinal evaluation of the initial Green House program.
  5. Keller et al (2012) – Does the perception that stress affects health matter? The association with health and mortality.
  6. Rosenberg (2021) – More nursing home staff linked to more COVID-19 cases.
  7. Shields et al (2023) – Why is subjective stress severity a stronger predictor of health than stressor exposure? A preregistered two-study test of two hypotheses.
  8. Slavich et al (2020) – Social Safety Theory: A biologically based evolutionary perspective on life stress, health, and behaviour.
  9. Spangler et al (2019) – Small is beautiful? Explaining resident satisfaction in Swedish nursing home care.
  10. Verderber et al (2023) – Residential environments for older persons: A comprehensive literature review (2005–2022).
  11. Vermeerbergen et al (2017) – A compairson of working in small-scale and large-scale nursing homes: A systematic review of quantitative and qualitative evidence.