Bigger councils have outperformed smaller ones in CQC adults' services assessments, finds analysis

About the CQC’s local authority assurance system

• All 153 councils in England are being assessed over a two-year period, starting in December 2023, on their performance in relation to their duties under the Care Act 2014.
• Authorities receive an overall rating: ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Of the first 43 councils to receive an assessment report, one has been rated outstanding (Camden), 26 good, 16 requires improvement and none inadequate.
• Councils also receive a score of 1-4 for each of nine quality statements on: assessing needs; supporting people to live healthier lives; equity in experiences and outcomes; care provision, integration and continuity; partnerships and communities; safe systems, pathways and transitions; safeguarding, and governance, management and sustainability. These scores inform the overall rating.
• The CQC’s assessments involve a combination of desk-based checks and visits to the council concerned. Prior to the visit, councils must provide the regulator with a self-assessment of its performance against the nine quality statements.
• Other sources of evidence include: feedback from people who receive care and support, including self-funders, carers, voluntary and community groups and staff, including the principal social worker, director of adult social services and social workers; analysis of performance data; surveys of staff, carers and people accessing care and support, and studies of a sample of cases.
• There is no observation of practice by social workers or other professionals, such as occupational therapists.

Correlation between council size and performance

The consultancy's analysis was based on the IMPOWER Index, its tool for measuring the performance of councils in England across different service areas, including adult social care.

The index assesses councils on their spending per head of adult population, outcomes - as measured by the government's adult social care outcomes framework (ASCOF) - and productivity (outcomes achieved per pound spent).

According to the latest index, councils rated good by CQC had an average older people's population of 82,000, compared with 47,000 for those graded as requires improvement; meanwhile good-rated authorities had an average working-age population of 282,000, while those with a requires improvement rating had an average of 185,000.

There was also a positive correlation between a council's adult population and its overall score (out of 100) from CQC, based on performance against the nine quality statements authorities are assessed on. The one exception to this was Camden, which scored 89, far higher than other authorities with a similar 18+ population to its own, which is around 200,000.

No link between CQC rating and outcomes

“We looked at whether there was a correlation between councils’ CQC assessment scores and their spend per head, outcomes or productivity," said IMPOWER's delivery director, Alex Fox.

"We couldn’t find one, but we did find a correlation with council size (although Camden, so far the only ‘outstanding' council, is an outlier in this). This raises interesting questions about what is being measured, the challenges for smaller councils in preparing for CQC inspections and the current outcomes measures (ASCOF)."

ASCOF, which was launched in 2011, includes survey-based data on the satisfaction with services and quality of life of people with care and support needs and carers, along with data collected from councils on areas such as take-up of direct payments, care home admission rates and the outcome of reablement services on independent living.

Fox said IMPOWER was working with organisations including the Association of Directors of Adult Social Services (ADASS) and Social Care Future, which campaigns for people to receive care and support that helps them live the lives they wish, to make recommendations for outcome measures "which more closely reflect what matters most to people".

CQC 'seeing positive impact from assessments of councils'

In response to the findings, a CQC spokesperson said: “This report from IMPOWER provides interesting findings, and a useful contribution to better understanding the use of local authority resources in relation to adult social care.

"Our assessment framework focuses on the care outcomes for the people the local authorities support. We have seen evidence of the positive impact assessments are having in helping councils to understand what is going well and what needs to be improved."

"We would like to encourage further learning and sharing of best practice in this area as we continue to learn and iterate our processes to ensure they remain efficient and meaningful, and provides informed findings to support further advancements and innovation in care delivery to local communities."

Possible link between ratings and deprivation levels

IMPOWER's analysis follows comments from James Bullion, the CQC's chief inspector of adult social care and integrated care, suggesting that there were factors other than a council's quality behind its rating.

“I think we can see a bit of a correlation between deprivation and also capacity of local authorities as well,” he told the ADASS spring seminar in April.

“We are planning to write an end of year report to draw out some of the issues so we can say to government, ‘there is a link between deprivation and poorer social care performance’. It’s obvious on one level, but needs evidencing.”

Councils raising spending but unequally

In line with government data, IMPOWER found that councils had increased spending on adult social care in recent years, from £346 per person aged 18+ in their area in 2020-21, to £474 in 2023-24, a rise of 37%.

A quarter of authorities raised spending by less than 20% over this period, while one in eight increased it by over 50%. The gap was starker in relation to spending on working-age adults, for whom spending had increased by less than 20% for one in five councils and by more than 50% for one in four.

IMPOWER found that those in the first group performed better on productivity than those in the second.

Fox said many of the second group of authorities were in the North of England and tended to be more deprived, though "increases [in spending] varied widely between councils with similar populations and challenges".

More expensive services 'often restrictive and institutional'

"We found a link between better outcomes and lower increases in spend, suggesting councils can’t just cut their way to financial sustainability, but need to increase their impact and productivity," he added.

"For working-age adults, the most expensive services are also often restrictive, institutional and out of area, so it’s in everyone’s interest to shift towards more community-based support.

"This is hard because councils told us that younger and working-age adults’ support needs and the support packages proposed by providers are shifting in ways many areas do not feel they completely understand or can influence.”