Social care 360: quality

10. Quality ratings

Quality is largely stable but fewer ratings have been 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 2024 was very similar to that in April 2023: 4% of services were rated ‘outstanding’, 78% were ‘good’, 16% ‘requires improvement’ and 1% ‘inadequate’. However, in April 2024 the CQC was in transition to a new Single Assessment Framework (SAF) for all health and care services. Though there were few published assessments and ratings using the SAF, and these are not included in the data here, CQC still recommends not drawing comparisons between April 2024 and previous years.    

What is the longer-term trend?  

Ratings have been relatively stable since 2018 when the initial programme of inspections under the then ratings framework (the predecessor to the current SAF) was completed.  Overall, there has been a small overall improvement, with the percentage of inspected services rated good or outstanding increasing marginally from 80.9% in April 2018 to 82.4% in April 2024. 

What explains the trends?   

The very similar pattern of results for quality ratings from April 2021 to April 2024 in part reflects the fact that fewer ratings were published during this period than previously. 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 were published – only 6,784 in 2022/23 compared to 13,505 in 2019/20.  

In 2023/24, CQC operational difficulties also meant only 4,447 ratings were published using the predecessor to the SAF (see ‘what has happened in 2023/24’ below).  

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’. The consistently high quality ratings may also be at odds with public perceptions: only 13% of people said in 2024 that they are satisfied with adult social care, albeit that this includes wider concerns such as accessibility and workforce pay, not just quality of care.  

What has happened in 2023/24?    

In October 2024, an independent review into the effectiveness of the CQC found that a ‘stark’ reduction in inspections across health and social care carried out in 2023, had resulted in a backlog in new registrations of health and care providers, delays in re-inspecting after a ‘requires improvement’ or ‘inadequate’ rating and increasing age of ratings. The review also raised significant concerns about the SAF and its application. A review of the SAF, commissioned by the CQC from the Care Provider Alliance, found issues including the number and overlapping nature of quality statements; inspectors’ lack of knowledge of the wide diversity of service types within social care; unclear, inaccurate and not timely reports; and poor communication with providers.   

The CQC responded to these criticisms in March 2025.  

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. The latest situation is available on the CQC website.  

11. Direct payments

Use of direct payments remains low, particularly among older people 

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 2022/23 to 118,000 in 2023/24. However, the proportion of people receiving long-term care who used direct payments fell from 26% to 25%. 

What is the longer-term trend? 

Around 9,400 fewer people used direct payments in 2023/24 than in 2015/16. Overall, just 25% of people (37% of working-age adults and 14% of older people) drawing on adult social care use direct payments, down from 28% 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. However, it is difficult to recruit PAs. In 2023/24, the vacancy rate for PAs stood at 11.0%.This was the highest vacancy rate for any job role in social care. For those not employing their own staff, direct payments may be less appealing. 

Once recruited, though, PAs are more likely to stay in jobs: at 18.2% the turnover rate of PAs was much lower than for care workers as a whole at 29.9%. A Department of Health and Social Care survey of the social care workforce conduced in 2022 found that PAs had higher work-related quality of life than the care workforce overall.  

12. User satisfaction

Satisfaction levels have remained stable over time 

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 2022/23 and 2023/24, the percentage of service users saying they were ‘extremely’ or ‘very satisfied’ increased from 64.4% to 65.4%. Working-age adults (69%) were more satisfied with their care and support than older people (63%). 

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 (60.4%) report much lower satisfaction than service users in England as a whole. 

What is the longer-term trend? 

The percentage of people satisfied with their care and support has increased slightly over time – in 2014/15, 64.7% expressed satisfaction while in 2023/24 it was 65.4%.  

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. 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, there are other reasons to be cautious, not least from surveys of carers. In 2023/24, only 36.7% of carers report they are extremely satisfied or very satisfied with the services and support received by themselves and the people they care for, down from 39% in 2016/17.  

Satisfaction among the public is also much lower. The 2023 British Social Attitudes Survey found that 64% of people who had used or had contact with social care either for themselves or for someone else were dissatisfied with it. This was 15 percentage points higher than people who have not had contact. The survey includes people who had used or had contact with self-funded care services as well as those that had used publicly-funded services.