The CQC State of Care report 2018/19: a quick-fire summary with commentary
Analysis by Royds Withy King
CQC have released their report on the state of care for 2018/19. They highlight that quality has continued to improve steadily but funding pressures and workforce challenges have affected access to services and providers’ profits. CQC have twice exercised their legal duty to notify local authorities when they thought there was a credible risk of service disruption because of provider business failure. These were the first notifications of this type issued during the four years of their running the Market Oversight scheme. It is unclear to us whether their involvement has helped prevent service failure.
Overall the quality of care has improved with 80% of adult social care services rated as good, up from 79% in 2017/18. Compared with last year, a further 282 services are providing care that is rated as outstanding, putting the total at 4%. This year the percentage of services rated as good or outstanding has improved in every region and there has been less variation in quality between regions.
Funding pressures have continued to cause a huge strain for the sector. Only 35% of adult social services directors are fully confident that their budgets will be sufficient to meet specific statutory duties in 2019/20. Looking further into the future, unfortunately that figure drops to just 5%. This comports with the pressures that we have seen on funding, where we regularly have to help providers fight their corner just to maintain fee rates.
The report goes on to highlight issues with the sustainability of the domiciliary care market. The United Kingdom Homecare Association reported that only 1 in 7 councils in the UK was paying their local domiciliary care providers the rate it estimates to be necessary to comply with National Minimum Wage regulations and the costs of running the service in a sustainable way.
Sadly, more care services are choosing not to support people funded by local authorities because their contracts do not cover the true cost of delivering their care. This has been the general direction of travel for some time.
The sector faces a range of challenges including a lack of qualified nursing staff, an insufficient number of high-quality registered managers, high vacancy rates, high staff turnover, and a resultantly high use of agency staff. We have observed CQC attempting to combat the lack of registered managers by threatening providers with prosecution, which we feel is wholly ineffective because it targets providers’ perceived motives rather than the real problem, a lack of qualified applicants. Staff turnover in all roles has risen over the last six years, with care workers representing the highest rate, at 40%. The vacancy rate for registered nurses working in social care more than doubled from 4.1% to 9.9% in the last 6 years. In some areas of the country these issues are severely limiting the care that providers are able to offer.
Access to services & capacity
Access to care continues to vary by locality but as care home provision has reduced across the country, the number of domiciliary care agencies has increased by 23% in the last five years. The number of residential and nursing home beds has been falling steadily in all regions over the last five years, probably reflecting commissioners’ financial motivations to support people in their own homes for as long as possible. London and the North East saw the greatest decrease in bed numbers with an 11% drop. There are concerns about the sustainability of the growing domiciliary care market and there are issues reported with continuity of care due to staffing issues once domiciliary care is secured.
Clearly this intersects with the funding and workforce challenge faced by providers and further highlights the urgent need to fund social care properly. Taking London as an example (where the number of domiciliary care agencies has risen by 37% in five years), agencies now outnumber care homes. In July 2019, there were just under 36,000 care home beds in London, compared with over 52,000 people being cared for by domiciliary care agencies. This means that ensuring domiciliary care services are able to run in a sustainable way while maintaining quality of care has become ever more crucial.
Local services working together
The report encourages providers to work together with other system partners to deliver care more effectively and also to create opportunities for career progression, while pooling resources and reducing costs. The report gives examples, such as smaller care homes joining together to deliver staff training, local authority quality teams promoting mentorship schemes for registered managers, and free training for frontline staff to deliver improved outcomes.
Innovation and technology
CQC also sets out what it sees as five key barriers to the adoption of technology in social care:-
• a lack of funding to invest in technology and the inability to make economic returns, particularly for smaller providers;
• a low level of knowledge and awareness of new technology among providers and staff;
• fear that technology could replace personal support;
• the perception that people who use adult social care are not interested or will respond badly to technology; and
• concerns about ethical or data protection implications in adopting technology that uses personal information, GPS or surveillance techniques.
Providers are encouraged to consider examples shared by others to learn how technology could assist with care delivery, recruitment of staff, administration and improving quality of life for service users.
Our own observation about the use of new technology is that CQC’s inspectors are sometimes ill equipped to judge its effectiveness. This is possibly because they don’t have the time during inspections to be able to get to grips with new systems or because they don’t have the knowledge or haven’t had the training to be able to understand them. Unfortunately, the results are that the benefits of technology (which CQC trumpets) are not always recognised by its inspectors and can be overlooked in inspection reports. Like providers, CQC should take steps to educate its workforce about the use of tech in care. Our view is that it must do so if it is to remain an effective regulator.
• The continued failure to find a consensus for a future funding model has driven instability in this sector; there is an urgent need for Parliament to prioritise a long-term sustainable funding solution.
• CQC want to see care services working together more effectively to ensure people get the care they need, but they have emphasised the need for support from the public sector on a local and national basis to foster real change.
• The adoption of technology offers huge benefits to service users, staff and providers but for many services, the funding crisis is one of the key barriers in preventing the implementation of that technology.