CQC praises improvements but calls for new drive to eliminate poor adult social care services

3 December 2009

The Care Quality Commission praised improvements in adult social care but called for a renewed effort to eliminate poor quality services.

The regulator will today (Thursday) give its first major statement on the quality of adult social care, drawing on four documents.

The documents, all published on 3 December, provide:

• An assessment of 148 councils' social care services for adults, including performance against seven outcomes set by the government
• An analysis of whether councils are commissioning the best possible care, whether this is from the private, voluntary or public sector
• An update on the performance of 24,000 care homes, home care agencies, nursing agencies and shared lives schemes looking at whether quality is improving
• CQC's formal response to the government's Green Paper on social care, called "Shaping the future of care together"

Drawing these documents together, CQC says:

Councils are improving their ratings overall, however the assessment highlights concerns that are real and affect people's lives. There has been steady improvement in ratings awarded to councils for their adult social care commissioning, with 95% of local authorities in one of the top two categories – performing either "excellently" or "well" – in the year to March 2009. This compares to 87% of councils in the previous year. However, looking at specific areas of the assessment, one quarter of councils are rated only "adequate" in terms of giving people choice and control over their care. For example, people should be able to expect help in taking control of their own support, with clear information and advice about support options, risks, costs and funding. Although this is partly the result of a harder test, it remains a priority for councils to address. A third of councils have more to do in terms of caring for people with dignity and respect – this includes improving arrangements around the safeguarding of adults.

Ratings for providers have also improved, however one in six providers are only "poor" or "adequate". The proportion of care homes, home care agencies, nursing agencies and shared lives schemes rated "excellent" or "good" rose from 69% in May 2008 to 77% in April 2009. However there are some 400 regulated adult social care services rated as "poor" and around 3,500 are only rated "adequate". CQC requires poor homes to produce an improvement plan and then subjects them to regular intensive inspection. Looking specifically at care homes and agencies, the minimum standards with lowest levels of compliance concern some of the basics of care. Issues highlighted include planning for individuals' care, how medication is managed, staff supervision and promotion and protection of people's health, safety and welfare. In care homes for older people, a fifth fail to meet the standard on social contact and activities. Performance on this standard has improved the least of any since 2003.

Councils must help get rid of poor quality care by purchasing from providers more effectively, particularly in some areas. CQC's analysis shows that some councils have been purchasing a significant proportion of residential and nursing home care from providers that have been rated as "poor" or "adequate", while other councils have been commissioning a high proportion that are "good" or "excellent" (as at December 2008 - the latest data available). This raises important questions about whether commissioning is as effective as it could be. CQC acknowledges that some councils may be constrained in their purchasing and have limited availability of care provision of the right quality and price in the short term. In addition, some people may choose to live in a poorly rated service for a variety of reasons. But it stresses that councils have a responsibility to develop markets over the long-term so that the right care is available. The regulator acknowledges that some councils have made progress with this. It says it wants a dialogue with councils on the issue and that it will monitor commissioning closely in future assessments.

CQC has identified councils where improvements in adult social care must be a priority. CQC has designated eight councils as ‘Priority for Improvement' councils. They will receive greater scrutiny from CQC and will benefit from practical support from government. CQC has also selected 16 councils for in-depth service inspection on the basis of concerns about performance, gaps in its evidence or the length of time since the last service inspection.

CQC will be vigilant about spotting the impact of the economic downturn on people's access to social care. CQC says it is encouraged to see that councils' eligibility thresholds for access to care services remain largely unchanged since last year. This follows two years in which the number of councils providing care to people with "moderate" or "low" needs fell markedly from more than 60 to only 42. But CQC stresses that there are already some areas where only people assessed as having critical needs receive any public help, with damaging consequences for individuals and carers. In other areas councils are investing in preventative services to be able to reduce the number of people needing higher levels of care. However, CQC is concerned that some councils may have to raise eligibility criteria further as public spending is squeezed in the years ahead, and will continue to monitor and provide support to councils where appropriate.

CQC is raising the bar on councils and providers. Council performance against the agreed rating system shows significant improvement and it is time to strive for a higher standard. Future assessments of councils will be tougher and they will be held to greater account for standards within the services they commission. Regulation will also be tougher for providers of services. From next year, CQC will introduce a new registration system covering adult social care providers, NHS providers and independent healthcare, underpinned by a single set of new essential standards on safety and quality. Adult social care providers will join this system in October 2010. CQC will have tougher enforcement powers and be able to respond to concerns more quickly. It will also give greater weight to the views of people using services in making its judgements. The regulator says that it is determined to drive poor care out of the market and that providers registered under the existing system cannot assume they will registered under the new regime.

Cynthia Bower, CQC Chief Executive, said: "It's good to see the steady improvements and this should be recognised. However, I am concerned that many care homes and agencies have more to do to deliver the quality of care expected of them. Those affected should be absolutely clear that we will be very persistent in ensuring they take action in the run up to registration and afterwards, using all the new powers that will be at our disposal.

"There are also serious issues for councils to address in areas such as giving people more control over their care, treating people with dignity, and ensuring commissioning is as effective as possible. I want to see the regulator and councils working in tandem to drive poor quality care out of the market."

Ms Bower added: "It is striking that many of the issues of most concern to the public – such as dignity – are not necessarily things that cost a lot of money to put right. So there is clearly room to continue improving services, despite the tough economic backdrop. There is no excuse for taking the foot off the gas.

"I have to say however that I am deeply concerned about the potential impact of lower spending on social care. We all know there are choppy waters ahead, so the issue is how well the system responds to the situation. We plan to be particularly vigilant about this on behalf of people who use services."

Other CQC findings include:

• For 2007–8 councils spent £16.5 billion on adult social care, £7.5 billion of which was on residential services.
• Eighty per cent of the places purchased by councils in the South East and 79% in the North West were places in "good" or "excellent" care homes, while the figures for West and East Midlands were 67% and 71% respectively.
• Care homes, home care agencies, nursing agencies and shared lives schemes run by councils and voluntary organisations perform better than those in private ownership. In April 2009, 87% of council services and 86% of those run by voluntary organisations were good or excellent, compared to 74% of privately-owned services. But the gap is closing – only 66% of privately-owned services were rated "good" or "excellent" in May 2008.
• When councils place people in care homes outside the council's own boundaries, most of the homes are of better quality than those within the council's area.
• Care homes for younger adults (age 18–65) perform better than those for older people (over 65) but the latter are catching up: 82% of homes for younger adults were good or excellent in April 2009 compared to 76% of those for older people; but that was 9% more for older people's homes compared to May 2008.
• Younger adults with learning disabilities receive better than average care, while those with mental health needs are more likely to be placed in ‘poor' or ‘adequate' homes.

Ends

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Notes to editors

1. The assessment of 148 councils social care services for adults, including performance ratings based on seven outcomes set by the Government, is based on data up to 31 March 2009.
2. The update on the performance of 24,000 care homes, home care agencies, nursing agencies and shared lives schemes, looking at whether their quality ratings are improving, relates to a snapshot of performance on 31 March 2009.
3. Councils only purchase about half the available beds in care homes and only a proportion of the care offered by home care agencies.
4. It should be noted that all comparisons with assessments from previous years are based on the 'Delivering Outcomes' element of the annual performance assessment. In previous years, councils were rated on 'Delivering Outcomes' and 'Capacity to Improve'. This year's assessment is based solely on 'Delivering Outcomes'.