The Care Quality Commission (CQC) has set out lessons from the first tranche of assessments of local authority adults’ services since it resumed performance checks in December 2023.

It said that support for carers was in need of improvement, while authorities also needed to enhance their understanding of population equality and diversity issues and use of data, though reablement was an area of strength.

CQC deputy directors Amanda Stride and Lella Andrews made the comments in a presentation to a Local Government Association webinar on its assessment system for councils in England.

Need to improve support for carers

Stride and Andrews said support for unpaid carers was an area of improvement identified by the CQC’s assessments to date.

This included improving the identification of carers, the range and capacity of services for them, the timeliness of assessments and the personalisation of support, based on the age and needs of the person being cared for.

The conclusion reflects the results of a recent Carers UK survey, which found that over half of carers felt they required more recognition of their needs from councils, with some reporting long waits for assessments or support.

The CQC officials also pointed to understanding of population equality and diversity issues as an area for improvement, and said councils’ inconsistent use of data made it harder for them to effectively plan and monitor services.

Challenges with recruitment and transitions

Transitions for young people to adults’ services were often challenging, especially if they did not start early, while councils faced ongoing recruitment pressures, particularly in relation to occupational therapists.

However, reablement was an area of strength, with the CQC having seen good practice in its use to support people to regain independence, said Stride and Andrews.

They added that, while the CQC’s assessment methodology would not change, it was working with sector bodies to make improvements, including in how it gathers evidence of lived experience and collects provider views.

Councils ‘want to work with the CQC to improve process’

In response to the findings, the chair of the LGA’s community wellbeing board, David Fothergill, said: “Councils are keen to learn and improve services. Identifying common themes is essential not only for addressing challenges but also for sharing what works well.

“We want to work with the CQC to ensure the assurance process is productive and valuable, helping councils build on strengths as well as tackle areas for improvement.”

He pointed to the LGA’s work, with the Association of Directors of Adult Social Services (ADASS), through the Partners in Care and Health sector-led improvement initiative, which “plays a key role in supporting the sector to continually drive progress”.

Partners in Care and Health has published guidance for councils on learning from CQC assessments carried out to date, including reflections on the process from adults’ services directors in authorities that have been assessed and an analysis of what it takes to get a good rating, based on the first set of reports.

A lack of staff and hospital beds, at a time of “overwhelming demand”, is leading to “harmful” gaps in mental healthcare, the Care Quality Commission (CQC) has said.

As a result, people were being discharged prematurely, often without adequate community support, leading to cycles of readmission to hospital, with increasing use of inappropriate out-of-area placements.

The warnings came in the regulator’s annual report on its monitoring of the Mental Health Act 1983, which covered 2023-24.

This was based on conversations with 4,634 patients and 1,435 carers from 823 monitoring visits to mental health services, interviews with other people with lived experience of detention and analyses of national data on mental health.

Spike in demand for care

Demand for mental healthcare has grown significantly in recent years, said the CQC, which reported that:

• There had been a 43% rise in the number of people in contact with secondary mental health services in the five years to March 2024, according to NHS England’s mental health services data set (MHSDS).
• There was an 18% increase in the number of adults with a serious mental illness who accessed community mental health services between March 2023 and March 2024 (source: MHSDS).
• The number of very urgent adult referrals to crisis teams more than doubled in 2023-24.

The latter figure suggested that people were becoming more unwell while waiting for help than was previously the case.

People ‘more unwell on admission than in the past’

This was reflected in services reporting that people admitted to hospital under the MHA now were more unwell than in the past, which the CQC said could increase recovery time and made it more difficult to admit new patients.

However, inpatient services lacked sufficient beds, which meant that occupancy levels in mental health wards continued to be much higher than the 85% maximum recommended by the Royal College of Psychiatrists. Since the start of 2023-24, the occupancy rate has ranged from 89.6%-90.6%, according to the college.

The pressure on beds meant people were placed on wards that were not suitable for them. For example, the CQC observed that people with dementia or cognitive impairments had been placed on wards for those with functional mental health conditions, meaning they were not cared for in dementia-friendly environments.

In another case, seclusion rooms – which are designed to segregate patients from others in times of crisis – were being used as bedrooms due to bed shortages, meaning people were being cared for in overly restrictive settings.

Rising numbers of out-of-area placements

The situation was also leading to people being placed in hospitals far from home, with official figures showing there were 5,500 new inappropriate out-of-area placements in 2023-24, up 25% on the previous year, the CQC said.

The regulator cited a report last year from the Health Services Safety Investigations Body (HSSIB), which found that people were being harmed by OAPs, due to the increased anxiety of not knowing new staff and being separated from support networks.

The CQC said it saw “multiple examples” of people being placed out of area, without clinical benefit, because of a lack of local beds.

‘Pressure to discharge least unwell patients’

The pressures on wards meant managers felt they had to discharge the “least unwell” patients, with carers also telling the CQC that loved-ones had left hospital too soon.

The regulator found examples of good practice in the provision of post-discharge support, however, this was affected by the pressures on community services, which increased the risks of readmission.

Though the MHA code of practice states that aftercare, provided under section 117 of the act, should encompass health, social care, employment support and supported accommodation, as required, the CQC said its provision was “often far less holistic” than this.

Lack of staffing

Service pressures were exacerbated by a lack of staffing, despite a 35% rise in the number of full-time equivalent mental health workers in the NHS from 2019-24.

Issues included wards not having a permanent responsible clinician, multiple wards not having occupational therapists available and others not having physiotherapists.

Staff shortages led to activities, such as group excursions, day trips and access to gyms, being delayed or cancelled, and patients being prevented from taking authorised leave, potentially delaying recovering and leading to distress.

The situation was leading services to use agency or bank staff, resulting in a lack of continuity of care for patients and, sometimes, poor interactions between staff and patients.

Also, shortages and a high turnover of care co-ordinators in the community led to challenges with the discharge process.

In addition, the CQC found that gaps in staff knowledge were affecting the quality of care for autistic people and those with a learning disability, with some staff having not completed mandatory learning disability and autism training.

People’s rights not explained to them

Other issues cited by the regulator included cases of people not understanding their rights under the MHA. This included:

• patients not being informed of their rights at admission or significant delays them being informed after admission;
• staff not providing updates to patients on their legal rights when the section of the act under which they were detained changed;
• patients not being referred to an independent mental health advocate (IMHA) when they did not understand their rights;
• legal rights information not given in a person’s preferred language.

‘Legislation alone won’t fix issues’

The report comes with the government legislating to reform the MHA in order to reduce the use of detention, improve patients’ rights over their care and prevent autistic people and those with learning disabilities from being detained without a co-occurring mental health condition.

While acknowledging the aims of the Mental Health Bill, the CQC said the sector’s problems could not be fixed by legislation alone, in the absence of additional resource.

“It is essential that the government addresses these significant gaps now to protect people for the future,” said the regulator’s interim director of mental health, Jenny Wilkes. “With the right funding, a sustainable and well-trained workforce and enough beds to meet demand, we can break this damaging cycle.”

‘The very opposite of dignified, humane care’

In response to the report, the chief executive of the charity Mind, Sarah Hughes, echoed the CQC’s calls for greater investment in community care, the workforce and mental health facilities.

“Fundamental problems with the very basics of safe care, like adequate staffing levels, bed capacity and run-down hospitals, are severely impacting people’s ability to properly recover,” she added.

“Being sent hundreds of miles away from your family and loved ones, and not even being able to contact them due to facility issues, would be difficult enough at the best of times, let alone when you’re experiencing a mental health crisis. Isolating people in this way, and holding them in crumbling, outdated facilities, is the very opposite of dignified, humane care.”

The Care Quality Commission has issued the first outstanding rating for a council since it resumed assessing local authority adult social services at the end of 2023.

The London Borough of Camden earned the accolade after the regulator found that it was offering “exceptional levels of service”, with no waiting lists across key services and a strong focus on tackling inequalities.

Camden is the 26th of the 153 councils in England to receive an assessment from CQC since its so-called local authority assurance process started in December 2023.

Of the others, 14 have been rated good, 11 requires improvement and none inadequate.

High scores across all areas assessed

Alongside their ratings, councils are given a score out of 100 indicating how well they performed against the nine quality statements that make up the assessment, for which the authorities are awarded a mark of 1-4.

Camden’s score was 89 – 11 more than the next best performer so far – thanks to it receiving the top score of 4 – which denotes an “exceptional” standard – in five of the quality statements. These were equity in experience and outcomes; partnerships and communities; safe pathways, systems and transitions; governance, management and sustainability, and leadership, improvement and innovation.

It was scored a 3 for the other four statements: assessing needs; supporting people to lead healthier lives; care provision, integration and continuity, and safeguarding.

Other councils encouraged to learn from borough

James Bullion, chief inspector of adult care and integrated care, CQC

The CQC’s chief inspector for adult social care and integrated care, James Bullion, said that Camden provided “high-quality and person-centred support”, underpinned by “strong partnership working, a commitment to equity and a focus on prevention”.

“Overall, Camden should be extremely proud of this assessment and the outstanding care they’re providing to people,” he added.

Other local authorities should look at this report to see if there’s anything they can learn.”

No waiting lists in key areas

In recent years, councils have struggled to manage demand without waiting lists for assessments and support, prompting the previous government to make cutting waiting times a priority.

However, the CQC found Camden had no waiting lists for care assessments, hospital discharge, care home placements, home care services, reablement, Deprivation of Liberty Safeguards assessments and safeguarding cases.

This was on the back of “significant action to reduce waiting times”, aided by the borough investing in 12 additional social worker and occupational therapy posts as part of a recent restructure.

Though there were high numbers of reviews overdue, this had reduced since October 2023, with partners praising the timeliness of reviews.

‘A prevention approach’ and meeting non-eligible needs

“A prevention approach was evident at all levels of the local authority,” the CQC found.

Camden uses the ‘three conversations’ model, under which practitioners seek to connect people with community sources of support and only determine if they are eligible for care and support if these do not resolve the challenges and risks that they face.

The CQC found that family group conferencing was also used effectively to support people without eligible needs to make decisions and link them with community groups.

There were also “many examples” of the council commissioning charities and social enterprises to provide services such as befriending, transport and shopping, as well as mental health and housing.

A higher proportion of older people discharged from hospital (4.7%) received reablement services than the national average (2.9%), with a higher proportion (87.2%) still at home three months after a discharge than average (83.7%), while feedback on reablement services was positive.

Equity ‘at the heart of services’

The regulator said it found that Camden had placed equity “at the heart of its adults’ services”, with the authority using data analysis to “identify and reduce inequalities in people’s care and support experiences and outcomes”.

This included plans to improve health and social care outcomes for the borough’s Bengali and Somali communities through the Better Care Fund in 2024-25.

The authority had also prioritised accessibility and inclusion arrangements for autistic adults and people with learning disabilities, sensory loss, multiple disadvantages, autistic adults or interpretation requirements.

‘Proactive’ monitoring of service quality

The London borough proactively monitored the quality of commissioned services.

This involved regular quality assurance visits, involving resident and carer feedback and analysis of CQC provider reports, and action plans to support those rated requires improvement by the regulator.

The council also took steps to ensure care staff in provider services were paid the London Living Wage plus travel and had appropriate working conditions.

Though adult social care vacancy levels across the borough in 2023-24, at 16.8%, were double the national average 8.1%, turnover rates were lower (10% vs 25%).

The CQC said Camden had “effective systems processes and practices to make sure people were protected from abuse and neglect”. This included having no waiting lists and an effective multi-agency safeguarding hub, through which all referrals were routed.

Rating is ‘testament to staff dedication, compassion and expertise’

Camden’s cabinet member for health, wellbeing and adult social care, Anna Wright, said the rating was a “testament to the dedication, compassion, and expertise of our adult social care staff”.

“The report highlights Camden’s positive and inclusive culture and our willingness to innovate and to test and learn,” she added. “It’s great to see the report also highlights the strong partnerships that we have built – with providers, health services, and our wider community – to deliver the best possible outcomes for our residents.”

She added: “We know that there are more improvements we must make, and I want us to build on this success and keep developing our services to ensure that people in Camden can rely on the best possible care and support.”

Celebrate those who’ve inspired you

Photo by Daniel Laflor/peopleimages.com/ AdobeStock

Do you have a colleague, mentor, or social work figure you can’t help but gush about?

Our My Brilliant Colleague series invites you to celebrate anyone within social work who has inspired you – whether current or former colleagues, managers, students, lecturers, mentors or prominent past or present sector figures whom you have admired from afar.

Nominate your colleague or social work inspiration by filling in our nominations form with a few paragraphs (100-250 words) explaining how and why the person has inspired you.

*Please note that, despite the need to provide your name and role, you or the nominee can be anonymous in the published entry*

If you have any questions, email our community journalist, Anastasia Koutsounia, at anastasia.koutsounia@markallengroup.com

“Chronic” Deprivation of Liberty Safeguards (DoLS) backlogs are leaving many people without the human rights protections the system was designed to provide, the Care Quality Commission has warned.

People will continue to be failed without “urgent action” to overhaul a system that “has needed reform for over 10 years”, the CQC said, in a damning verdict on DoLS, delivered in its annual State of Care report, published last week.

The regulator found councils lacked sufficient assessors to deal with the volume of cases they received from care homes and hospitals, but also identified a “wide variation” in how authorities managed applications and in backlog levels.

It also said that a lack of knowledge of the DoLS, and the wider Mental Capacity Act 2005 (MCA), among provider staff was leading to unnecessary DoLS applications and overly restrictive practices in relation to people needing care and support.

A mounting DoLS caseload

The report comes ten years after a House of Lords committee dubbed the DoLS “not fit for purpose” on the grounds that thousands of people were being unlawfully deprived of their liberty without safeguards. At the time, councils in England were receiving about 13,000 applications a year.

In the same month as the committee’s report, the Supreme Court’s landmark Cheshire West judgment widened the definition of a deprivation of liberty, resulting in a tenfold rise in the number of DoLS cases from 2013-14 and 2014-15.

Application numbers have continued to mount since, reaching a record 332,455 in 2023-24. While councils have vastly increased the number of cases processed over the same time – with a record 323,870 completed in 2023-24 – this has not stopped a huge backlog emerging, with 123,790 cases left incomplete as of 31 March 2024.

Planned reform stalled

Despite legislation to replace the DoLS with a more streamlined system – the Liberty Protection Safeguards – passing into law in 2019, the Conservatives failed to implement this, while Labour has given no indication, as yet, that it will do so.

“At present, it is unclear when or if the LPS reforms will be implemented,” said the CQC. “We are keen to establish a dialogue with the new government about this.”

The CQC said the issues raised by the Lords committee in 2014 had been “exacerbated by the stark increase in the volume of applications” since.

Like several previous reports, it highlighted that, because of the backlogs, many people were being deprived of their liberty unlawfully, without the safeguards required by the European Convention on Human Rights that are supposed to be provided by DoLS.

Lack of assessors ‘a primary barrier to performance’

Based on a survey of the National DoLS Leads Network, the CQC heard “widespread concern” that councils were “often significantly under-resourced” to deal with caseloads, as their funding had not kept pace with the increasing number of people requiring assessments.

It found that a lack of assessors, many of whom are social workers working as best interests assessors (BIAs), was a “primary barrier to performance”. Many councils were struggling to recruit and several were “relying significantly on independent assessors to manage the volume of applications”.

Some respondents also reported high turnover, describing DoLS as a practice area in which practitioners either thrived or, more often, left the service.

‘Wide variation’ in local authority approach

The CQC found significant differences in backlog levels, driven by factors including budgets, demography and the numbers of care homes and hospitals in an area, but also said there was also a “wide variation” in how councils managed applications.

Many were making use of the Association of Directors of Adult Social Services’ (ADASS) screening tool to prioritise applications. This grades applications into higher, medium or lower priority, based on factors such as whether the person was actively objecting to their arrangements, the level of restraint or sedation they were experiencing and whether they were in a settled placement.

However, the CQC said it was concerned that certain groups, such as people with dementia or learning disabilities, risked facing disproportionate levels of delay due to being classified as lower priority.

The tool was also reliant on councils receiving detailed, accurate applications from care homes or hospitals, which some authorities were not confident that they were given.

Lack of DoLS knowledge among provider staff

Councils also told the CQC that a lack of knowledge among provider staff was an ongoing factor contributing to delay, either because of unnecessary applications being made or authorities having to go back to the provider to seek further information.

“This risks people who need the safeguards getting lost in the high volume of referrals, or not having an application made when they need one,” the regulator said.

The CQC saw examples of applications that did not include mental capacity assessments, did not specify what and why specific restrictions were needed and failed to acknowledge less obvious restrictions that were already being implemented, such as sensor movement trackers or bed rails.

There was a “misconception among some providers that a DoLS application equated to an authorisation being in place”, while in a few services, providers were applying blanket restrictions that deprived all residents of liberty, despite this not being necessary for everyone.

Poor understanding of MCA

The CQC also found issues with providers’ understanding of the MCA more generally. For examples, in some services, there were cases of organisations assuming that, because a person lacked capacity to make one decision, they were unable to make all decisions, contrary to the requirement for capacity assessments to be time- and decision-specific.

In some services for people with learning disabilities or autistic people, there was a lack of consideration of the least restrictive option when making decisions, contrary to the fifth principle of the MCA.

Analysis of 139 CQC decisions to refuse providers’ applications to register, or to impose conditions on registrations, found 66 related to the MCA, nearly all of which were due to a lack of knowledge of the act.

Other issues raised in the report included poor communication with those subject to a DoLS application or their family members, including because of lack of interpreting services or tools to support non-verbal communication.

Reform urgently needed, says CQC

However, despite the many practice issues it raised, the CQC concluded by calling for urgent reform to the DoLS.

“The DoLS system has needed reform for over 10 years,” it said.

“Unless there is substantial intervention, we are concerned that these challenges will continue, leaving people at the heart of this process without the key human rights safeguards that the DoLS system was intended to offer.”

Care Quality Commission (CQC) assessors’ lack of social work experience was among criticisms of the regulator’s approach to assessing English local authorities shared with a damning review of the regulator.

In the final report of her review of the CQC, Dr Penny Dash listed a number of concerns about its local authority assessment system, introduced last year, which had been shared with her by councils that had been through the process and by sector leaders.

Dash’s interim report, published in July, which focused much more on the commission’s assessments of care providers than of councils, found the regulator could not effectively judge the quality of services, including because of a lack of inspections and of inspector expertise.

Regulator ‘not fit for purpose’

This prompted health and social care secretary Wes Streeting to declare the CQC “not fit for purpose”, triggering an overhaul of the regulator, including the appointment of a new chief executive – Julian Hartley – more government oversight and increased numbers of staff and inspections.

The regulator also commissioned a separate review of its single assessment framework (SAF) by its former chief inspector of hospitals, Mike Richards, the report of which was also published yesterday, alongside Dash’s final report.

The SAF, introduced last year to provide a single framework covering all the health and social care services the CQC regulates, was heavily criticised in Dash’s interim report, including for inadequately setting out what good or outstanding care looks like.

These criticisms were echoed in both Dash’s final report and Richards’, with the former chief inspector concluding that the SAF was “certainly not proving to be beneficial” in adult social care.

Reintroduction of local authority assessments

On the back of the Health and Care Act 2022, the CQC reintroduced assessments of local authorities in December last year, after a 13-year gap, with a plan to assess all 153 councils over two years on their performance of their Care Act 2014 functions.

The policy sparked significant concerns from councils about the additional burdens it would place on them and the validity of giving them single-word ratings – outstanding, good, requires improvement or inadequate – as required by the Department of Health and Social Care (DHSC).

So far, the CQC has fully assessed nine councils, six of whom have been rated good and three requires improvement. All of these authorities shared their experience of the process with Dash, as did sector bodies.

Overall, they said that both the assessment process and CQC’s reporting of it could be improved and compared it unfavourably to Ofsted’s inspection of local authority children’s services.

Perceived lack of assessor expertise

She said there was “a perception among some local authorities that the assessment teams lacked the expertise and insight into how local authorities work in adult social care”, including that “very few had social work experience”. The CQC has a dedicated team of about 14 people carrying out the local authority assessments, about 40% of whom are expert external reviewers, according to Richards’ review of the SAF.

Councils and sector leaders also questioned the small number of cases reviewed by the CQC, with assessors tracking, typically, six cases, compared with an average of 5,600 people receiving long-term care and support in each authority. Although Ofsted also primarily focuses on six cases in its inspections of council children’s services, it also looks at a sample of other cases.

While some respondents to Dash’s review praised the level of engagement they had received from CQC assessors, others said there was insufficient opportunity to discuss the regulator’s findings during the assessment, resulting in a missed opportunity for learning.

Dash reported that the CQC recognised that it needed to do more to build relationships with councils and was considering introducing relationship owners and annual engagement meetings, in addition to current feedback meetings following an assessment. Ofsted holds an annual engagement meeting with every council in relation to its children’s services.

Insufficient focus on commissioning 

Councils and sector representatives also criticised the lack of focus on authorities’ commissioning role in the assessment, despite ministers having intended for the CQC to do this.

Of the nine quality statements against which councils are judged, one relates directly to their commissioning functions: “We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.”

“It is not clear from current assessments how comprehensibly commissioning functions are assessed, which misses an opportunity to improve commissioning capabilities and, as a result, quality and efficiency of care,” Dash concluded.

Councils and sector representatives also said there were insufficient descriptors of what good or outstanding performance looked like in the CQC’s assessment framework, making it difficult for authorities to know how to improve.

Inspectors criticise scoring of councils

Richards’ review of the SAF made limited reference to local authority assessments, concluding that it was “still too early to assess how well these assessments [were] working or the value of the reports”.

However, he did say that assessment teams had criticised the process of scoring councils, from 1-4, on their performance against each of the quality ratings, as well giving them an overall rating.

Richards said the feedback from staff had been that scoring can “drive towards a rating that is not felt to be appropriate”.

Among seven recommendations made in her review, Dash called on the CQC to consider the feedback it had received about local authority assessments, including her findings, to improve the assessment process, its robustness and councils’ experience of it.

In response, the CQC said: “Local authority assessments will continue with ongoing improvements and continued engagement with the health and care sector. In line with changes to the assessment framework, CQC will make scoring of evidence more transparent, and will strengthen its focus on nationally agreed priorities.”

Council heads working with CQC to ‘refine assessments’

For the Local Government Association, community wellbeing board chair David Fothergill said: “Given the ongoing rollout of CQC local authority assessments, we are keen to ensure there is adequate time for CQC, DHSC and local government to learn and reflect on the process so far, to help make sure adult social care assurance is fair and proportionate.”

The Association of Directors of Adult Social Services said it was continuing to “work closely with the CQC to improve and refine the assessment of local authority social care departments”.

The government has no plans to scrap single-word judgments of local authority adults’ services, despite the decision to ditch the approach for children’s social care.

The Local Government Association today urged ministers to end overall ratings of council adult social care performance by the Care Quality Commission (CQC).

The LGA made the call in the light of last week’s decision to ditch single-word ratings for all services inspected by Ofsted, including in children’s social care.

Ending single-word ratings for children’s services

Though there is no date set for the reform, in future, council children’s services and regulated services, such as children’s homes and independent fostering agencies, will not be rated as outstanding, good, requires improvement or inadequate following full inspections.

Instead, they will be assessed using a report card-style tool, which will likely involve evaluating performance across a range of areas.

The decision was made in response to the Big Listen, Ofsted’s biggest ever consultation, carried out in the light of a coroner’s verdict that its  2022 inspection of Caversham Primary School, Reading, contributed to headteacher Ruth Perry’s decision to take her own life.

Social care providers more supportive than not of ratings system

The consultation, responded to by over 20,000 people, including 4,325 children, revealed strong opposition to single-word judgments. Ofsted said these were “heavily criticised for oversimplifying the complexities of providers and not providing a full picture of their performance”.

However, separate research with 3,496 providers and 3,831 professionals from across the sectors Ofsted regulates found those in social care were more supportive than not of single-word judgments.

While the CQC has rated regulated adult social care services on a similar basis to Ofsted since 2014, it only started assessing councils last year, following the reintroduction of performance checks of local authority adults’ services.

Return of adults’ services assessments

In the face of opposition from council leaders, the Department of Health and Social Care (DHSC) determined that authorities would receive a single-word judgment.

Of the first nine authorities to be rated, six were judged to be good and three requires improvement, with the judgment being accompanied by a narrative report and a score, based on the council’s performance against nine statements.

The LGA said councils valued the CQC’s narrative reports but added that single-word judgments of adults’ services did not do justice to the complexity of social care, particularly in the context of funding constraints.

Single words ‘cannot capture complexity of adult social care’

“Local government fully supports transparency and accountability,” said David Fothergill, chair of the LGA’s community wellbeing board.

“But while assessment and regulation are both important and helpful in driving improvements to services, single word or phrase judgements cannot ever adequately capture the complexity of adult social care and the work councils do to meet their legal obligations.

“The government must ensure that the assurance process is, and remains, productive and supportive for councils. Sufficient time must be given to learn the lessons from councils’ experiences as more go through the assessment process.”

CQC deemed ‘not fit for purpose’

The LGA’s call comes with the CQC under intense scrutiny, after health and social care secretary Wes Streeting declared the regulator “not fit for purpose” in the wake of a damning report.

In the interim report of her government-commissioned review, Dr Penny Dash found that inspection levels were still well below pre-Covid levels, a lack of expertise among inspectors, inconsistency in assessments and problems with the CQC’s IT system.

In response to the LGA’s call to end single-word judgments, a CQC spokesperson said: “Our assessments were developed alongside the sector to help drive improvement by highlighting good practice and areas for further development.

“Local authorities have told us of the value of sharing findings to help make immediate improvements, by identifying their strengths and where gaps may exist. The narrative assessments and conversations they spark are central to this.

‘No plans’ to end single-word judgments

“The precise methodology for our local authority assessments, including if assessments result in a rating, is subject to ministerial approval. Any changes to this methodology would be a matter for the Department of Health and Social Care.”

A DHSC spokesperson said: “We are thoroughly reviewing the Care Quality Commission (CQC) and as part of that work we have asked the CQC to improve the transparency of their ratings. We are not currently considering a change to the single-word ratings system.”

Sixty per cent of community social care services in England have no or an ‘outdated’ performance rating, an analysis of Care Quality Commission (CQC) data has found.

Almost a quarter of home care, extra care, shared lives or supported living services (23%) had never been rated by the CQC as of June 2024, despite more than half of these having been registered with the regulator for more than 18 months at that point.

A further 37% of services had ratings that were four to eight years old, found the analysis by the Homecare Association, the representative body for domiciliary providers.

The association also found that 49.5% of residential services had a rating that was four to eight years old, though only 3.6% of these were unrated. It is possible that some of the findings are due to providers re-registering an existing service as a new location, making them appear as having not been inspected despite having received a relatively recent visit from the CQC.

However, the Homecare Association said its findings showed that the CQC was not inspecting enough services to ensure the quality and safety of social care.

CQC found ‘not fit for purpose’

The study echoes the damning findings of the interim report of a government-commissioned review of the regulator, published in July.

Dr Penny Dash found that an estimated one in five of the services CQC had the power to inspect had never received a rating and the average age of ratings was 3.7 years, while also criticising a lack of specialist inspection regime and the effectiveness of the regulator’s IT systems.

Her findings led health and social care secretary Wes Streeting to conclude that the regulator was “not fit for purpose”.

The Homecare Association’s analysis provides more detail than Dash’s interim report on the lack of inspections of social care services and the reasons behind this.

Huge increase in number of services

The association found there had been a 5.5-fold increase in the number of regulated community social care services from 2013 to 2024, from 2,303 to to 12,574.

However, over the same period, annual CQC expenditure only rose by a third, from £175m to £231.2m. As a result, its expenditure per registered location fell from about £7,700 in 2013-2014 to £4,400 in 2023-2024, while its number of staff per service dropped from 0.10 to 0.06.

The CQC operates a risk-based model of regulation, in which inspections are focused on those where there are greatest concerns about safety and quality.

The association found the regulator was identifying a greater number of under-performing providers, with the proportion of community social care providers rated requires improvement (the second lowest of the four ratings) increasing from 0.5% in 2017 to 26.3% in 2024.

However, it added: “A risk-based approach to regulation is fine, provided there is enough resource to reassess all providers. As the data show, 60% of all community care providers have no recent rating or no rating at all. Market intelligence suggests there are still too many poor quality providers operating undetected.”

Councils criticised for proliferation of services

But while the report was heavily critical of the regulator, the Homecare Association also took aim at councils for promoting a proliferation of home care services in their areas, making it harder for the CQC to effectively regulate the market.

It said authorities were spreading the home care hours they commissioned among multiple providers, with some contracting with about 200 organisations.

“By their own admission, they do not have the resources to monitor the quality of 200 providers in one local authority area. Neither does CQC. Spreading the hours across so many providers makes efficient deployment of the workforce difficult. It also makes it difficult for providers to be
financially efficient and sustainable since they cannot benefit from economies of scale.”

Among its recommendations, the association called on the government to commission “a realistic review of CQC’s resourcing needs” and to address the impact of local authority commissioning practices on care quality and market stability.

CQC ‘committed to increasing inspection numbers’

The study comes ahead of the final report from Dash’s review, due this autumn.

In a statement, the CQC’s interim chief executive, Kate Terroni, said: “We accept in full the findings and recommendations in the Penny Dash interim review, which identifies clear areas where improvement is urgently needed.

“Many of these align with areas we have prioritised as part of our work to restore trust with the public and providers by listening better, working together more collaboratively and being honest about what we’ve got wrong. We are working at pace and in consultation with our stakeholders to rebuild that trust and become the strong, credible, and effective regulator of health and care services that the public and providers need and deserve.

“We’ve committed to increasing the number of inspections we are doing so that the public have an up-to-date understanding of quality and providers are able to demonstrate improvement. Alongside this we are working to improve how we’re using our new regulatory approach.

“We’re increasing the number of people working in registration and working to improve on current IT systems with involvement from providers and colleagues, so we can improve waiting times and deliver better outcomes for everyone.”

Story updated 29 July 2024

The Care Quality Commission is “not fit for purpose”, health and social care secretary Wes Streeting has declared, after a damning report found significant failings within the regulator.

Dr Penny Dash found that inspection levels were still well below pre-Covid levels, a lack of expertise among inspectors, inconsistency in assessments and problems with the CQC’s IT system.

Also, social care providers were waiting too long to be registered and have their ratings updated, affecting capacity levels in local areas, said the interim report of Dash’s government-commissioned review of the regulator.

As a result of these problems, the CQC was unable to consistently and effectively judge the quality of services it regulates, including residential homes, nursing homes and domiciliary care agencies.

Probe focused on new assessment approach

The review, commissioned in May 2024 by the previous Conservative government, was designed to assess the suitability of the CQC’s single assessment framework (SAF) for assessing and rating health and social care providers.

This was introduced in November last year and was designed to reduce duplication in the previous four separate assessment frameworks and move away from inspections being the CQC’s primary source of evidence of a service’s quality and compliance with regulations.

Instead, it planned to collect data and insights on services on an ongoing basis, for example from feedback from people who used services or partner organisations or from information submitted by providers.

Dash, whose interim report was based on conversations with 170 health and social care leaders and staff and 40 CQC senior managers and professional advisers, identified significant problems with the regulator beyond the implementation of the SAF.

‘Poor operational performance’

She found that the organisation’s operational performance was “poor” and had deteriorated, including that:

• The CQC carried out just 7,000 inspections and assessments in 2023-24, compared with 16,000 in 2019-20.
• At the end of 2023-24, 54% of provider registration applications were more than 10 weeks old, up from 22% at the end of 2022-23.
• Of the services CQC had the power to inspect, an estimated one in five had never received a rating, some of which had registered more than five years ago.
• The average age of providers’ overall ratings was 3.7 years, while some organisations had not been reinspected for several years: the oldest rating for a social care provider dated back to 2015.
• Call centre performance was poor with the regulator taking 19 minutes on average to answer calls about registration from January to June 2024.
• The provider portal – launched last year to enable providers to submit information to the regulator – had resulted in significant problems for some users, who said they were unable to easily upload documents and waited hours for password resets.

Lack of inspection expertise identified

Dash also identified a lack of specialist expertise among inspectors, linked to a decision by the regulator to rely much more on generalists in inspection teams.

Her review was told of care home inspectors who had not met a person with dementia before.

She also found a significant reduction in ongoing relationships between CQC staff and providers, which had previously been useful for sharing good practice and building providers’ confidence in the regulator.

Dash concluded that these trends were “impacting the credibility of CQC, resulting in a lost opportunity to improve healthcare and social care services”.

No description of what constitutes good or outstanding care

In relation to the SAF itself, Dash found that it did not contain a description of what good or outstanding care looked like.

“The review heard time and again from providers that they struggle to know what inspectors are looking for, they are not learning from them and, as a result, they don’t know what they need to do to be better.”

Providers also reported a lack of consistency in ratings, with multi-site organisations saying that differences in ratings between services did not accord with what they knew about differences in performance.

No reference to use of resources in framework

There was also no quality statement within the SAF relating to use of resources or efficient delivery of care, despite it being a legislative requirement for the CQC to assess this.

Dash said this was disappointing as “effective use of resources is one of the most impactful ways of improving quality of care for any provider”.

And though the SAF was designed to increase the emphasis on gathering the voice of service users, the review found a lack of transparency in the data used to measure this, how representative this was and how it was analysed.

Most of the data was apparently harvested from surveys, “which may or may not be representative or statistically significant at a service level, and this is then supplemented by a number of interviews with service users”, Dash said. There could be as few as tens of such interviews carried out even where a service was looking after thousands of people a year, the report added.

Issues with how ratings are calculated

The interim report also identified a longstanding problem of providers’ ratings being based on outcomes from inspections over several years, which it said could not be “credible or right”.

While the SAF was designed to correct this by basing ratings on more frequent assessments of a service drawn from up-to-date information, the problem continued because the regulator was not undertaking sufficient such assessments.

Dash also heard that providers did not understand how ratings were calculated, resulting in a sense that it was “impossible” to change ratings.

She is due to publish her final report this autumn, but made five recommendations at this stage, urging the CQC to:

1. Rapidly improve operational performance.
2. Fix the provider portal and regulatory platform.
3. Rebuild expertise within the organisation and relationships with providers in order to resurrect credibility.
4. Review the SAF to make it fit for purpose.
5. Clarify how ratings are calculated and make the results more transparent, particularly where multi-year inspections and ratings have been used.

CQC ‘not fit for purpose’

“I have been stunned by the extent of the failings of the institution that is supposed to identify and act on failings,” said Streeting. “It’s clear to me the CQC is not fit for purpose.”

He added: “I know this will be a worrying development for patients and families who rely on CQC assessments when making choices about their care.

“I want to reassure them that I am determined to grip this crisis and give people the confidence that the care they’re receiving has been assessed. This government will never turn a blind eye to failure.”

The DHSC said that, on the back of the interim report:

• The CQC has appointed Professor Sir Mike Richards to review its assessment frameworks. A former hospital doctor, he was the regulator’s first chief inspector of hospitals from 2013 until his retirement in 2017.
• There would be improvements in the transparency of how the CQC determined its ratings for health and social care providers.
• The department would increase its oversight of the CQC, with the regulator regularly updating the DHSC on progress, to ensure that Dash’s final review recommendations were implemented.

Last month, Ian Trenholm resigned as CQC chief executive, to be replaced, on an interim basis, by his deputy, Kate Terroni.

Regulator ‘accepts findings in full’

In response to today’s interim report, Terroni said: “We accept in full the findings and recommendations in this interim review, which identifies clear areas where improvement is urgently needed. Many of these align with areas we have prioritised as part of our work to restore trust with the public and providers by listening better, working together more collaboratively and being honest about what we’ve got wrong.

“We are working at pace and in consultation with our stakeholders to rebuild that trust and become the strong, credible, and effective regulator of health and care services that the public and providers need and deserve.

‘Work is underway to improve how we’re using our new regulatory approach. We’ve committed to increasing the number of inspections we are doing so that the public have an up-to-date understanding of quality and providers are able to demonstrate improvement.

‘We’re increasing the number of people working in registration so we can improve waiting times. We’re working to fix and improve our provider portal, and this time we’ll be listening to providers and to our colleagues about the improvements that are needed and how we can design solutions together.

“We’ll be working with people who use services and providers to develop a shared definition of what good care looks like. And we’re also developing a new approach to relationship management that enables a closer and more consistent contact point for providers.”

Provider leaders demand improvements

Care provider leaders joined Sweeting in heavily criticising the regulator in the wake of Dash’s interim report.

“It is outrageous that social care providers are left waiting interminably for registrations and ratings, directly impacting local capacity, quality of care and sustainability of providers,” said Homecare Association chief executive Jane Towson.

The association cautiously welcomed the DHSC’s response to the report but urged further action, calling for:

• A complete overhaul of the CQC’s inspection and assessment system.
• Immediate action to clear the backlog of uninspected and unrated providers.
• A significant investment in recruiting experienced, sector-specific inspectors.
• Regular, mandated reporting on the CQC’s progress in addressing these failings.

“We want and need an effective regulator and are dismayed that CQC’s incompetence is actively harming the sector it’s meant to regulate and protect,” Towson added.

“This is going to be a long and difficult journey for the CQC, but one that is entirely necessary,” said Care England chief executive Martin Green.

“The CQC must embark on a radical improvement program that should not only include some tangible improvements in their performance, but also needs to move away from a culture of blame.

“We all want proportionate and effective regulation, and the challenge now is for CQC to take action and work with organisations across the sector to deliver it.”

The Care Quality Commission has awarded good ratings to the first three councils it assessed under its new adults’ services performance regime.

Hertfordshire, Hounslow and West Berkshire all gained the second top rating – behind outstanding – in assessments under the CQC’s local authority assurance system, published last week.

The CQC also awarded each authority a score out of 100 indicating how well they performed against nine quality statements, for which the authorities were awarded a mark of 1-4.

Hertfordshire’s 78 score indicates that it was close to getting an outstanding rating, for which a score of 80 is required. Hounslow scored 70 and West Berkshire 64, just above the boundary between requires improvement and good (62).

The overall ratings are in line with those for five pilot assessments carried out last year, for which four authorities were graded good and one requires improvement.

They were based on feedback from people who receive care and support, including self-funders, carers, voluntary and community groups and staff, including the principal social worker (PSW), director of adult social services and social workers; analysis of performance data on, and surveys of staff, carers and people accessing care and support, and studies of a sample of cases.

Hounslow (good, 70)

Hounslow was awarded a 3 for all but two of the nine quality statements, receiving a 2 in the others.

Assessors praised the council’s use of short-term care and reablement to promote people’s independence. Data showed that 86% of people who received a short-term service in the borough did not require ongoing support, while 84% of older people were still at home 91 days after discharge from hospital to a reablement service, exceeding the England average in both cases.

Tackling inequalities

The CQC also praised the authority’s work in tackling inequalities between groups in access to social care, saying it had “invested significant time and resources” in listening to different communities. This included talking to people from a well-established Traveller site using a representative group and existing connections within the council to identify barriers they faced in accessing adult social care and design a plan to tackle these.

The report was also positive about aspects of commissioning practice, particularly how the authority had minimised the use of long-stay or secure settings for people with mental health and substance misuse needs who would not typically accept help. This involved designing a service that felt like a hotel but was secure and through which people could access supportive in-reach services.

And the regulator hailed social workers’ strengths-based approach to to practice, with assessments and care planning reflecting what people wanted to achieve and how they wished to live their lives.

People with care and support needs could easily access services and waiting times were generally low for initial assessments and care planning, with staff triaging cases based on risk and putting in place interim care arrangements before completing assessments when people required urgent support.

Criticisms of carer services

However, assessors were critical of Hounslow’s service to carers. Relatively few received an assessment last year, though despite this waiting times averaged 24 days. Staff attributed this to “a relatively weak offer” for carers, with most such provision being for the person they were caring for, rather than the carer themselves.

Carers also reported poorer than average outcomes, based on responses to the national survey of adult carers in the borough.

Only 27% of carers felt they had encouragement and support and 44% of carers were not in paid employment because of caring responsibilities, significantly below the England average of 28%.

Performance was mixed in relation to safeguarding. Most concerns were triaged in a timely manner and there were clear standards and quality assurance arrangements for enquiries under section 42 of the Care Act. However, the specialist safeguarding team had reduced in size, adding pressure to workloads and putting Hounslow’s ability to deliver on its section 42 obligations at risk.

The council’s cabinet member for adult social care, public health and transformation, Samia Chaudhary, said the CQC’s assessment underscored “the unwavering dedication and tireless commitment demonstrated by our staff and partners on a daily basis as they strive to provide crucial support to some of our most vulnerable”.

She said the authority recognised the “imperative to continuously enhance [its] services” and would continue to do so through its improvement agenda.

A strike-hit council is struggling to deliver an approved mental health professional service (AMHP), it had admitted.

Swindon council said that recruitment problems were affecting its ability to consistently deliver an AMHP service and it was working to address the issue.

Its admission came after trade union GMB said Swindon now had just one approved mental health professional in its emergency duty service (EDS), which is responsible for the borough’s out-of-hours AMHP service.

This was down from four AMHPs on the EDS as of September 2023, just after GMB members in the service started taking on-and-off strike action in a dispute with the council over pay.

Since then, there had been several instances, on evenings and weekends, in which AMHPs were not available to respond to people in mental health crisis who may require detention under the Mental Health Act 1983 (MHA), the union claimed.

It claimed Swindon was acting contrary to the MHA in not providing a round-the-clock AMHP service (see box).

Union informs CQC

The union has written to regulator the Care Quality Commission about the issue, warning that the borough was not funding other EDS staff to train as AMHPs.

The CQC told Community Care that the information from the GMB had been passed to its local authority assessment team, which is responsible for the new system of assuring the performance of council adult social services. It said it would also use it in its monitoring of health and social care providers’ compliance with the MHA.

A Swindon council spokesperson said: “Like many councils across the country, we are experiencing challenges recruiting approved mental health professionals and this is impacting on our ability to consistently deliver a service. We are working with our teams to explore how we can address this issue going forward.”

Latest strike by emergency duty staff

EDS staff at Swindon staged their latest walkout for a week from Christmas Eve 2023 onwards. The dispute was triggered by a pay and grading review that removed a payment from staff worth £8,400 annually for working unsocial hours.

The council has said that other changes it is making would leave EDS staff about £3,000 a year better off, however, the GMB has claimed that these are not guaranteed – a view Swindon rejects.

At the same time, 11 assistant team managers (ATMs) in social work teams, who are also represented by the GMB, held a two-week strike over Christmas in a separate dispute, also tied to the pay and grading review.

Walkout by assistant team managers

The GMB claimed that, as a result, the average gap in pay between ATMs and advanced social workers (ASWs) has narrowed. It said this meant ATMs’ additional responsibilities – including supervision and running case conferences – were not acknowledged in their salary.

Swindon council said that it was able to cover services during the latest strikes and there were no issues.

The union said that the council had now agreed to meet with it over the disputes in talks mediated by employment relations body Advisory, Conciliation and Arbitration Service (ACAS).

However, the union has also balloted a third group of social workers – independent reviewing officers – to stage a walkout, also over the fallout from the pay and grading review.

The story has been updated.