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1. The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. We monitor, inspect and regulate services and publish what we find. Where we find poor care, we will use our powers to take action.[1]
2. We have specific duties and powers under the Mental Health Act 1983 (MHA) to protect and safeguard the interests of people whose rights are restricted under the Act[2], and we also assess how local authorities are meeting their duties under Part 1 of the Care Act (2014).[3]
3. The evidence provided in this submission focuses on findings from our annual report to parliament, State of Care.[4] Our evidence primarily describes non-monetised costs of not reforming adult social care.
4. As of 1 August 2024, over two-thirds of rated adult social care services registered with CQC had a rating of ‘good’ (78%), while 14% were rated as ‘requires improvement’, 4% as ‘outstanding’ and 1% as ‘inadequate’. Residential care homes made up the largest proportion of rated adult social care services in 2024 (n=9,993), followed by home care providers (n=8,946) and nursing homes (n=4,044).[5]
5. The Health and Care Act 2022 introduced a new responsibility for CQC to assess how well councils are delivering their responsibilities under Part 1 of the Care Act 2014. After co-producing our approach with local government, key stakeholders, providers and the public, we began our assessments in December 2023.
6. As well as publishing individual reports and ratings for local authorities[6], we have used our most recent annual State of Care report to highlight trends and themes from our early findings.
7. Findings from our assessments will provide the evidence base to further drive improvement in the way care is funded, commissioned and delivered. Together with our assessments of providers, we will use our findings to showcase opportunities for the whole sector to improve, encourage collaboration across all parts of the system to address issues, and inform national government policy on adult social care reform.
8. From the assessments we have completed so far we have seen themes around:
9. Challenges impacting the adult social care sector are contributing to delayed discharges from acute hospitals. Our inspections in urgent and emergency care found issues around triage and patient flow that affect care for all patients. This includes the link between delayed hospital discharges and availability of home-based care and care home beds, which is acutely apparent.
10. Data published by NHS England shows that, as of April 2024, the combined waits for care home beds and home-based care accounted for an average of 45% of the total delayed discharges from acute hospitals (for people who had been in hospital for 14 days or longer).[8] This was equivalent to nearly 4,000 people on an average day. Of these people:
11. It should be noted that waits for care home beds are predominately in adult social care but can include some NHS-funded nursing beds or continuing healthcare. Waits for home-based care can involve NHS and housing services as well as adult social care services.[9]
12. We also heard from people who had first-hand experience of using intermediate care services that “discharge had to be delayed due to a lack of reablement facilities” and, in some cases, there was a lack of local provision.[10]
13. There is regional variation in the proportion of delayed discharges from hospital due to waits for care home beds or home-based care. For much of 2023/24, the Northeast and Yorkshire region had the highest proportion of delayed discharges from acute hospitals due to waiting for home-based care, and the North East region had the fewest homecare services per 100,000 population of older people. Meanwhile, London had proportionally the most delayed discharges from acute hospital due to waiting for a bed in a care home, and the fewest residential care home beds per 100,000 population of older people.[11]
14. In our State of Care report, we said how a quick discharge when patients are medically fit and have an appropriate place to go not only improves flow, but also helps minimise how much people deteriorate, which can make it harder to return to their home or other previous setting.[12]
Admissions
15. In 2023/24, we have seen a small increase in the percentage of attendances at emergency departments that resulted in admissions. March 2024 saw the highest numbers of emergency admissions through this route in over 5 years. The increases in attendance and admission figures, while not huge at a national level and compared with the more level long-term trend, are signs of continued pressure on an already stretched part of the system.[13]
16. Despite ongoing problems with capacity in the adult social care sector, in 2022/23 we saw increasing pressures to discharge people from hospital. In the face of this pressure, we heard examples of people being discharged too early without appropriate risk assessment or having a care package or intermediate care in place.[14]
17. Unsafe discharges were putting people at risk, potentially leading to poorer outcomes in their health and care and being re-admitted to hospital. During the 12 months to June 2023, on average around 9% of people had to go back to the emergency department within 7 days of their previous attendance.[15]
18. The ‘Next Steps to Put People at the Heart of Care’ policy paper published under the previous government emphasises the importance of a capable, skilled, stable and valued workforce in delivering high-quality, personalised care that supports people to lead independent and fulfilled lives. Action on the full workforce commitments set out in these reforms could avoid unnecessary hospital admissions, using skilled social care interventions.
19. Members of the public have told us about examples of adult social care services delivering care for people living with dementia where the levels of staffing, their abilities and behaviours did not always meet the additional and complex needs of people, particularly as their condition deteriorated. Through our Give Feedback on Care service, people told us that critical aspects of good dementia care—such as stimulation, interaction with others, and familiarity with surroundings—were sometimes lacking.[16]
20. Through our provider information return, adult social care providers told us about some of the challenges they were facing in supporting people with dementia, including:
21. Early themes from our local authority assessments have highlighted issues with recruitment of occupational therapists, and the impact of this. We found that the use of agency or locum staff was common as local authorities tried to maintain stable workforces, but it was hard to recruit to occupational therapy positions, which was affecting waiting lists and people’s ability to maintain independence.[18]
22. Issues around access to adult social care services place further pressure on the wider healthcare sector. For example, we found that staff shortages have made it increasingly difficult for some services to accept referrals, such as people being discharged from hospital.
23. During 2022/23, some homecare providers told us they had seen an increase in hospital referrals, which they were unable to accept as they did not have the care staff to meet the needs of these people. This can increase the likelihood of people having to stay in hospital for longer than necessary, increase the demand for hospital beds, and affect people’s independence and quality of life.[19]
24. In 2022/23, we also heard from a provider that ‘due to high demand from local councils and the NHS and the strategic plan to allow care at home, it has meant a higher need for staff in the community along with a higher push for staff to work more hours’.[20]
25. The current government has committed to three strategic shifts for the NHS:
In light of this, current pressures on the adult social care workforce highlight the need to consider what adult social care reforms are required to support these strategic shifts effectively. For example, we support the adoption of Skills for Care Workforce Strategy to ensure that recruitment, training and resource allocation are grounded in local needs, fostering stronger collaboration across health and social care settings.
26. As part of the previous government’s reforms, a ‘Market Sustainability and Improvement Fund’ was set up to make improvements and increase capacity in adult social care services, along with the ‘Fair Cost of Care’ scheme. Evidence from the last two years suggests that current commissioning practices are a barrier to access.
27. Our Market Oversight scheme monitors the financial sustainability of adult social care providers that have a large national, local or regional presence which, if they were to fail, could disrupt continuity of care in a local area.[21] Providers who are part of this scheme tell us that the amount of homecare commissioned by local authorities is less than the available capacity. Where comparisons can be made, data from providers in the Market Oversight scheme over the last 2 years suggests there is a reduction in the number of homecare hours that have been provided. [22]
28. This echoes findings from a survey we carried out last year, which found the most common reason from care providers for unused capacity was a lack of commissioning opportunities. [23] Providers also told us that poor access to, or a lack of transparency in the bidding process, affected their ability to increase capacity and to recruit accordingly. [24]
29. Local authority assessments in 2023-24 showed that local authorities are taking steps to address known inequalities, including working to meet cultural needs. However, feedback shows that the market is generally not well developed to meet culturally specific provision, particularly in residential or nursing care. Effective co-production with faith and voluntary groups resulted in understanding local communities and targeted commissioning, however local authorities did not always have sufficient resources to commission the necessary services. It was also more common for autistic people, older people and people with sensory needs to potentially struggle to engage with local authorities, including in finding services and co-production inaccessible[25].
30. In 2021-22, we commissioned a survey of more than 4,000 people aged 65 and over who had used health or social care services in the previous 6 months. The findings painted a distinct picture of inequality. In particular, we have seen how deprivation can affect people’s health and access to health and care services.[26] Tackling inequalities is a core priority for us, and we reviewed how this can be done most effectively through regulation in a recent rapid evidence review we commissioned.[27]
31. The ongoing challenges with adult social care funding and care costs can have an impact on people and their ability to access care. Local authority budgets have failed to keep pace with rising costs and the increase in the number of people needing care. As adult social care places funded by a local authority are often less profitable, there is the risk that people who live in more deprived areas and are more likely to receive local authority-funded care, may not be able to get the care they need.[28]
32. We have also seen how rising adult social care costs, driven by factors like the cost of living crisis, have forced self-funding individuals who receive care at home to cut back on essential care visits, with an impact on their quality of life.[29]
33. In the all-age national autism strategy and the National Disability Strategy, the government set out specific actions to level up support for disabled people and autistic people across the country. However, we know from our local authority assessments over the 2023-24 period that local authorities said they had gaps in services for people whose needs are more complex to meet, particularly nursing needs or complex mental health needs, as well services for autistic people and people with a learning disability.[30]
34. The gaps resulted in widespread examples of people being placed out of their local area – some in a nearby area, but others a long way from home. A common finding was that people with more complex needs, including autistic people and people with complex mental health needs, were more likely to be placed out of area. Some assessed local authorities acknowledged that long-term work was needed to shape the market and resolve this problem. Among the ways this is affecting people, we found:
35. At the end of March 2024, there were 220 autistic people or people with a learning disability whose discharge from hospital was recorded as delayed. When looking at the most common reasons for these delays, a third (33%) involved delays while awaiting a place in a residential home, while a quarter (24%) involved a lack of social care support. [32]
36. Currently, we find that unpaid carers continue to struggle to access the support they need, and, based on early findings from local authority assessment work, this was more pronounced in local authority areas where there were staff vacancies or difficulties with recruitment. Carers also said information is not always presented in accessible ways.[33]
37. From the local authority assessments we have carried out so far, we have heard of a number of challenges impacting the experiences and support available to unpaid carers:
38. In our latest State of Care report, we shared an example of a local authority undertaking additional work to improve how unpaid carers are identified. In this specific example, the local authority was working with partners in the Integrated Care System through the Accelerating Reform Fund to develop digital self-assessment and address waiting times for a carer’s assessment. [35]
39. We also reported evidence we collected from engagement with unpaid carers for people with dementia. Family members and other unpaid carers play an essential role in supporting people with dementia to access services and to receive appropriate care and treatment, but their own needs often appear neglected, or they feel poorly communicated with. One person told us:
“I was unable to leave her, even for the toilet, due to her wandering and ripping out her cannula. I didn’t eat or drink anything for over 26 hours as I had to remain by her side. I had a stool (no proper chair) to prop on all night while she slept and was freezing cold.” [36]
40. Many adult social care providers are worried about the financial stability of their services. In July 2023, we carried out a survey of adult social care services to find out more about the challenges they face. We found that over a quarter (26%) of services said they had considered leaving the adult social care sector in the past 12-months.
41. We’re also acutely aware when assessing local authorities that we do so against a backdrop of increasing demand for social care, along with workforce and financial pressures in local government.
42. Staffing challenges and high demand are having an impact on how services are delivered. In community adult social care, we have heard how less urgent visits are not being prioritised. This includes, for example, calls that should have 2 care workers being delivered by only one person, with too little time allocated to each visit, overloaded rotas, overlapping call times, not allowing for travel time between clients.[37]
43. A survey of representatives from local authorities expressed widespread concern that they are often significantly under-resourced to process increasing volumes of Deprivation of Liberty Safeguards (DoLS) applications to deliver their duties under the Mental Capacity Act, as their funding has not increased in line with the number of people requiring assessments. The DoLS system has needed reform for over 10 years. 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.[38] In the context of expected reforms in the sector, it is yet still unclear when the DoLS system will be reformed.
44. Our recent State of Care report notes that improved bed occupancy, reduced agency staffing costs, stabilised operational costs and increases in local authority fees all helped to improve profit margins in the year, but providers in the Market Oversight scheme are telling us that the increases for 2024/25 do not fully meet increased costs, for example increases in the National Living Wage.[39] This is supported by the 2024 Spring Survey from the Association of Directors of Adult Social Services, which stated that higher costs due to inflation and workforce challenges have impacted the financial position of a number of providers, meaning they have reduced resilience in facing future financial and operational challenges.
45. Our report also includes insights shared with us by ARC England, a membership organisation for providers of services for people with a learning disability and autistic people. According to ARC, the impact of long-term underfunding of its members includes loss of services driven by providers handing back contracts and declining to offer services, and “opportunity loss” in the long term, meaning that recent progress made in supporting choice and control in individual’s lives and promoting their independence is placed at risk.[40]
46. As part of improving access to care and support, the April 2023 ‘Next Steps to Put People at the Heart of Care’ policy paper set out plans to support employers to recruit and retain care staff, including a commitment to continued national support, supporting jobseekers into the care sector and funding sector partners to advise employers on good recruitment and retention practice, as well as additional workforce recognition and career development. Through our work we know that continued high turnover and a lack of staff with the right skills is impacting individuals and the quality of care they receive.
47. Through our provider information return we asked adult social care providers to describe the challenges they face in providing good quality care. They told us about difficulties in recruiting new staff, for example how potential candidates can be deterred by issues such as high demand for care services and perceptions of caregiving roles as being low-paying and physically demanding.[41]
48. In focus groups with our inspectors, we heard that high staff turnover can lead to poor practice as there are not enough established staff to mentor new staff. Vacancy rates and high staff turnover can place a great deal of pressure on existing adult social care staff. We saw these pressures illustrated during an inspection of a care home this year, which was rated as ‘requires improvement’ for the well-led key question.[42]
49. As well as pressures on providers and existing staff, high turnover can also have an impact on people who are using services. For example, one homecare provider told us about how staffing changes can be challenging for people when they have built relationships with staff, particularly for people with a learning disability. [43]
50. A lack of suitable skilled and trained staff to support people who are distressed has led to multiple examples of abuse and inappropriate and illegal restrictive practices being used, particularly in the care of people with a learning disability and autistic people. For example, during an inspection of a residential care home for autistic people and people with a learning disability, we found that staff used blanket restrictive practices such as verbal, authoritative commands to instruct people what to do and what not to do but they did not recognise this as a restrictive intervention. [44]
51. In this year’s State of Care, we reported that in 2023-24 we made 106 referrals to partner agencies who have the duty to investigate concerns regarding modern slavery and labour exploitation. This is nearly 3 times as many as the previous year – we made 37 referrals in 2922/23 and 8 referrals in 2021/22.[45]
52. We welcome the work that Skills for Care has overseen on the development of the sector-led workforce strategy and have fed into the detail of the findings and recommendations. We support the need for a national workforce strategy for social care, alongside the NHS workforce strategy, to give parity of approach – a message we have consistently stated in recent years.[46] We also support the continued development and implementation of the Care Workforce Pathway, which has the potential to address some the issues raised in this submission.
53. This work on workforce must be seen in the wider context of social care reform – where we have called for investment and long-term sustainability for the sector, and better access to support to create a fairer system - and can see the contribution that effective regulation can play in improvement and assurance.
54. Intermediate care is expected to result in improved outcomes, experiences and independence for people, as well as reducing avoidable re-admissions to hospital and avoidable or premature long-term care provision. Further expected benefits include improved flow and discharge from acute and community hospitals and freeing up NHS hospital capacity for those who need it most.[47] Adult social care plays a key role in intermediate care because it provides the necessary support to enable individuals to transition from hospital care or avoid unnecessary hospital admissions.
55. We carried out a survey of 720 people to understand their experiences of intermediate care services. We found that, of the 245 respondents who said they or a loved one had received intermediate care, the majority (59%) were positive about their experience, with 38% saying it was ‘good’ and 21% saying it was ‘very good’. However, a quarter (25%) of respondents described the care as ‘average’ and just over 1 in 10 (10%) said it was ‘poor’ or ‘very poor’.[48]
56. Most of the people we spoke with were grateful for the care they received, with some saying, “I couldn’t fault it”, “The carers were excellent”, “the physio was really encouraging”. However, we also heard that for some people, the discharge from hospital was “rushed”, and that “Hospitals are desperate to discharge at any costs”. We also heard that “discharge had to be delayed due to a lack of reablement facilities” and, in some cases, there was a lack of local provision.
57. Availability of high-quality adult social care provision can also contribute to better delegation of healthcare tasks, but without a stable, skilled, and well-supported social care workforce the sector is likely to struggle to take on additional responsibilities effectively, with an impact on capacity in the healthcare sector.
December 2024
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[1] About us - Care Quality Commission
[2] https://www.cqc.org.uk/about-us/mental-health
[3] Local authority assessments - Care Quality Commission
[4] https://www.cqc.org.uk/publications/major-report/state-care
[5] The state of health care and adult social care in England 2023/24 - Care Quality Commission p 165
[6] Local authority assessment reports - Care Quality Commission
[7] Emerging themes from local authority assessments | by Care Quality Commission | Dec, 2024 | Medium
[8] Statistics » Discharge delays (Acute) (referenced in State of Care p.41)
[9] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.41
[10]The state of health care and adult social care in England 2023/24 - Care Quality Commission p.45
[11] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.9, (then in more detail at pp.42-43)
[12]The state of health care and adult social care in England 2023/24 - Care Quality Commission p.85
[13] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.82
[14] State of Care 2022/23 - Care Quality Commission, p. 37
[15] State of Care 2022/23 - Care Quality Commission, p. 37
[16] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.120
[17] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.121
[18] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.162
[19] p. 105
[20] State of Care 2022/23 - Care Quality Commission, p. 105
[21] Market Oversight of adult social care - Care Quality Commission
[22] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.53
[23] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.53
[24] State of Care 2022/23 - Care Quality Commission, p.122
[25] The state of health care and adult social care in England 2023/24 - Care Quality Commission pp.157-158
[26] State of Care 2021/22 - Care Quality Commission, p. 53
[27] Rapid evidence review: Tackling inequalities through the regulation of services and organisations - Care Quality Commission
[28] State of Care 2022/23 - Care Quality Commission, p. 5
[29] State of Care 2022/23 - Care Quality Commission, p.5
[30] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.156
[31] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.156
[32] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.112
[33] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.155-56
[34] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.155-56
[35] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.155-56
[36] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.120
[37] State of Care 2022/23 - Care Quality Commission, p. 36
[38] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.125-134
[39] The state of health care and adult social care in England 2023/24 - Care Quality Commission pp.51-53
[40] The state of health care and adult social care in England 2023/24 - Care Quality Commission, p.54
[41] The state of health care and adult social care in England 2023/24 - Care Quality Commission p. 47
[42] The state of health care and adult social care in England 2023/24 - Care Quality Commission, p. 47
[43] The state of health care and adult social care in England 2023/24 - Care Quality Commission, p.47-8
[44] The state of health care and adult social care in England 2023/24 - Care Quality Commission pp.114/115
[45] The state of health care and adult social care in England 2023/24 - Care Quality Commission p.49
[46] The state of health care and adult social care in England 2023/24 - Care Quality Commission p. 50
[47] NHS England, Intermediate care framework for rehabilitation, reablement and recovery following hospital discharge, September 2023