Social care 360: quality

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10. Quality ratings

More services are being rated ‘good’ or ‘outstanding’, though fewer ratings were published in 2020/21  

Figure 10: a chart showing that the percentage of care services rated 'outstanding' or 'good' remained high in 2021

Why is this indicator important?  
The CQC inspects and rates adult social care services, giving an overall picture of the quality of social care provision in England.  

What was the annual change?  
Quality ratings in April 2021 were almost identical to those in April 2020. 5 per cent of services were rated overall ‘outstanding’, 80 per cent were ‘good’, 15 per cent ‘requires improvement’ and 1 per cent ‘inadequate’. However, as a result of Covid-19, in March 2020, the CQC paused routine inspections and 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. As a result, only 3,038 CQC inspections that resulted in an allocation of quality ratings were carried out in 2020/21 compared to more than 13,000 in 2019/20.

There are differences between the ratings of different service types in adult social care. At July 2021, community social care services had the highest overall ratings with 92 per cent rated ‘good’ or ‘outstanding’, followed by domiciliary care agencies (88 per cent ‘good’ or ‘outstanding’), residential care homes (85 per cent) and nursing homes (78 per cent).   

What is the longer-term trend?
Over the past six years, the percentage of adult social care services rated ‘good’ or ‘outstanding’ by the CQC has increased. 85 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 the trends?
In June 2017 the CQC published a new assessment framework that was adopted from November 2017. Ratings have been relatively stable since 2018 when the initial programme of inspections was completed, though there has been a small overall improvement with the percentage of services rated good or outstanding increasing from 80.9 per cent in April 2018 to 84.3 per cent in April 2021.

This 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. It might also be expected in a residential care market made up largely of for-profit providers. CQC ratings correlate with higher occupancy rates, which in turn leads to higher income.

Nonetheless, 1 in 6 services remain below standard and the CQC says there remains a problem with small minority of underperforming services that have continually failed to improve: as at 31 March 2020, 3 per cent of care homes and a similar percentage of community care agencies had never been rated better than ‘requires improvement’.

What has happened since?
In May 2021, the CQC set out its new five-year strategy. A key element of this involves targeting its resources services at greater perceived risk of failure and where care is poor.

In its social care White Paper, the government announced a number of measures intended to improve care quality, including funding to support workforce training and development and up to £30 million for an innovative models of care programme to help mainstream innovation in the sector.

11. Direct payments

There has been a continuing fall in the number of people using direct payments

Figure 11: Chart showing that the number of service users using direct payments has fallen for the past four years

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.  

What was the annual change?  
The number of people using direct payments fell from 123,000 in 2019/20 to 118,000 in 2020/21.   

What is the longer-term trend?  
The number of people using direct payments is now lower than in 2015/16 and has fallen for each of the past four years. Overall, just 26.6 per cent of people drawing on adult social care use direct payments, down from 28.1 per cent in 2015/16. This represents 38.4 per cent of working-age adults and just 15.3 per cent of older people.   

What explains this?  
There is likely to be more than one reason behind this fall and, despite government guidance that local authorities should be as flexible as possible in their oversight of direct payments during Covid-19, the pandemic seems to have made little difference to the long-term trend.   

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. 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 has happened in 2021/22?  
In December 2021 the government published a White Paper on reform of adult social care which included commitment to a vision that people using care services would have ‘choice and control over the care they receive’. However, there was no specific mention of how this would be achieved and no measures to increase the use of direct payments. 

12. User satisfaction

User satisfaction is high but no data is available for 2020/21

Figure 12: a chart showing that before 2020/21 satisfaction had remained high, with just a slight fall since 2014/15

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 change?  
Due to Covid-19, the annual satisfaction survey became voluntary for local authorities in 2020/21 and, unfortunately but understandably, only 18 out of 151 took part. There is therefore insufficient data to gauge the annual trend.   

What is the longer-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 explains this?  
The simplest explanation is that service quality had held up quite well, at least before the pandemic, during a period when social care budgets had been struggling (seeIndicator 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 surveys of 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 more satisfied with their care (68 per cent) than older adults (62 per cent); white service users report higher satisfaction than service users from Black and minority ethnic backgrounds; 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 has happened in 2021/22?  
There is no further data on user satisfaction. Data for the 2021/22 period will be published in autumn 2022.   

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Ian Beach

Retired NHS Chief Officer,
Comment date
03 March 2022

Overall, a very informative and useful report. Thank you for it.

Section 10. Quality ratings. The chart would be made more easily understood with a key to the colours used.

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