Care Quality Commission assessments for adult social care: Must know guide for chief executives

Key messages

You should familiarise yourself with the key themes from the self-assessment and other requested evidence submitted to CQC. Ensure it reflects the council’s ambition, corporate priorities, and how adult social care and health are integrated with them.

The CQC approach adopted has a different feel from that of Ofsted and is described as assurance or assessment rather than inspection. It will, however, generate a single rating (outstanding, good, requires improvement, inadequate). The methodology is different but equally rigorous and the preparation, communication, and reputational considerations are similar. There are also cross-over issues: transitions, community health, mental health, public health, equipment, and adaptations. The CQC will consider Ofsted reports as part of their baseline assessment.

The CQC assurance report will provide a short summary of the key features of the local authority and will focus on people’s experiences of care. It will include their most current findings against four themes (how local authorities work with people, provide support, ensure safety, and leadership), and for each of nine quality statements. The report can be challenged for inaccuracies. It is also subject to CQC’s internal moderation. Major weaknesses identified can trigger some form of intervention.

You will want to work with the director of adult social services (DASS) and lead member(s) to prepare a communication plan for the publication of the CQC assessment report, to include sharing it within the council and with key partners.

You will need to support the DASS in developing any improvement plan to address areas identified by the CQC, with particular attention to areas rated as weaknesses.

Introduction

This guide provides background on the CQC assessment process of adult social care for chief executives and includes information on the approach, and how to prepare for it. It also covers the process of reporting and rating and current understanding of how improvement requirements or possible intervention could follow for councils with the two lowest ratings.

While children’s services have been regularly inspected by Ofsted since 2006, there has not been an inspection of adult social care at an authority level for almost 15 years. The last inspections were conducted jointly by the Social Services Inspectorate and the Audit Commission and generated a four-level rating of zero to three stars.

The CQC continues to regulate and inspect the home care and residential and nursing home care market, including any directly managed by the council itself.

The CQC approach adopted has a different feel from that of Ofsted and is described as assurance or assessment rather than inspection. It will, however, generate a similar, single rating.

The government first announced this process in a White Paper, Integration and innovation: working together to improve health and social care for all in February 2021. A second White Paper, People at the Heart of Care in December 2021 confirmed arrangements as well as new legal powers for the Secretary of State for Health and Care to intervene in authorities where there are significant failings in the discharge of their adult social care functions. These were included in the Health and Care Act 2022.

The first five assessment reports, based on pilots in Lincolnshire, North Lincolnshire, Birmingham, Nottingham, and Suffolk, were published in November 2023.

A similar CQC assurance process for integrated care systems is being piloted currently.

What is in scope for the assessment?

The key focus is to assess how well local authorities are performing against their duties under Part 1 of the Care Act 2014.

The focus of the Care Act is to promote wellbeing, with emphasis is on supporting people to maintain their independence. The Act also concentrates on providing individuals with more choice about the care they wish to receive.

The Government created a national eligibility threshold. This means the point at which local people become eligible for social care support is equal across the whole of England.

There is a legal duty for an adult’s ‘eligible needs’, determined after an assessment, to be met by the local authority, subject to their financial circumstances.

Related duties require the provision of a care and support plan (support plan for a carer), a legal entitlement to a personal budget (unless it is just for intermediate care or reablement), and the right to ask for a direct payment.

Other significant areas of the Care Act include:

the requirement of local authorities to provide information and advice to individuals, helping them make informed decisions about the best way they can receive care.
people who pay for their own care should be offered support in assessing, planning, and managing their care.
new rights for carers, giving them the same eligibility for services as the adults they care for.
the requirement to help develop a market that delivers a wide range of sustainable high-quality care and support services that will be available to their communities. This combines commissioning, sufficiency of supply, and market shaping roles.

The CQC approach

The CQC assessment framework has been developed in close collaboration with the Department of Health and Social Care (who are required to approve it), ADASS and the LGA.

The assessment report will include financial information from published sources on what the council is expected to spend based on government grants, what it is spending, and whether it has raised the precepts permitted. It will also give the number of people accessing long-term and short-term support. It is not considering the adequacy of funding for adult social care, locally or nationally, but does have regard to the sustainability of the service.

The assessment is based on four themes:

How local authorities work with people
Assessing needs
Supporting people to live healthier lives
Equity in experiences and outcomes

How local authorities provide support
Care provision, integration, and continuity
Partnerships and community

How local authorities ensure safety within the system
Safe systems, pathways, and transitions
Safeguarding

Leadership
Governance, management, and sustainability
Learning, pathways, and transition.

There are nine quality statements mapped to one of the themes, and these are in turn linked to one or more “I” statements in the Think Local Act Personal ‘Making It Real’ framework.

Each quality statement will be judged against four evidence categories:

People’s experience
Feedback from staff and leaders
Feedback from partners
The effectiveness of processes, including metrics such as waiting times, audits, policies, strategies.

Each quality statement will be assessed against the required evidence and a score will be assigned, as follows:

Evidence shows significant shortfalls in the standard of care.
Evidence shows some shortfalls in the standard of care.
Evidence shows a good standard of care.
Evidence shows an exceptional standard of care.

The CQC is following the person’s journey in the care and support system, beginning with the assessment of their needs and a decision about whether their needs are eligible. This includes a financial assessment where necessary to determine whether people should pay for their own care. After the assessment process concludes, the CQC is tracking how decisions are made about whether the adult is entitled to care and support and how it is arranged by the council.

To this end they are asking for 50 cases to be identified by the council against CQC criteria using a coded system they will send. The person (and their carer as appropriate) will need to be happy to talk to the CQC about their experience and outcomes, usually by telephone or Microsoft Teams. From these, they will choose six to study, with a further four in reserve. It is not a case audit, rather a chance to follow the journey through the records. They are not routinely talking to the relevant practitioner(s).

The assessment team will comprise the following (not all being part of the visiting team):

planner
assessment manager
assessors (including lead assessor)
executive reviewer (who will help with interviews with executive leaders)
specialist adviser
expert by experience.

Timescales

After the pilot phase, the CQC has been announcing councils to be assessed in batches of six or seven. With a completion date of December 2025, the pace will need to step up considerably.

They have shared some principles for scheduling: to avoid elections, to ensure a mix of political leadership, size and type of authority, the schedule of ICS assessments, and avoiding coinciding with other regulatory activity of which they are aware. There are also issues about their recruiting staff and the availability of expert advisers.

What to expect

Your DASS will be notified by email

This notification will include a request for an information return to be completed within three weeks and a date for the on-site interviews. It should be noted the on-site visit could be up to six months after the initial notification . Study of the return, data analysis and some preparatory interviews will be undertaken during that period.

Current practice seems to be to give the DASS at least six to eight weeks’ notice

... of the on-site date to ensure consistency. Around the fourth week, the assessment team will seek a meeting with the DASS and their senior team and the council assessment lead(s) to understand how adult social care is structured and organised and the roles and responsibilities of senior managers and their teams. They also want to understand key partners, provider, user, carer, and advocacy groups, and Safeguarding Board Chair. This is an opportunity for the DASS to share what they are proud of and what challenges they face to bring life to the information return.

After this

...they will confirm who they want to talk to in advance relating to the six cases chosen, and some of the key external stakeholders.

As part of their advance preparation

...CQC will send a survey to all registered providers in the area.

What needs to be prepared and by whom

As this is a new responsibility for the CQC, it is establishing a baseline of completed initial assessments for all councils. These are intended to help develop their understanding of relative performance across local authorities.

For this first round, it is assessing:

evidence it has (insight from existing regulatory activity, and data on the effectiveness of some processes). This includes metrics from your council’s returns for the Adult Social Care Outcomes Framework (ASCOF), Safeguarding Adults Collection, Adult Social Care Survey (ASCS) and Survey of Adult Carers in England (SACE).
evidence it needs to request from councils (policies and strategies; survey information councils have; councils’ self-assessment of their current performance; information from peer reviews)
evidence it needs to actively collect (people’s experience from case tracking and focus groups; engagement with partners and conversations with staff and leaders).
insights from key national and local partners including health and care providers, professional regulators, national and local Healthwatch, the Local Government and Social Care Ombudsman.

Each council should designate a lead contact for the CQC assurance process, supported by an appropriate team. They will act as conduit for requests for information, set up arrangements, and regular liaison. They will be given access by CQC to a secure portal for uploading information including case-tracking. Experience from the five pilots suggests this is a demanding and time-consuming role.

The CQC has not specified that a self-assessment is returned or any required format for the requested evidence. We have produced guidance to help councils to complete an objective, honest, and authentic view of their strengths and areas for improvement, including a useful tool to use in your preparation with staff and partners. {ADD LINK TO SELF_ASSESSMENT]

Each council should develop a communications strategy, for internal use, and for partner organisations, in the run up to the assessment. This should combine information on the process and key messages from the self-assessment, as well as anticipating publication of the final report. It should make clear who is responsible for communicating with whom, particularly the roles of the council communications team and the directorate.

What is likely to happen when CQC are on site

The timetable for onsite assessment activity will include:

Individual interviews with key posts

... including Chief Executive, DASS, Principal Social Worker, Director of Public Health, Council Leader, Lead Member, Local Safeguarding Board Chair. They may specify other named people to talk to.

Interviews with small groups of frontline staff

... (informed by the information return and developing hypotheses about the council). They are unlikely to specify named individual staff to attend, just the team.

Open invitation drop-in sessions for frontline staff (not managers)

... not otherwise involved near the beginning and near the end.

Scheduled interviews with organisations

... identified to explore issues like engagement, co-production, and equalities.

The CQC is on site for three or four days. Interviews may be face-to-face or virtual. It is possible they will give some initial feedback, but their main findings will be in a draft report shared with the council and including the rating.

The report and rating

The report will provide a short summary of the key features of the local authority and will focus on people’s experiences of care. It will include their most current findings against the four themes and for each quality statement. The report can be challenged for inaccuracies. It is also subject to CQC’s internal moderation, currently using calibration panels to ensure consistency in reviewing and validating scores and ratings.

Once the rating and report is agreed, it will be published on the CQC website. The CQC will communicate with your council’s communications team in advance of publication. The CQC estimates this will usually be around eight weeks after the site visit.

The parallel assurance process for integrated care systems

The Health and Care Act 2022 also conferred powers on CQC to assess ICSs in the same two-year period as that for adult social care. The aim of their framework is to understand how they are tackling health inequalities and improving outcomes for people. CQC will look at how services are working together within an ICS, as well as how systems are performing overall. This process has been piloted in Birmingham and Solihull.

Reviews will take into consideration the four statutory purposes of ICSs and consider and report on the effectiveness of:

Arrangements for place-level working within the system.
Variations in service quality.
People’s experience.
Health inequalities and population health outcomes, and wider determinants of health across the system.

The assessments will cover:

The quality and integration of healthcare and adult social care within each ICS.
How partners in each ICS (the integrated care board, local authorities, and registered service providers) are meeting their own responsibilities within the system.
The functioning of the ICS, especially how well system partners are working together to deliver good care and meet the needs of their populations, including through the work of integrated care partnerships.

The approach to themes (3) and quality statements (17), again based on ‘I’ and ‘We’ statements, is broadly the same as for adult social care. There will be a baseline approach, followed by formal assessments, reporting findings, and awarding a rating.

Some evidence, such as data on population health and service performance, can be collected entirely off-site. Some can only be collected on-site, including interviews with key players, observing meetings, and understanding the culture and staff interactions.

Chief Executives and DASSs will want to consider the links between the process.

How you can prepare as chief executive

Ensure that your council is embracing the assurance process as an opportunity to celebrate the good work being done and how you are addressing areas that you want to improve.

Ensure that the council as a a whole is giving priority to the preparation for CQC assurance, allocating resources, and ensuring relevant elected members are fully briefed. The pilot sites reported that they had underestimated the cost and staff time involved in the preparation for, and hosting of, the assurance process. Ask to be kept informed on emerging themes from published reports.

Familiarize yourself with the key themes from the self-assessment and other requested evidence submitted to CQC. Ensure it reflects the council’s ambition, corporate priorities, and how adult social care and health are integrated with them.

Ensure that this process is informed by previous Ofsted inspections. The methodology is different but equally rigorous and the preparation, communication, and reputational considerations are similar. There are also cross-over issues: transitions, community health, mental health, public health, equipment, and adaptations. CQC will consider Ofsted reports as part of their baseline assessment.

Make sure you are aware of the central themes of the Care Act 2014, including its key intent and specific statutory requirements.

Assessors will be seeking evidence of how the council is reducing inequity in experience and outcomes, and how it provides a culturally competent service.

Ensure all the conditions are in place for political leadership of adult social care, including a productive relationship between the DASS and Lead Member(s).

Understand the key questions you need to ask of the directorate’s leadership on how your council is performing against comparators (from national data sets) and on key metrics such as waiting lists, delayed transfers of care, budget pressures, market capacity and quality. You will also want to be aware of staffing considerations such as caseloads, vacancies and sickness absence and measures of staff morale.

Keep abreast of the status of key partnerships within the council, with the NHS, and the wider market that are an essential part of securing the outcomes expected by the Care Act. This includes your own participation and that of the political leadership of the council.

Effective adult safeguarding arrangements rely on joint working across several different agencies and on communication with them. Your Adult Safeguarding Board oversees the effectiveness of your safeguarding arrangements and reports annually on actions taken and progress made in sustaining these. Ensure you are working with partners to ensure recommendations are acted upon and monitored.

Work with the DASS and Lead Member(s) to prepare a communication plan for the publication of the CQC assessment report, to include sharing it within the council and with key partners.

Support the DASS in developing any improvement plan to address areas identified by CQC, with particular attention to areas rated as weaknesses.

What questions may chief executives be asked?

What priority does adult social care have in your council? What is your ambition for it?
How do you supervise and support your DASS to deliver the outcomes expected from the Care Act 2014?
How well do you think the whole council supports people with care and support needs to secure the outcomes envisaged in the Care Act 2014?
What is your own role in key partnerships with NHS at an ICS and place level?
How productive do you find these relationships?
If you have multiple ICSs in your council area, how do you ensure parity of service and outcomes?
How does your council promote wellbeing and seek to reduce inequalities?
How does your council understand people’s experience of adult social care?
How are people who use care and support and their carers informing and shaping the council’s approach?
What do you know about the quality and impact of social work practice with adults in your authority? How do you know it? What are your plans to maintain and improve practice?
Do you have feedback, whether from staff surveys or other means, on the visibility and effectiveness of management and leadership, including from elected members, and, of course, your DASS?
What is the level and confidence in the data set being used and how well embedded performance management is within the service?
Are you aware of any developing trends from the performance data, and of plans to address them?
Do you benchmark your adult social care performance with other councils? How do you learn from innovation and best practice?
How well sighted are you on the work of your Adult Safeguarding Board and how its recommendations to improve the effectiveness of safeguarding arrangements are acted upon and monitored?

Improvement expectations and possible intervention approaches

The CQC’s assessment reports will clearly set out required improvements and best practice. Where there are concerns, councils will be expected to review the findings and publish action plans which the CQC will monitor.

It is anticipated that the CQC will also raise any concerns with national partners (including the Local Government Association, ADASS, the Department for Health and Social Care, and the Department for Levelling Up, Housing and Communities, and NHS England where appropriate). The relevant organisations will oversee support or make an intervention.

The CQC is required to inform the Secretary of State for Health and Social Care if any of the quality statements, other than for leadership, are rated 1 (such as significant shortfalls). The CQC has confirmed that no quality statement carries a greater significance or weight in this process.

Details of the adult social care intervention framework can be accessed in the further reading section.

What support is available for councils to prepare

We are supporting councils to improve the way they deliver adult social care and public health services, and helping Government understand the challenges faced by the sector. We have developed a range of offers to help councils prepare for CQC assurance.