Social care 360: quality

10. Quality ratings

Quality is largely stable but fewer ratings are now being published 

Why is this indicator important?

The Care Quality Commission (CQC) inspects and rates care services, giving an overall picture of the quality of social care provision in England.  

What was the annual change?

The pattern of quality ratings in April 2023 was very similar to that in April 2022: 4% of services were rated ‘outstanding’, 79% were ‘good’, 15% ‘requires improvement’ and 1% ‘inadequate’.   

What is the longer-term trend? 

Ratings have been relatively stable since 2018 when the initial programme of inspections under a new ratings framework was completed, though there has been a small overall improvement, with the percentage of inspected services rated good or outstanding increasing from 80.9% in April 2018 to 83.2% in April 2023.

What explains the trends?  

The very similar pattern of results for quality ratings from April 2021 to April 2023 in part reflects the fact that in March 2020, due to Covid-19, the CQC paused routine inspections. Instead, it focused its activity on services where there was a risk to people’s safety and on inspections to assess care homes’ infection, prevention and control measures. These inspections did not result in ratings and, as a result, far fewer ratings have been published in recent years – only 6,784 in 2022/23 compared to 13,505 in 2019/20.  

The longer-term upwards trend reflects efforts by care services to improve ratings and is consistent with the high level of satisfaction reported by people who use publicly funded care services (see indicator 12, user satisfaction,). It might also be expected in a residential care market where people are able to make choices between providers. CQC ratings correlate with higher fees. 

Nonetheless, 1 in 6 services remain below standard and there remains a problem with services that stubbornly fail to improve: as of March 2020, 3% of care homes and a similar percentage of community care agencies had never been rated better than ‘requires improvement’.   

What has happened in 2023/24?   

During 2023/24, the CQC began rolling out its new single assessment framework for care providers, local authorities and integrated care systems.  

In November 2023, the CQC published the five pilot assessments in response to its new duty to independently review and assess local authority performance in delivering their adult social care duties. It began rolling out the assessment programme to all local authorities in December 2023.

11. Direct payments

The fall in people using direct payments levelled off in 2022/23

Why is this indicator important?

Direct payments are intended to allow people using care services more choice and control over their own support. They were intended as a key route to reform of social care in the Care Act 2014.

What was the annual change?

The number of people using direct payments increased slightly from 117,000 in 2021/22 to 117,500 in 2022/23. However, the proportion of people receiving long-term care who used direct payments fell from 27% to 26%.

What is the longer-term trend?

Around 9,700 fewer people used direct payments in 2022/23 than in 2015/16. Overall, just 26% of people (38% of working-age adults and 15% of older people) drawing on adult social care use direct payments, down from 28.1% in 2015/16.

What explains this? 

There is likely to be more than one reason for this. Opting for a direct payment requires more involvement and responsibility than simply receiving a service, and people may need support to manage one. Equally, if there is limited choice of local services on which to spend a direct payment, people may wonder whether it is worth the extra work.

If an individual wants to employ their own care worker (personal assistant (PAs)), then direct payments make that possible. Skills for Care estimated that around 70,000 people receiving direct payments were employing their own staff in 2021. For those not employing their own staff, direct payments may be less appealing. However, it is difficult to recruit PAs. In 2022/23, the vacancy rate for PAs stood at 11.4%. While this was lower than for care workers generally (where the vacancy rate was 11.8%), it may still reduce the attraction of using a direct payment to employ personal assistants. However, at 19.9% the turnover rate of PAs was much lower than for care workers as a whole. 

12. User satisfaction

Satisfaction of people drawing on services is stable

Why is this indicator important?

This annual survey by local authorities of people using publicly funded social care services has limitations but is one of the few available indicators of individual satisfaction with care and support.

What was the annual change?

Between 2021/22 and 2022/23, the percentage of service users saying they were ‘extremely’ or ‘very satisfied’ rose slightly from 63.9% to 64.4%. Working-age adults (68%) are more satisfied with their care and support than older people (61.9%).

What is the longer-term trend?

The percentage of people satisfied with their care and support is essentially unchanged over time – in 2014/15, 64.7% expressed satisfaction while in 2022/23 it was 64.4%. 

What explains this?

The simplest explanation is that service quality has largely held up well during a period when social care budgets have been struggling (see indicator 1, requests for support). This suggests that the most detrimental effect of underfunding has been on the number of people receiving publicly funded care (see indicator 2, receipt of social care) rather than its quality. This would be consistent with the stability in quality as measured by Care Quality Commission (CQC) ratings.   

However, satisfaction varies between service users and according to setting. Working-age adults are significantly more satisfied with their care than older adults; white service users report higher satisfaction than service users from Black and minority ethnic backgrounds; people using residential care report higher satisfaction than people using nursing care or community care; and service users in London (59.5%) report much lower satisfaction than service users in England as a whole.

There are other reasons to be cautious, not least from surveys of carers. In 2021/22, only 36.3% of carers report they are extremely satisfied or very satisfied with the services and support received by themselves and the people they care for; 8.5% of respondents say they are extremely dissatisfied or very dissatisfied. The 2022 British Social Attitudes survey found that two-thirds of people who had used or had contact with social care either for themselves or for someone else were dissatisfied with it. This was 20 percentage points higher than people who have not had contact.

What has happened in 2023/24?

In December 2023, the government’s Care Data Matters committed to revising the adult social care survey (and also the survey of adult carers), which is the primary source of information on people’s satisfaction with publicly funded care services.

During 2023/24, the CQC began rolling out its single assessment framework for care providers, local authorities and integrated care systems. This places significant emphasis on individuals’ experience of the services they receive.