Unpaid carers and Care Quality Commission assurance

This toolkit is designed to support councils with Care Quality Commission (CQC) assurance as it relates to unpaid carers. It builds on published information about the CQC's approach to assessing how well councils are discharging their duties under The Care Act (2014).

Introduction

This resource was commissioned by the Association of Directors of Adult Social Services (ADASS) Carers Group, and co-produced by a small working group including councils, Carers UK, Carers Trust, National Institute for Health and Care Excellence (NICE), an unpaid carer and Partners in Care and Health officers.  It builds on what the CQC have published to date about their approach to assessing how well councils are discharging their duties under The Care Act (2014).

Since 1 April 2023, initial ‘baseline’ assessments for all councils have been underway. The CQC has adopted a phased approach to its assessments with a focus on developing the assurance approach, gathering evidence, exploring relative performance by councils, and building relationships.

There will be some themed reporting at national level with focus on care provision, integration, continuity and assessing needs plus access, commissioning, market shaping, workforce, and personalisation.

The CQC has said their baseline assessments will involve:

  • benchmarking councils against each quality statement
  • evidence collection both on and off site, including by Experts by Experience
  • utilising six categories of evidence as appropriate, depending on which quality statement is being assessed
  • people’s experience is a required evidence category for all quality statements when assessing councils, and is weighted as highly as other sources of evidence 
  • considering the experiences of unpaid carers most likely to have inequitable access, experiences or outcomes from care 
  • examining how councils encourage, enable and act on feedback from unpaid carers who draw on support, including from people who face communication barriers, and how they work with them as equal partners to improve carer support, services and experience.

Our toolkit sets out how the CQC will approach evidence collection; the types of evidence they will use; their likely lines of enquiry as they relate to unpaid carers and links to useful resources and materials.

From September 2023, the CQC will introduce formal assessments of all councils within two years. These assessments will include ‘one word’ ratings. It is expected that 20 assessments will run from September to November 2023.

CQC approach to evidence collection

The CQC will seek evidence in support of each quality statement in their assessment framework, and have set out the types of evidence they will use in support of their assessment decisions.

Evidence already held or accessible to CQC

This includes:

  • evidence already collected as part of CQCs regulatory activity eg insights from partners, providers, people using regulated care 
  • data on effectiveness of some processes 
  • outcomes data: Short and Long Term (SALT) data and Survey of Adult Carers in England (SACE) data
  • census data
  • GP Survey data
  • Carers UK data reported via their ‘State of Caring’ Reports

Evidence which will be requested from councils (lead-in times are yet to be confirmed)

This includes:

  • specific policies and strategies
  • surveys and other data collected and held by councils (qualitative and quantitative) 
  • councils’ own self-assessment against the quality statements underpinned by ‘A guide to support the development of an Adult Social Care Self-Assessment’ as part of what CQC call their ‘Local Authority Self-Assessment and Information Requirements’ (LASAIR)
  • relevant feedback from peer reviews 

Evidence which will be directly collected by CQC 

The CQC will wish to hear directly from unpaid carers about their experiences (for example, through case tracking and focus groups), and from focused engagement with partners such as organisations commissioned to provide carer support, including assessment, and conversations with councils’ staff and leaders.

The ‘I’ statements in CQC’s assurance framework
The CQC has opted to use some of the ‘I statements’ from TLAP’s ‘Making It Real framework’ to support them in gathering and assessing evidence under the ‘People’s Experience’ evidence category. The consensus among those working with unpaid carers seems to be, however, that these statements are not as useful as the statements in the Government’s ‘People at the Heart of Care: adult social care reform’ policy paper.

Categories of evidence used by CQC

People’s experiences

All types of evidence about people’s experience of care and support, or a pathway across services, including unpaid carers, families, advocates and young carers; examples include interviews, focus groups, feedback on care from any source, surveys from any source, feedback from groups representing people who draw on care and support, and case tracking.  

Feedback from council staff and leaders

Feedback collected through CQC interviews and surveys with council staff and leaders, including portfolio holders and overview and scrutiny, equality, diversity and inclusion leads, quality assurance teams, commissioners, council staff carers networks and feedback received by CQC about people’s experience of care, such as compliments and concerns. 

Feedback from partners

Feedback collected from partners involved in the wider determinants of health and wellbeing such as housing, local NHS Trusts and commissioners and intermediate care boards.  

Feedback will also be collected from voluntary sector groups, including those representing people who are more likely to experience poorer care and outcomes, people with protected equality characteristics, unpaid carers, health and wellbeing boards, information and advice providers, advocacy providers, care providers, the Social Care Ombudsman, published special educational needs and disabilities (SEND) reports, Office for Standards in Education, Children's Services (Ofsted) reports.

The CQC will also wish to hear from carers organisations commissioned to undertake delegated carers assessments of behalf of the council.  

Observation

Not applicable to councils.

Processes 

These are defined as steps, activities or pathways to delivery of care and support that is safe and meets people’s needs. The CQC say that their focus will be on the effectiveness of these processes “rather than simply the fact they exist.” Evidence in this category would include metrics such as waiting times for assessment and review, audits, policies, and strategies. 

Outcomes 

The CQC define this as “the impacts processes have on individuals and communities, and how people’s physical, functional or psychological status is affected by care and support provided.” Evidence will include information on the quality of care provided, relevant wellbeing measures, quality of life assessments, and population data.

Likely lines of enquiry

We've set out below what we think the CQC’s possible lines of enquiry could be as they relate to unpaid carers.

Unpaid carer data 

Some of this data will be available to the CQC from published sources (see below), but they may request data from the council’s own surveys of unpaid carers and from commissioned carers services, such as data on waiting times for a carer’s assessment. 

Data sources could include:

  • demographic data, including census data
  • unpaid carer population data 
  • equalities data
  • public health data
  • frequency of use of care services
  • waiting list times for carers assessment and for services/support
  • outcomes data (SALT and SACE) 
  • profile of commissioned services for unpaid carers
  • council’s own survey data, for example from carers and from commissioned carers services
  • other data sources, for example GP survey  

Attention will need to be paid to any data showing declining quality of life scores and satisfaction levels with unpaid carer support. Councils will need to demonstrate understanding of the risks associated with these findings, and what action is planned to mitigate these risks. (See Data sources below for more information).

The GP Survey shows that overall carers are less likely to report positive experiences of primary care, and there seems to be a correlation between caring for 35+ hours and smoking.

People’s experience of care, how councils learn from it, and respond to it 

The CQC will have some data from their own and public sources, such as Ombudsman reports, but are likely to request much of this evidence from councils, and as part of their conversations with unpaid carers and groups which support them. 

Things to consider include:

  • the diversity of methods councils have in place for collecting and responding to carer feedback: surveys, forums, interviews, case tracking, feedback from unpaid carers, those they care for, unpaid carer/representative groups, advocates, young carers, and people moving across different parts of the system, including transition from being a young carer to an adult carer 
  • how councils collect feedback from their system partners, and particularly how they use this to improve overall experience for unpaid carers
  • how councils evidence they pro-actively seek and respond to carer feedback (rather than making improvements in response to a one-off incident or complaint), and the improvements or changes made as a result (known as double-loop learning) 
  • evidence that council leaders are committed to learning from carers’ feedback and can show how it informs strategy, improvement activity and decision making at all levels in the council
  • sharing relevant evidence and learning from peer reviews, and how this has been used to improve the experience of unpaid carers
  • how to show there is an inclusive and positive culture of continuous learning and improvement, and this is shared by all leaders and staff across the council.

Knowing what ‘good’ looks like

The CQC will be looking at how councils assess themselves using external quality and other standards, and how these standards are used to drive improvement in carer support. 

They will be looking for:

  • evidence of how council’s benchmark or assess themselves against the ‘We’ statements in their assessment framework
  • evidence that providers, commissioners and system leaders live up to and own these statements 
  • evidence of how councils use good practice and quality standards to drive improvement and innovation (see Resources section)
  • evidence of use of research and evidence to continuously improve people’s experience of care and support.

Co-production

The CQC will be looking for evidence of meaningful, mature approaches to co-production with unpaid carers as equal partners  

This would include:  

  • evidence of the extent to which unpaid carers can influence, plan and shape safe, person-centred care. This includes shaping commissioned and non-commissioned support 
  • evidence that unpaid carers are treated as equal partners in decision-making and processes which affect them
  • evidence that council leaders foster a culture of openness and learning to improve safe services for unpaid carers.

Equity

The CQC is keen to examine the equity of people’s experience and their access to, and transfers between, services. They say they will focus on people who are most likely to experience inequality in their experience of support or outcomes and are likely to be looking for:

  • evidence of how councils identify and reduce inequalities of experience and outcomes relating to Care Act duties through their strategies, action plans and equality impact assessments
  • councils’ annual reporting for the Public Sector Equality Duty
  • council arrangements for engaging with unpaid carers to understand their experiences relating to Care Act duties. This should include young carers in transition to adulthood, and parent-carers 
  • information, advice and advocacy support which is accessible and offered in digital and non-digital formats
  • inclusion and accessibility arrangements, for example British Sign Language or interpreter services.
Do parent-carers have equitable access to assessment and support? The Contact's Transitions research concludes that parent-carers of young people under 18 were less likely to have their needs considered than those caring for someone aged 18-25. Parent-carers also said that Care Act rights to carers assessments were not made known to them.
Are young carers transition assessments happening in line with the Care Act? The Children's Society research said that only 13 per cent of young adult carers reported they had received a transition assessment, with some having this happen after they became 18. Confusion among practitioners about this process was also reported.

 

Safe and effective processes

The CQC will be looking at the effectiveness of processes for safe, personalised care and support, using their own feedback, feedback from unpaid carers, feedback from councils, information and advocacy providers, and from partners including those undertaking carers assessments on behalf of the council. 

They will be looking at:

  • feedback and evidence of effective processes including arrangements for carer assessment, support planning, review, help at first contact, availability of direct payments, clear criteria for eligibility decisions, and clear pathways when carers move between services and organisations (including young carers in transition to adulthood)
  • carer-specific policies and strategies including carers strategies, market position statements, commissioning intentions, Joint Strategic Needs Assessments, co-production strategies 
  • arrangements for information and advice for all unpaid carers, regardless of whether they receive state-funded support, and which is accessible and in range of formats (not only online)
  • arrangements for access to independent advocacy support for unpaid carers, including young carers and parent-carers
  • processes for responding to reports and reviews that feature safeguarding issues relating to unpaid carers
  • whether unpaid carers know who to contact if they have concerns about their own safety, that of the person they support, or a care provider 
  • evidence that care and support is planned and organised with unpaid carers, partners and communities in ways that mitigate risk and improve safety across care pathways, particularly when people move between different services (including moving from being a young carer to a young adult carer)
  • evidence that councils are co-operating with key partners, including the NHS, to improve care and support for unpaid carers.  

Data sources

The CQC specifically reference looking at data on carers from the Adult Social Care Finance Return (ASC-FR) and Short and Long Term (SALT) data set, and the Survey of Adult Carers in England (SACE) which runs every two years.

Other data which councils can use to tell their data story could include:

  • carer outcomes data from locally commissioned carers support services with evidence of how this is used to inform commissioning intentions and strategies or for benchmarking, quality assurance and improvement purposes (this should include data from organisations commissioned to undertake carers assessments on behalf of the council)
  • numbers of Care Act transition assessments undertaken with young carers
  • numbers of carers (including young carers) referred for independent advocacy, and outcomes
  • numbers of parent-carers identified and how they have been supported
  • feedback from frontline staff involved in first contact with carers and trend data on how many contacts translate into carers assessments; this could potentially include how many assessments were offered but refused.
It’s worth noting that all-England data shows that over time, unpaid carers are reporting a reducing quality of life, reducing satisfaction levels with social services, and increasing isolation. 

Resources and good practice materials