Getting the right care, at the right time and in the right place is an ongoing challenge, finds CQC

We suspect readers may not have been as interested in CQC’s State of Care report 2023/24 this year due to the conclusions of Dr Penny’s Dash’s review and more pressing issues arising from the budget. However, we thought we would draw out a few key points within the 172 pages. 

Adult social care

This is covered in detail at pages 39-57.

• In April 2024 waits for care home beds and home based care accounted for 45% of delays in discharging people who had been in an acute hospital for 14 days or more, with nearly 4,000 people delayed on an average day. Nearly 23% of these people were waiting for an assessment to start a care package in their own home (daily average of just under 2,000), and increase from 18% in April 2021. 22% were waiting for a long- term care home bed to become available (a daily average of 1,900 people) – an increase from 14% in April 2021. Although some of these delays will have involved waits for health rather than social care services, social care is likely to have been a significant factor in these delays.   
• In 2023/24 CQC made 106 referrals to partner agencies who have the duty to investigate concerns regarding modern slavery and labour exploitation. This is nearly three times as many as the previous year – they made 37 referrals in 2022/23 and 8 in 2021/22.
• As part of their Market Oversight Scheme a key measure of profitability that CQC monitor is EBITDARM. This shows that profitability in care homes for older people was 26.9% in March 2024, representing a recovery from 22.5% in March 2022. While various factors have contributed to this such as fee increases and stabilised costs, CQC noted the impact of reducing costs for agency staff on overall staffing costs – a fall from 14% to 5%. Over the same period, agency staff costs for specialist care home and home care providers fell from just over 11% of total staffing costs to just over 7%.
• Profitability for homecare services was 17% at March 2024, an improvement of 4% in the last 12 months.
• Providers of care homes for older people within the Market Oversight Scheme report improvements in recruitment and retention of people within the UK. However, specialist providers continue to refer to workforce as a key challenge.
• They note concerns around the sustainability of the adult social care market (and that was before the budget…) with ARC England telling them that increases in fee rates over the last six years have been lower than the actual inflation rate when salary costs are taken into account.
• Examples of innovative care are set out at page 57 around monitoring infections in care homes and reducing risk of falls.

Mental health and learning disability

This is covered in detail at pages 58-71 and pages 108-118.

• In the foreword, the Chair takes the opportunity to remind readers of their special review of the care provided by Nottinghamshire Healthcare NHS Foundation Trust (you can read our article on the review here), where they made clear recommendations to improve oversight and treatment of people with serious mental health issues. They called for national action to tackle systemic issues in community mental health, including a shortage of mental health staff and lack of integration between mental health services and other healthcare, social care and support services.
• In June 2024, for every 1,000 people, 34 were in contact with services compared with 24 for every 1,000 in June 2019. However, CQC note there has not been a corresponding rise in the numbers of interactions people have had with services.
• More than 1,500 people were in an inappropriate out of area placement at the end of June 2024. This, together with high occupancy rates, suggests to CQC there isn’t enough capacity in in patient settings to meet the needs of patients being referred from the community. CQC also comment on lack of capacity leading to people under 16 being placed in inappropriate settings.
• CQC note that the NHS Long Term Plan set out the ambition that people should have in patient stays of no longer than 32 days. However, figures for June 2024 show that nearly 2,500 patients had stays of 60 days and nearly 1,400 had stays of over 90 days. They accept however that these longer stays are a) down from March 2024 and b) may be due to people being more ill on admission as well as other factors such as being placed out of area, housing etc.
• CQC are concerned about the rise in the number of mixed sex accommodation breaches.
• CQC are concerned that only a quarter of the estimated 1.3m people with a learning disability were recorded on the LD register, which means that many people are missing out on the proactive care and treatment they are entitled to.
• At page 111, CQC set out various statistics to show that three NHS Long Term Plan commitments to reduce the number of patients with autism or LD on inpatient units have not been met.
• The previous government asked CQC to take the lead on Independent Care (Education) and Treatment Reviews for the next two years. They restarted the programme in May 2024 and are engaging with NHS Integrated Care Boards to prioritise 96 patients with LD or autism who are in long-term segregation.
• On an inspection of a residential care home providing personal care and support to autistic people and people with LD, they found staff using blanket restrictive practices without ensuring safeguards were in place to protect people’s rights. Staff had not recognised what they were doing was a restrictive intervention and the provider didn't have a monitoring system to evaluate whether they met ethical and legal standards. CQC state that where they have found disproportionate restrictive practice and unlawful deprivations of liberty, they have taken enforcement action and shared their concerns with local authority commissioners and safeguarding teams to make sure people are protected from harm. Their concerns about excessive restrictive practices are reinforced by their experimental analysis of provider information returns from April 2021 to April 2024. They specifically flag that it's not acceptable that staff who haven't received training, which is mandated in regulations, continue to provide services to people. Their focus is on how providers and leaders are assured that their staff have the skills they need.

Deprivation of Liberty Safeguards (DoLS)

See pages 125-134.

• CQC are concerned that too many people are waiting too long for a DoLS authorisation, despite multiple examples of local authorities trying their best to reduce backlogs and ensure sustainable improvement. CQC are worried about the rights of people at the heart of the DoLS system. They say they continue to see people in vulnerable circumstances without legal protection, which not only affects them but also their families, carers, staff and local authorities. They note that the system has needed reform for 10 years and say that unless there's substantial intervention they are concerned that the challenges will continue.
• While they see services routinely reviewing restrictions to check if they remain the least restrictive option, rather than assuming the restrictions continue to be necessary simply because the DoLS authorisation was granted they see other providers continuing to have a mixed understanding. In this regard, they saw examples of DoLS applications from providers that did not include capacity assessments, did not specify what and why restrictions were needed and failed to acknowledge less obvious restrictions that were already being implemented.
• CQC refer to having seen lack of person centred planning and staffing issues leading to blanket restrictions. They repeat the fact that it is vital staff do not assume people lack capacity to make all decisions too.
• Almost half of Notices of Proposal to impose conditions on a new provider were based on a lack of compliance with standards outlined in the Mental Capacity Act.

Miscellaneous

• Bed occupancy has reduced from an average of around 109,000 in 2010/11 to 104,000 in 2023/24. Since the beginning of 2022, more than one in ten occupied beds are being used by someone whose discharge was delayed.
• There's an entire new section on environmental sustainability at page 97. Here they discuss The Regulators’ Pioneer Fund, Net Zero by 2045 and the 2022/23 Investment and Impact Fund. They specifically discuss nitrous oxide, desflurane and asthma inhalers.
• CQC will be developing a cross-sector dementia strategy shaped by the question: “How can CQC use its role to improve the experience of using health and social care services for people living with dementia and their carers?” They plan to share their findings in 2025.
• A summary of CQC ratings for services can be found at pages 163-172.

We’ll have to wait and see to what extent the regulator’s findings will feed into the government’s 10-year health and care plan expected in spring 2025.

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