Social care 360: quality

This content relates to the following topics:

10. Care ratings

More adult social care services are rated ‘outstanding’ or ‘good’.

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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 percentage of care services rated ‘good’ or ‘outstanding’ at April 2020 was slightly higher than in April 2019, with all the percentage growth coming in the outstanding category. At 1 April 2020, there were 1,073 services (4.6 per cent) rated ‘outstanding’ compared to 792 (3.5 per cent) in 2019.  

There is variation between different sectors of social care in terms of quality ratings. Community services have lower percentages of services rated ‘inadequate’ or ‘requires improvement’ (7 per cent) while nursing homes have the highest percentage (23 per cent). 

What is the longer-term trend? 
Over the past five years, the percentage of adult social care services rated ‘good’ or ‘outstanding’ by the CQC has continued to edge upwards. 84 per cent of services are now in these categories compared to 68 per cent in 2016. The number of ‘outstanding’ services has increased more than ten-fold from just 77 in 2016 (0.6 per cent). The percentage of services rated ‘requires improvement’ or ‘inadequate’ has fallen.  

What explains this? 
There are some excellent care services in England to be celebrated (and learnt from: an Outstanding Society, comprised of care homes rated ‘outstanding’ by the CQC, exists to share experience and help to drive up quality across the sector). Similarly, people using publicly funded care services report high levels of satisfaction, although these have fallen slightly in recent years.  

This drive to improve ratings might also be expected in a residential care market made up largely of for-profit providers. CQC ratings can correlate with higher occupancy rates which in turn leads to higher income. However, 1 in 6 homes remain below standard and there remains a problem with services that stubbornly fail to improve: 3 per cent of care homes and a similar percentage of community care agencies have never been rated better than ‘requires improvement’.  

What is likely to be the impact of Covid-19? 
During the pandemic, CQC analysis of deaths in care homes shows a small ‘skew’ towards more deaths in homes rated ‘requires improvement’ but overall there is no clear correlation re the distribution of deaths and care home ratings.  

More broadly, since safety is a key element of quality, Covid-19 has clearly had a negative impact on quality of care. There have been around 27,000 excess deaths in care homes and residents have experienced months of limited interaction with other residents and, due to visitor bans, their families and friends. This was largely outside the control of the care homes, however, whose staff in many cases made major efforts to reduce the impact of the pandemic on residents and users of services.  

11. Personalisation

For the third year in a row, fewer people are using direct payments.   

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Why is this indicator important? 
Direct payments 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.  

Since 2015, everyone receiving support in the community from their local authority must receive a personal budget setting out the money allocated to meet their needs. People can choose how to receive their personal budget. One option is a direct payment – money paid to the person to organise and pay for their own care and support themselves (often by hiring someone to work for them as a personal assistant who carries out a wide range of support tasks for them in the home, at leisure or in work).

What was the annual change? 
The number of people using direct payments fell from 126,000 in 2018/19 to 123,000 in 2019/20.  

What is the long-term trend? 
The proportion of people using direct payments has fallen to its lowest since 2015/16: 39.5 per cent of working-age adults and just 16.9 per cent of older people. The number of people using direct payments is also lower than in 2015/16 and has been falling for each of the past three years.  

What explains this? 
There is likely to be more than one reason. Opting for direct payment requires more involvement and responsibility than simply receiving a service, and people may need support to manage one. However, service-user groups say some local authorities offer far more support than others. Some are also more prescriptive than others about what direct payments may be spent on. Think Local, Act Personal, a national partnership of more than 50 organisations committed to transforming health and care through personalisation and community-based support, argues that ‘People’s experience suggests that the law has not been implemented as originally envisaged, and the full benefits of direct payments have not been realised.’ 

This may reflect different approaches to personal budgets by local authorities, or even individual social workers within those authorities. 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), then direct payments certainly make that possible. If they do not, then direct payments may be less appealing. Just under half (47 per cent) of people receiving a direct payment for their care and support needs were estimated to be employing staff in 2018/19

What is likely to be the impact of Covid-19? 
It remains to be seen whether Covid-19 will make any difference to take-up of direct payments, though there have been some positive stories about how they have been used. In the initial stages of the pandemic, some users of direct payments describe feeling abandoned by local authorities. The needs of direct payments users, especially where they employed their own personal assistants, was not understood so support and guidance from national agencies, for example, around usage of PPE, was slow to arrive.   

However, some people did find that, during the pandemic, local authorities were less prescriptive in how direct payments might be used and, as the pandemic progressed, so did the quality of support and guidance from national bodies. Think Local, Act Personal says it has seen many positive stories of where the pandemic led to ‘a proportionate approach to monitoring direct payments and increased flexibilities around expenditure, in line with the intentions of the Care Act.’ It is possible these changes will be maintained.   

12. Satisfaction

There has been a small, long-term fall in user satisfaction. 

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Why is this indicator important? 
This annual survey by local authorities of people using publicly funded social care services is one of the few available indicators of individual satisfaction with care and support. However, there is no data on the satisfaction of people paying for their own care.  

What was the annual trend?
The percentage of people saying they were ‘extremely satisfied’ or ‘very satisfied’ with their care and support fell very slightly from 64.3 per cent to 64.2 per cent. 

What is the long-term trend? 
There has been a slight overall fall in the number of people satisfied with their care and support – in 2014/15, 64.7 per cent expressed satisfaction, but by 2019/20 this had fallen to 64.2 per cent. There has also been a small overall increase in the number saying they are ‘extremely dissatisfied’ or ’very dissatisfied’ (from 1.5 per cent in 2014/15 to 2.1 per cent in 2019/20).  

What might explain this? 
The simplest explanation is that service quality has held up quite well during a period when social care budgets have been struggling (see indicator 1). This suggests that that the most detrimental effect of underfunding has been on the number of people receiving services (see indicator 2) rather than its quality. This would be consistent with the slow increase in quality as measured by CQC ratings.  

However, there are reasons to be cautious, not least from carers. Only 38.6 per cent of carers report they are ‘extremely satisfied’ or ‘very satisfied’ with the services and support received by themselves and the people they care for. 7.2 per cent of respondents say they are ‘extremely dissatisfied’ or ‘very dissatisfied’. There is also research to suggest that some people may be expressing gratitude for services rather than satisfaction. Satisfaction also varies between service users and according to setting. Working-age adults are significantly more satisfied with their care (68 per cent) than older adults (62 per cent); white service users report higher satisfaction than Black and minority ethnic service users; people using residential care report higher satisfaction than nursing care or community care service users; and service users and carers in London report lower satisfaction than service users in other areas of England. 

What is the impact of Covid-19 likely to be? 
It is not possible to forecast responses to this survey in 2020/21 and, unlike in previous years, participation by local authorities will be voluntary. Questions will, however, include ones specifically asking how users of services feel about the support they received from professionals involved in their care during the Covid-19 pandemic.  

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