Care Quality Commission publishes annual report

Care Quality Commission publishes its fifth annual report on the state of health and care services in England

• Care Quality Commission publishes its fifth annual report on the state of health and care services in England
• There is much excellent care but the variation in the quality and safety of care in England is too wide and is unacceptable
• Safe services occur where effective leadership builds a culture of safety
• By looking at CQC's reports on outstanding and good care, other services can learn and improve
• CQC's ratings provide transparent information that allow people information to make choices

Over the past year, the Care Quality Commission's (CQC) inspections have found front line staff delivering excellent care but inspectors have also found poor services where people were not getting the care they should expect. CQC says this variation in the quality and safety of care in England is too wide and unacceptable and has a detrimental impact on people who use health and care services and their families.

State of Care gives CQC's perspective on the state of health and adult social care in England in 2013/14. It offers a unique perspective across more than 40,000 health and care services.

CQC's Chief Executive, David Behan said: ‘The findings from our inspections over the last year clearly show there is too much variation in quality and safety between services and within services. People need to have confidence that they will get good care. Our role is to identify what works well and why, and what doesn't work, and use this information to drive improvement and close the gap.

‘We have seen some excellent care in all sectors. For example the Accident & Emergency team that worked with patients to identify their support needs and meet those needs in the community, reducing the number of patients needing to be admitted to hospital. Or the care home where we saw how supporting people living with dementia was built into each care plan.

‘In primary care, we saw an out-of-hours GP service that had a system to quickly identify and respond to the needs of people who had long-term conditions, complex needs and those needing end of life care, who received a call back from a duty doctor within 20 minutes or home visit within two hours.

‘But we have also seen very poor care, such as the care home that inspectors found smelling of urine and where residents were still in bed at 10.30am, with many not getting the help they needed to eat breakfast. In one hospital we found that patients who had undergone surgery were being cared for in the recovery area for extended lengths of time. Patients were being returned to clinical areas that were inappropriate given the complexity of their needs.

‘Our inspections have also found variation within services. For example, while most hospitals are rated at least good for the way they care for people, the majority require improvement when it comes to keeping people safe.

‘While we will celebrate good and outstanding care where we find it, we are calling time on unacceptable inadequate care. When our inspections identify poor care, they must lead to improvement by providers, who should learn from the good and outstanding care we champion through our new ratings.

‘We acknowledge the rising pressure on care services. Financial pressures are real but not unexpected, and yet we continue to see many examples of good and outstanding care even in financially challenged organisations. 

‘Understanding the quality of care is complex - it is about how people experience services, it is about the outcomes of the services and about how safe they are. Quality and safety is underpinned and influenced by the quality of the leadership and the culture that the leadership creates within a provider. We have found in our new more rigorous inspections that being well-led promotes quality and safety overall.

‘From our inspections, the safety of services is our biggest concern. Care providers must make the basics of safe care a priority and build a culture of safety in their organisations, learning from the best. The principle of keeping people safe from harm is fundamental. Strong, effective leadership at all levels in an organisation is vital. Our new inspections of NHS trusts have found that good leadership drives up quality and safety overall.'

What needs to be done

• The public should be at the heart of good care. Our judgments will help people make choices about their care and become more demanding of those who should be acting in their interests.
• Providers should accept where there are problems and use our inspections to drive up quality.
• Some services need help to improve. When we identify failings, the wider health and care system needs to work together to put things right for the safety and wellbeing of people who use services.
• CQC will use its new approach to regulation to shine a light on poor quality care and highlight good and outstanding care and encourage a learning culture in organisations.

Many of the issues raised in this report involve new approaches across the NHS. That is why CQC supports NHS England and the other NHS leaders' Five Year Forward View, due to be published soon, setting out why the NHS needs to change and what it needs to do in order to meet the needs of patients and close the care gap. CQC looks forward to seeing how the plans will improve the quality of care.

Caroline Abrahams, Charity Director at Age UK says:

‘We welcome the fact that the report shows that care in some areas has improved and that the CQC is committed to improving services . However let's not mince words about what some of the findings show - leaving someone in soiled beds or clothing for a long time or failing to ensure that an older person is able to eat or drink is neglect and should be treated as such.

‘The post code lottery of care continues to cause worry with no consistency  as people living in different parts of the country with similar problems still receive  different levels of support.

‘Staff shortages are an area of real concern especially in nursing homes. Too few staff puts those who need care at a huge risk. This is particularly the case if skilled and experienced staff such as nurses or care home managers are not present.

‘Providing care for older people must not be about completing tasks in whatever is the quickest or cheapest way. Decent care is about looking after a fellow human being in the way that we would like to be cared for when we are older.'

Notes to editors

Key findings for different sectors

Adult social care

Positive findings
•         We see many examples of excellent care being delivered up and down the country. Providers need to look at those who are doing it well and learn from them.
•         Good leadership is central to people receiving high-quality care. We found that the care provided by care homes with a registered manager in place was substantially better than by those homes that had not had a registered manager in place for six months or more.
•         We found examples of high-quality, where care staff were supported, valued and trained well.
 Areas for improvement
•         There is significant variation in the quality of adult social care. In particular, people living in nursing homes tend to receive much poorer care than those living in residential care homes.
•         Encouraging more nurses to work in the care home sector should be a higher priority. In 2013/14, one in five nursing homes did not have enough staff on duty to ensure residents received good, safe care.
•         We have concerns about 15-minute home care appointments, and whether they can truly deliver care and support that is safe, caring, effective and responsive to people's needs.

Hospitals, mental health care and community health services

The first acute trusts to be inspected under our new tougher approach tended to be higher risk. Of the 38 acute trusts, nine were rated good, 24 required improvement and five were inadequate.
Positive findings
•         In September 2014, we awarded the first outstanding rating to an NHS hospital: Frimley Park in Surrey.
•         In our initial community healthcare inspections, we found that most staff were compassionate and caring and patients were very positive about the quality of care they received.
•         We have seen some excellent examples of care in England's hospitals, mental health and community health services.
 Areas for improvement
•         We had issued ratings to almost a quarter of NHS acute trusts in England by the end of August 2014. We found wide variation in care between trusts, between hospital sites, between hospital services and within each service - from outstanding to inadequate.
•         Safety was the biggest concern: four out of every five safety ratings were inadequate or requires improvement.
•         Our new tougher inspections of mental health care found problems with poor physical environments and a lack of admission beds. Also we found that too many people were taken to police cells when experiencing a crisis in a public place, because of problems accessing a place of safety in a mental health service or an emergency department in a general hospital.
•         It is very concerning that providers have such limited ability to assess the effectiveness of their own services.
 

Primary medical services and integrated care

Positive findings
•         We inspected 30 NHS GP out-of-hours services, serving a combined population of around 19 million people - more than a third of England's population. We found that the majority of the services were safe, effective, caring, responsive and well-led.
•         The quality of dental care was generally good.
 Areas for improvement
•         We inspected GP practices for the first time in 2013/14, and found variations in the quality of care.
•         We found that, on average, larger GP practices delivered better quality of care than smaller practices.
•         Our work with the primary medical services sector to understand the components of high-quality care has highlighted the importance of introducing a clear quality assessment framework, alongside better data through Intelligent Monitoring. Until now, the sector has had no robust way of assessing the overall quality of care.

Number of warning notices issued in all sectors in 2013/14
•         Social care organisations - 1149
•         NHS healthcare organisations - 71
•         Independent healthcare organisations - 53
•         Independent ambulance - 3
•         Primary dental care - 30
•         Primary medical services - 24

A copy of the report is available on our website: www.cqc.org.uk/stateofcare2013-14
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