This briefing provides highlighted information from CQC's annual assessment of health and social care in England, with a particular focus on the regulator’s findings in relation to social care.
CQC ratings across both health and social care sectors suggest that quality overall has been largely maintained, and in some cases improved from last year, and the report notes that public sentiment about health and care services remains largely positive. This is despite the continuing challenges CQC sees around demand and funding, and the significant workforce pressures they identify, as all sectors struggle to recruit and retain staff. The Regulator says that the continuing efforts of staff and leaders to ensure that people continue to receive good safe care must be recognised and applauded.
Nonetheless CQC does have some core concerns, with safety remaining a real problem area: 40% of NHS acute hospitals’ core services and 37% of NHS mental health trusts’ core services were rated as requires improvement on safety at the end of July 2018. One in four people receiving NHS mental health services also did not feel they got services often enough to meet their needs.
CQC says that all providers face the same challenges – in acute hospitals, the pressure on emergency departments is especially visible – but while many are seen to be responding in a way that maintains the quality of care, some are not.
Two further common findings are highlighted by CQC. The first is that people’s experience of health and care varies depending on where they live and in relation to the services they use; and that relates to the second common finding – that these experiences are often determined by how well different parts of local systems work together. The report say that some people can easily access good care, while others cannot access the services they need, experience ‘disjointed’ care, or only have access to providers with poor services.
CQC’s new reviews of local health and care systems found that ineffective collaboration between services affects access to care and support services in the community, which in turn leads to increased demand for acute services. They say it means that a struggling acute hospital can be symptomatic of a struggling wider, health and care system.
I think a key point to make about the annual report is that, although it is based on CQC’s findings from their inspection and regulation activity, it does also address the sector’s wider difficulties and, in particular, does not stint from criticising the level of resource provided by central government, for social care.
On this, CQC welcomes the NHS funding announcement of June 2018 (£20bn), and the additional short-term crisis funding that had been announced just before the annual report was completed (£240m), but says that the NHS investment risks being undermined by the lack of a similar long-term funding solution for social care.
CQC also says that the adult social care market remains fragile, with providers continuing to close or cease to trade, and with contracts being handed back to local authorities. Two years ago, CQC warned that social care was ‘approaching a tipping point’ – as unmet need continues to rise, they now say that tipping point has been reached for some people who are not getting the care they need. And they note that, in ADASS’s annual budget survey, more than three-quarters of directors (78%) were concerned about their ability to meet the statutory duty to ensure market sustainability within existing resources.
It seems likely that CQC’s concerns about funding will only have been partially addressed by the subsequent budget announcement of a £650m short-term boost to adults’ and children’s social care services. For a full account of the financial and other pressures facing adult social care, please see this CareKnowledge Special Report.
Interestingly, in looking at the pressures facing the adult care sector, CQC quotes estimates from Age Concern. These suggest that 1.4 million older people do not have access to the care and support they need, and that, in the previous two years, the number of older people living with an unmet care need has risen by almost 20%, to nearly one in seven older people.
Age UK also estimate that, of the 1.4 million people affected, there are more than 300,000 who need help with three or more essential daily tasks. Their study found that more than half of the 300,000 people received no help at all from paid carers or family and friends.
CQC says that Age UK’s Behind the Headlines report showed that, from 2009/10 to 2016/17, the average spend per adult on social care fell by 14%, from £439 to £379, and from 2008/09 to 2013/14 more than 400,000 fewer older people received social care as eligibility criteria tightened in response to reduced resources. In addition, Age UK reported how the amount of home care provided by councils fell by more than three million hours since 2015. (They also noted that recent annual increases in NHS spending have averaged 1.1% a year (2010/11 to 2014/15), compared with an average annual increase of 3.7% since the start of the NHS)
Other figures quoted in CQC’s report show that, compared with 2010/11, fewer people are eligible for publicly funded social care in England in 2018/19, with the financial thresholds for accessing social care staying unchanged and therefore going down by 12% in real terms.
CQC point to the importance of short-term care, with its potential to reduce the need for costlier longer-term care at a later stage, but note that the latest data from NHS Digital (for 2016/17) show that spending on this type of social care rose by less than 1% from 2015/16, or around £5 million. In comparison, spending on long-term support increased by £539 million (around 4% in cash terms).
ADASS have also warned that, although moving towards prevention and early intervention is an important priority for councils, as budgets reduce, it is becoming harder for councils to manage the tension between prioritising statutory duties towards those with the greatest needs, and investing in services that will prevent and reduce future needs.
The ONS Family Resources Survey 2016/17 is also cited by CQC, and shows that informal care remains a considerable component of care provision, with around 8% of people reporting that they provide some level of informal care, and that this falls disproportionately on women. NHS Digital data shows that informal carers continue to absorb much of the pressure in the system: 77% said they had not received any support or service that allowed them to take a break of between one and 24 hours from caring in the last 12 months.
Other social care issues highlighted in the report include:
- Challenges in recruiting and retaining care workers and nursing staff were found to be common, and were affecting systems' ability to meet people's care needs in care homes and in the community
- A lack of social workers might mean that they were working with high caseloads of people with complex needs, and having an impact on the timeliness of support for older people
- The highest vacancy rates in adult social care, in all regions in 2017/18, were for the regulated professions that include registered nurses, allied health professionals and social workers. They reached 16% in the East of England and 15% in London
- Vacancy and turnover rates for all staff groups were generally higher in domiciliary care agencies than in care homes
- CQC says that the capacity of adult social care provision continues to be very constrained. From April 2017 to April 2018, the number of nursing homes decreased by a further 1.4%, with a drop of 0.2% in the number of nursing home beds (347 beds). The number of residential homes decreased by 2.4% during the same period, also with a reduction of 0.2% of beds (418 beds)
- In contrast, the number of domiciliary care agencies has continued to rise since April 2017, by 4.3%
- CQC note that, at a local level, there was a great deal of variation in these trends. For example, from April 2016 to April 2018, the range of change in nursing home was from a 58% loss to a 44% rise. The 32 local authorities with more than a 10% loss in nursing home beds were dominated by those in the North East, London and the West Midlands, with 17 coming from these areas. These also tended to be areas with lower proportions of people paying for their own care, independently. Of the 19 areas that gained at least 10%, nine were in the South East, South West, and East of England, where higher proportions of people fully fund their own care
- CQC believe that, in some cases, nursing homes may be re-registering as residential homes, possibly due to difficulties in recruiting enough nurses. Some of the areas with the highest nursing home bed loss also saw some large rises in the numbers of residential home beds.
Social care inspection results
- More than four-fifths of adult social care services were rated as outstanding (3%) or good (79%). 17% of services were rated as requires improvement and 1% as inadequate. There are now 605 services rated as outstanding – nearly 250 more than CQC reported last year
- CQC judged that staff continued to care well for people, with 91% of services rated as good and 4% rated as outstanding for the inspectorate’s key question on caring
- By contrast, 2% of services were rated as inadequate and 21% as requires improvement for the question about how well-led services are
- There was variation in ratings between different types of adult social care service, with 4% of community social care services rated as outstanding, 86% rated as good, 10% rated as requires improvement, and none now rated as inadequate. This compares with 3% of nursing homes rated as outstanding, 69% as good, 25% as requires improvement, and 3% as inadequate
- Of the 396 services that were originally rated as inadequate and have been re-inspected since 1 August 2017, 89% improved their rating
- But CQC says that improvement is challenging for many services. Of the 3,031 services that were originally rated as requires improvement and have been re-inspected since 1 August 2017, 42% failed to improve and have retained this rating. A further 7% dropped to a rating of inadequate
- CQC point to evidence that some inequalities in experience are slowly reducing for some people. Specific comment is made on the way improvements in person-centred care and values-led cultures can play a big part in advancing equality and inclusion. Innovative new technology is also being used to help improve equality, for example through enabling disabled people to communicate their needs
- But CQC says that overall progress is very slow and there is potential for much more improvement
- CQC still has concerns about the experience of people in some equality groups, particularly people with a learning disability, mental health conditions or dementia who need to use acute hospital services, and people from Black and minority ethnic (BME) groups using acute mental health inpatient services. And, too few adult social care services carry out specific work to ensure equality for people using their service
- CQC says that more work is needed to implement the Accessible Information Standard to improve communication with disabled people using health and social care services
- Some gaps in access to services and in health outcomes for people who use services are seen to be widening. CQC says this cannot be addressed by providers alone and suggests that health and social care leaders in local areas need to consider differences within population groups, when planning and commissioning services
Key points on the Deprivation of Liberty Safeguards (DoLS)
- CQC says that good practice in applying the DoLS and the requirements of the Mental Capacity Act (MCA) closely aligns with putting the person at the centre of care and focusing on human rights
- Variation in how providers implement DoLS and MCA requirements continues to be an issue, as are delays in local authorities assessing and authorising DoLS applications
- CQC notes that services that use overly restrictive practices often do so because they lack understanding of the MCA and DoLS legislation, but also recognises that services can find it challenging to balance safety and freedom, with limited staff time and resources
- Strong leadership and governance, with a positive organisational culture are seen as key factors underlying good DoLS and MCA practice. These strengths need to be supported by effective partnership working, adequate staffing levels and embedded staff training, which foster positive risk-taking, and encourages greater autonomy for individuals
- A dedicated MCA (including DoLS) lead and team in hospitals are recommended as ways to drive change and improvement in practice
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