Social care 360: quality

This content relates to the following topics:

10. Quality ratings

Quality is largely stable but fewer ratings were published during Covid-19  

Chart showing that the percentage of adult care services in England whose overall rating is 'outstanding' or 'good' has increased since 2016

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 2022 were almost identical to those in April 2021. 5 per cent of services were rated ‘outstanding’, 79 per cent were ‘good’, 15 per cent ‘requires improvement’ and 1 per cent ‘inadequate’.   

What is the longer-term trend? 
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 83.8 per cent in April 2022.  

What explains the trends?  
The nearly-identical pattern of results for quality ratings in April 2022 and April 2021 reflects the fact that, due to Covid-19, in March 2020, 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 rating and, as a result, far fewer ratings have been published in recent years – only 5,081 in 2021/22 compared to 13,337 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. It might also be expected in a residential care market where people are able to make choices between providers. CQC ratings correlate with higher occupancy rates which, in turn, leads to higher income. 

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 per cent of care homes and a similar percentage of community care agencies had never been rated better than ‘requires improvement’.   
What has happened in 2022/23?   

Since May 2021, the CQC has been operating to a new five-year strategy. A key element of this involves targeting its resources at services at greater perceived risk of failure and where care is poor.  

In April 2023, the CQC is due to begin carrying out a duty to independently review and assess local authority performance in delivering their adult social care duties, as set out in the government’s 2021 social care White Paper.  

11. Direct payments

Fewer people receive direct payments 

Chart showing that the number of service users in England receiving direct payments continues to fall

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 fell from 118,000 in 2020/21 to 117,000 in 2021/22.  

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 five years. Overall, just 26.7 per cent of people (38.4 per cent of working-age adults and just 15.5 per cent of older people) drawing on adult social care use direct payments, down from 28.1 per cent 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 proving difficult to recruit PAs. In February 2022, the vacancy rate for PAs stood at 13.1 per cent, even higher than that for care workers, so this may also reduce the attraction of using a direct payment to employ personal assistants. However, the turnover rate of PAs was much lower than for staff in the social care sector as a whole.  

What has happened in 2022/23?  
In December 2022, the House of Lords Adult Social Care Committee recommended the government should develop innovative models to make direct payments and personal assistance easier to access and manage.  

12. User satisfaction

Satisfaction of people using services is edging downward 

Chart showing that service-user satisfaction in England is starting to show a small decrease in satisfaction levels

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? 
The response rate was very low for the annual satisfaction survey in 2020/21 due to Covid-19 but between 2019/20 and 2021/22 the percentage of service users saying they were ‘extremely’ or ‘very satisfied’ fell from 64.2 per cent to 63.9 per cent.  

What is the longer-term trend? 
There has been a small overall fall in the number of people satisfied with their care and support – in 2014/15, 64.7 per cent expressed satisfaction, but by 2021/22 this had fallen to 63.9 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 2.6 per cent in 2021/22).    

What explains this? 
The simplest explanation is that service quality has largely held up quite well during a period when social care budgets were struggling (see indicator 1, requests for support). This suggests that that the most detrimental effect of underfunding has been on the number of people receiving services (see indicator 2, requests for support) rather than its quality. This would be consistent with the stability in quality as measured by 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 report 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 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; 8.5 per cent of respondents say they are ‘extremely dissatisfied’ or ‘very dissatisfied’. The 2021 British Social Attitudes survey of satisfaction with social care also reports low levels of satisfaction among people who have used or had contact with services, with 66 per cent dissatisfied. This survey includes both publicly and privately funded care.  

What has happened in 2022/23? 
There is no further data on user satisfaction.  

Return to the Social care 360 landing page >>


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.

Add your comment