CQC: State of Care Report 2023/24 - Social Care Focus

In its State of Care report in 2022, CQC commented on a healthcare system emerging from the pandemic and noted a system in gridlock. In this year’s report, CQC highlights that increased running costs and workforce challenges have escalated pressures on services even further, increasing health inequalities and producing a system where, increasingly, those who can afford to pay for treatment do so, and those who can’t face reduced access to services and longer waits whilst their conditions deteriorate.

In terms of social care, CQC note that its Market Oversight data (monitoring the largest groups of social care providers) shows care home profitability remains at historically low levels mainly due to staff costs, fuel and food costs and inflation; this is particularly the case for specialist services, where profitability has declined to a margin of 14.6% (down from 19.7% in September 2021).

Some key points arising from the report specific to Social Care providers are:

Access to Care

• CQC states that insufficient capacity in adult social care is continuing to contribute to delays in discharging people from hospital. As at August 2023, there were 12,000 patients in hospital awaiting discharge (although this was down from 14,000 in January 2023).
• CQC’s analysis shows care home occupancy running at 84% in July 2023 (85% pre-pandemic) but the number of registered care home beds in England reduced by 2,905 in the year to July 2023. According to CQC, social care providers are reluctant to increase capacity due to lack of staffing.
• CQC reports instances of the cost of living crisis leading service users who self-fund their homecare reducing their care packages, impacting on their quality of life.
• The report also warns of the dangers of unsafe discharges from hospital without adequate risk assessments and care plans in place and notes that, in the 12 months to June 2023, 9% of people had to go back to the emergency department within 7 days of their previous attendance.
• The impact a lack of access to NHS services is having on social care providers is highlighted noting difficulties securing GP appointments for service users in adult social care services and ambulance delays exacerbating the ability of providers to support service users who have fallen.
• CQC notes that its first look across local care systems, using its new powers to regulate local authorities and ICBs, shows that not all systems have sufficiently clear timeframes and measures in place to reduce health inequalities in terms of access to, and experience of, health and social care.

Quality of Care

• Staff reported that increasing demand and pressures are taking a toll on their mental health and wellbeing, which is in turn (without the appropriate support) affecting the quality of care they deliver.
• A high staff turnover is leading to skills gaps, particularly in services for autistic people and people with a learning disability.
• Inspections showed that staff do not always have the training to carry out key assessments/reviews, which has led to delays in people receiving (or not receiving at all) higher level assessments (e.g. dysphagia, and behaviour assessments). This in turn has led to people receiving poorer quality care.
• Care home providers raised the challenges of managing pain and relieving symptoms for people receiving end of life care, including delays to treatment, and the cost and lengthy process of obtaining Home Office licences to hold small doses of controlled drugs as anticipatory medicines.
• CQC was encouraged to see evidence of providers using innovation – both technology and non-technology driven – to improve the quality of care.

Inequalities

• The pandemic and cost of living crisis have widened and exacerbated inequalities, both for people using health and social care services and those who work in these services. There remain unacceptable inconsistencies in outcomes for autistic people with a learning disability.
• CQC is concerned that, for autistic people and people with a learning disability, failures in the system and a lack of funding can result in budgets being prioritised over truly person-centred approaches to support. This can hinder the delivery of quality care and support to individuals.
• CQC states that its inspection activity shows that care providers do not always address the physical health needs of autistic people and people with a learning disability; for example, delaying seeking appropriate medical attention when needed.

Deprivation of Liberty Safeguards

• The number of applications has continued to increase (by 11% since last year) and CQC remains concerned that the current system is unable to cope with the demand for assessments, leaving many in vulnerable circumstances without legal protection for extended periods.
• Only 19% of standard applications to deprive a person of their liberty were completed within the statutory 21-day timeframe, with the average application taking 156 days (over 7 times the statutory timeframe).
• The delay of the implementation of Liberty Protection Safeguards (“LPS”) is of concern. CQC states that those who are disabled or old are likely to be disproportionately affected by the decision to delay LPS.
• Remote assessments are often used to tackle local authority resourcing issues. However, CQC expresses concern that such assessments may not always provide enough detail to assess the care environment.
• There remains a concern that some providers have a limited understanding of the Deprivation of Liberty Safeguards (“DoLS”) framework, resulting in the overuse of restrictive practices and staff not always implementing the conditions attached to a DoLS authorisation.
• Some providers are not delivering adequate training on DoLS and there continues to be poor recording of mental capacity assessments.

Health and care workforce

• CQC continue to call for a national workforce strategy that raises the status of the adult social care workforce and ensures that career progression, pay and rewards attract and retain the right numbers of professional staff. They note that it is encouraging that Skills for Care has made this a focus.
• CQC’s adult social care provider survey reports ongoing challenges in recruitment and retention of staff. But care home vacancy rates have reduced from 11% (January to March 2022) to 7% (April to June 2023) with 70,000 overseas care workers arriving in the UK in 2022/23 (up from 20,000 in 2021/22).
• CQC raise concerns, however, about a growing trend of unethical international recruitment practices, having made 37 referrals regarding modern slavery, labour exploitation and international visas in 2022/23.
• The report recognises the significance of promoting the wellbeing of staff and building a culture that invests in staff and their wellbeing. There is a need to create supportive working environments and systems to address issues such as stress and burnout.

Systems

• CQC note that their assessments of local authorities have identified that workforce capacity and capability pressures, and financial pressures are forcing some care providers out of the market or increasing their reliance on self-funders.
• Nationally, there is under-provision of services for autistic people, specialist dementia care, and nursing home beds.
• There is a shift from long-term care to community-based services that promote independent living, prevention and enablement.
• CQC comment that significant market investment will be needed to provide extra care housing, supported living and suitable community housing, as well as homecare services.
• There is a need for respite, reablement and step-down/discharge-to-assess services to help support the speedy discharge of people from hospital.
• Despite the recognised challenges for staffing, CQC note that very few authorities have published workforce strategies.
• Local authorities have reported a strategic focus on unpaid carers and working with employers to support carers to stay in employment. However, CQC found most local authorities have not published a recent carers strategy and there is little up-to-date data on local carers that they have shared publicly.
• CQC note that its first look across local care systems, using its new powers to regulate local authorities and ICBs, shows that not all systems have sufficiently clear timeframes and measures in place to reduce health inequalities in terms of access to and experience of health and social care.

Ratings

CQC states that when it looked at the ratings as at 1 August 2023, it found that 83% of Adult Social Care Providers were rated Good or Outstanding (compared to 84% in 2022), with 16% rated as Requires Improvement and 1% rated as Inadequate (15% and 1% respectively in 2022). The ratings are further broken down by the type of Adult Social Care service provided. To view the full ratings see Appendix: CQC ratings charts - Care Quality Commission. It will be interesting to see how the new Single Assessment Framework, soon to be introduced, will impact the overall ratings for services in the sector moving forward.

To read the full report, click here: State of Care - Care Quality Commission (cqc.org.uk)

If you would like to discuss the issues raised in this report in more detail, or have a regulatory query, please get in touch with Carlton Sadler, Partner, Siwan Griffiths, Partner or Amelia Bauer, Solicitor.