The CQC must improve how it assesses local authorities against delivery of the Care Act
The recent review of the CQC led by Dr Penny Dash concluded that assessments of local authority Care Act duties needs improving. One of the criticisms was that there are “insufficient descriptors” of what ‘good’ or ‘outstanding’ looks like to enable local authorities to improve their performance.
Another of the criticisms was that there is a perception among some local authorities that the CQC's assessment teams lack the expertise and insight into how adult social care works in local authorities. It is incumbent, therefore, on us in the sector to propose how the assessments could be improved.
The overall score awarded to a local authority is made up of ratings from one to four for each of nine quality statements. Of the nine local authorities assessed so far, most scored two or three in each statement and the overall average score was 2.6.
I have analysed these assessments, focusing on “Assessment, care planning and review arrangements” and “Eligibility decisions for care and support”. These are two of the seven elements under the quality statement of “Assessing needs” which produced the lowest average score, with an average of just 2.2.
What follows are thoughts on how the CQC could improve their assessment of how decisions are made about meeting eligible need.
Assessment, care planning and review arrangements
The CQC states it will consider the following when assessing processes in this category:
“Assessment, care planning and review, including processes and pathways from first contact with the local authority”.
Much of this section is devoted to descriptions of how staff are deployed to deliver assessments and the different models used, for example, ‘three conversations’. Reference to care planning was less detailed, with some reports giving examples of positive feedback on individual cases, others just noting that “care planning was person-centred and strengths based”. Reviews were most often mentioned alongside assessments and care planning.
A typical comment was “people gave mixed feedback about their experiences of assessment, care planning and reviews”. These comments were usually accompanied by a statement such as “this feedback was supported by national data which shows (x)% of people are satisfied with their care and support”, and a comparison was made with the England average of 61.2 per cent being satisfied in the 2023 Adult Social Care Survey, 2023.
Eligibility decisions for care and support
The CQC states it will consider the following when assessing processes in this category:
“Arrangements for determining eligibility for Care Act assessments, support and care funding. Appeals made against decisions.”
The factors the CQC seemed to focus on were transparency and consistency in applying the eligibility criteria and dissatisfaction about its applications from individuals.
The first three of the CQC assessments considered whether the “local authority’s framework for eligibility for care and support was transparent, clear and consistently applied”. They concluded that two were, and for one they “received mixed feedback”. But in the second batch of six, transparency was only referred to in one local authority. A more typical statement was simply noting that the “local authority had a framework in place for assessing eligible care and support needs under the Care Act”.
As well as looking at the framework for eligibility determination, this section of the assessment also looked at data on complaints in relation to eligibility. In the first batch of three assessments, they appeared to be looking for qualitative information. For example, in one local authority they considered data where there was “significant or repeated failure to provide a service” and concluded that dissatisfaction expressed was not clearly linked with the way the eligibility criteria was applied.
However, in the second batch a more typical statement was simply noting that complaints were “recorded and monitored” and the local authority’s response “included noting action as a result of the complaint such as service improvement or training and development of staff”.
Comment
Most of the local authorities are described as having a “framework in place for assessing eligible care and support needs”, but there is no explicit reference to any frameworks for meeting needs - what the CQC describes as “support and care funding”. Much of the focus is on the application of eligibility criteria, seemingly in the belief that this is the most crucial part of the framework for making decisions about meeting needs.
The data obtained by the CQC shows there is little dissatisfaction with the way that eligibility criteria is applied. This is further born out by the fact that historically there have been relatively few complaints to the Ombudsman about poorly applied eligibility criteria.
People are more likely to complain because they believe their needs are not being met, and less so about assessment and eligibility determination. Many of these complaints are about insufficient funding being made available to meet eligible needs.
This has led me to the view that CQC assessments of arrangements for support and care funding should more explicitly take account of the Care and Support Statutory Guidance (CSSG) which states “the most important principles in setting the personal budget are transparency, timeliness and sufficiency” (paragraph 11.24).
CQC assessments consider transparency in relation to the application of eligibility criteria, but there are only two mentions of complaints about the application this in relation to care funding. These are references to the operation of funding panels in Derby County and Harrow.
Timeliness is addressed elsewhere in the CQC assessments, but there is no consideration given to how local authorities address the sufficiency principle.
The CSSG specifies that transparency with care funding means making “their allocation processes publicly available as part of their general information offer” and ensuring “that
people fully understand how the personal budget has been calculated”.
Paragraph 11.25 of the CSSG states that the care funding calculation “must be sufficient to meet the person’s needs which the local authority is required to meet”. It gives some guidance on what a framework for care funding decisions should comprise of, but this is not neatly set out in one place as with eligibility criteria.
The following should be taken into account in determining sufficiency: desired outcomes and preferences (paragraph 11.24), value for money (paragraph 4.94), affordability (paragraph 10.27 ) and the promoting of wellbeing (paragraph 1.7).
The importance of addressing sufficiency is given weight by the Ombudsman’s annual complaints reviews which have expressed concern about “an under-resourced system unable to consistently meet the needs of those it is designed to serve” and “processes that fail to put the individual at the centre, care that fits with the system’s offer rather than the person’s needs and preferences”.
One of the most challenging elements of applying the Care Act is managing the tension that can arise between people’s desired outcomes and the resources available, in a fair and balanced way.
Most local authorities use funding panels to make the final decision. The CSSG states they “should refrain from creating or using panels that seek to amend planning decisions, micro-manage the planning process or are in place purely for financial reasons” (paragraph 10.85). It would useful if the CQC assessments considered to what extent this is applied.
It is outside of the brief of the CQC to refer to the issue of under-funding of social care, but there is sufficient guidance on transparency in making decisions about care funding for the CQC to make an assessment.
Arguably the CSSG needs revising to set out more clearly a framework for making care funding decisions, but in the absence of this it would be useful if the sector could work with the CQC to develop such a framework.
Peter Feldon is author of The Social Worker’s Guide to the Care Act 2014
BASW members are encouraged to get in touch to discuss and explore any of the themes highlighted in this article. Email England@basw.co.uk