Evidence used in this report

This report sets out the Care Quality Commission’s (CQC’s) assessment of the state of health care and adult social care in England in 2022/23.

In this report, we use data from our inspections and ratings, along with other information and personal experiences, including that from people who use services, their families and carers, to inform our judgements about the quality of care.

We have collected bespoke qualitative evidence to supplement our findings. Through this work, we have gathered views from our Operations teams and subject matter experts on quality issues, in particular for specific sectors of health and social care or aspects of our monitoring and regulatory approach.

This report is also informed by our wider horizon scanning activity. We have reviewed reports published by our stakeholders, drawn on findings from national surveys, and analysed publicly available datasets to supplement our understanding of the challenges facing health and social care today and the experiences of people using services. Where we have used data from other sources, these are referenced within the report.

To ensure that the report represents what we are seeing in our regulatory activity, analytical findings have been corroborated, and in some cases supplemented, with expert input from our Chief Inspectors, colleagues in our Regulatory Leadership directorate, specialist advisers, analysts and subject matter experts. Where we have used other data, we reference this in the report.

Here, we provide further detail relating to the evidence used in this report.

People’s experiences and what they have told us

Our view of quality and safety has been informed by information that people have shared with us through our online Give feedback on care service, phone calls and social media.

• To understand the concerns and issues faced by the health and social care workforce, we analysed a random sample of 700 comments received from staff through Give feedback on care between 1 April 2022 and 31 March 2023. The sample was selected to represent all sectors in proportion to the number of staff from each sector who had left feedback throughout the year. This meant that the larger part of the feedback we analysed was from staff working for adult social care providers, with relatively fewer comments from people working in hospitals, GP practices and other care settings.
• We looked at 4,368 comments from Give feedback on care that we received from the first 42 locations that were part of the National Maternity Inspection Programme between August 2022 and March 2023. We also reviewed the first 30 published reports from the National Maternity Inspection programme to understand the emerging themes.

We have drawn on the findings of our published surveys to inform what we say about what people think of the NHS services they use. Additionally, we have used data and insight from bespoke surveys that we developed or commissioned.

Towards the end of 2022, we recruited a group of young people aged between 13 and 25 from across England as ‘Young Champions’. This is a group of volunteers who support and challenge us on the way we reach and engage with young people and represent their experiences across our work. We invited the Young Champions to help us inform this year’s State of Care by co-designing and testing a survey about their experiences of health and care services and circulating it within their networks. We received feedback and experiences from 159 young people from the end of May to the beginning of July 2023.

In June 2023, we used our CitizenLab digital platform to reach out to providers to ask for feedback on their experience of using PEOPLE FIRST as part of the evaluation of this resource. This was to better understand how providers use this and other mechanisms to support them to improve. We received 384 responses to the questionnaire, including 97 from people in NHS services or integrated care systems, before the survey closed on 7 July 2023.

In June 2023, in partnership with Care England, we conducted a survey of adult social care providers. The survey sought to understand the challenges facing providers and asked questions around capacity, recruitment and retention, sustainability, innovation, and engagement with the local system. We received 1,928 responses spread across all regions and types of service. The survey closed on 12 July 2023.

Our Clinical Fellows, Dr Emily Audet, Dr Victoria O’Brien and Dr Natalie Vanderpant co-led a piece of work to deepen our understanding of what good workforce wellbeing looks like. We created a survey sent to staff, providers and a wider group of stakeholders across all sectors to assess their views on workforce wellbeing. This had 2,420 respondents representing all health and social care sectors. We also engaged with health and care professionals, providers, and our own inspectors, through a series of focus groups to further explore what good workforce wellbeing looks like, and how CQC can help improve this. Responses from the survey and focus groups were analysed using both quantitative and qualitative methods.

To better understand factors affecting the experience of patients with long-term conditions, we conducted quantitative analysis of our inpatient, and urgent and emergency care surveys, as well as the GP Patient Survey from NHS England. We focused on how experiences differed for patients from different ethnic backgrounds.

For maternity care, we commissioned qualitative research to explore the experiences of staff from ethnic minority groups working in NHS maternity services. The research comprised 10 interviews with midwives from ethnic minority groups during June and July 2023.

To ensure we have a better understanding of the voices of people from ethnic minority communities who have a long-term health condition, we commissioned the NHS Race and Health Observatory and the Race Equality Foundation to review relevant literature and conduct interviews with people with lived experience. This project involved 30 participants from a range of ethnic backgrounds and demographics. It included 2 group interviews with 23 people and 7 one-to-one interviews during July 2023.

Specific areas of risk

For this year’s report, we also used information from our Medicines Optimisation team about specific areas of risk with medicines. The team gathered information by:

• speaking with NHS trusts to understand how well prepared they were to ensure that people who experience a sickle cell crisis can access timely and effective pain relief
• speaking with a range of providers and other stakeholders to understand how they were managing medicines in virtual wards and how CQC can work with them to help drive improvement in this area
• highlighting areas of risk and good practice in relation to the safer management of controlled drugs, through our regulatory oversight activity and inspection findings in 2022.

Local health and care systems

To form an initial view of the performance of local authorities regarding their adult social care duties, we carried out a desk-top assessment of 2 quality statements: ‘care provision, integration and continuity’ and ‘assessing needs’. The quality statements in our new assessment framework are the commitments that providers, commissioners and system leaders should live up to and show what is needed to deliver high-quality, person-centred care. The findings of this review are based on our review of publicly available information for all 153 local authorities in England. It includes, where available, carers strategies, joint workforce development plans and market position statements. We only considered documentation from March 2020 and did not measure how they were implemented or their impact as part of this methodology.

For a view on local systems, we undertook a desk-top assessment of the 'equity in access’ quality statement for all 42 integrated care systems in England. Our findings are based on reviewing publicly available information that related to the system’s vision and strategies for: integrated care, equity in access or equalities, engagement or people and communities, as well as Healthwatch reports and minutes of board meetings. We considered publicly available health data reflecting healthcare inequalities to understand differences in care provision across areas. Again, we did not measure how the documents were implemented or their impact on equity of access, as it was too early to do so.

Providers of health and care services

For providers of health and adult social care services, we have used the data and insight gained through our routine monitoring of and engagement with providers, for example information collected through our surveys and our notifications data.

To help us understand how adult social care providers are responding to challenges and improving services, we qualitatively analysed information submitted through provider information returns. We ask adult social care providers to complete a provider information return (PIR) form every year. As well as helping to monitor the quality of care, the PIR gathers qualitative data through a set of 12 open-ended questions, asking the provider about any changes that have been made in the past 12 months and how they are ensuring their service is safe, effective, caring, responsive and well-led. We used PIRs submitted between 1 April 2022 and 31 March 2023 in this analysis. We analysed a random sample of 97 PIR documents, using a mix of adult social care providers, including both residential and homecare services.

Provider information returns were also used to report on vacancy, turnover and occupancy rates in adult social care providers between 1 April 2021 and 31 July 2023.

We analysed notes from group discussions of the Supported Living Improvement Coalition (collected August to December 2022), inspection additional question notes (collected May and June 2022), and transcripts from interviews and focus groups with Coalition partners. Our thematic analysis explored what respondents told us and made inferences about what their feedback might mean.

This report also provides an analysis of data submitted to us by providers in our Market Oversight scheme, as well as information and insight gained from our engagement with providers in the scheme. The scheme covers providers that have a large local or regional presence and which, if they were to fail, could disrupt continuity of care in a local authority area.

We have conducted quantitative analysis of our inspection ratings of more than 33,000 services and providers. Aggregated ratings for the main sectors and services we regulate are provided in the data appendix of this report. In March 2020, we paused routine inspections and focused our activity where there was a risk to people’s safety. Since then, we have continued to carry out inspection activity where there were risks to people’s safety or where it supported the health and care system’s response to the pandemic. We have also started to carry out inspections in low-risk services to quality-assure our risk identification process.

We continue to review and improve our ratings data on an ongoing basis. This means our figures for 2022 ratings may vary to what we published in last year's State of Care.

This year, quantitative analysis of inspection ratings includes information on the proportion of services that are categorised as having ‘insufficient evidence to rate’. This rating can be used when, on inspection, we have not been able to collect enough information to give a rating of either: outstanding, good, requires improvement or inadequate. Charts in our data appendix visualise the proportion of all active services with a current rating of either outstanding, good, requires improvement or inadequate. We indicate the proportion of services where there was insufficient evidence to rate in a note below the chart, where applicable.

The ratings data for primary medical services, adult social care and NHS ambulance trusts were extracted on 1 August 2023, while ratings for NHS acute hospital services and independent health services were extracted on 7 September 2023.

Statutory responsibilities

We report on our own notifications data for Deprivation of Liberty Safeguards (DoLS) received between 1 April 2022 and 31 March 2023, excluding Court of Protection orders and notifications from primary medical services, as well as the annual data publication from NHS England published on 24 August 2023.

We also analysed qualitative data gathered from a survey distributed in June 2023 to members of an Expert Advisory Group to examine the DoLS system. It included 6 open-ended questions seeking insights around the management of the safeguards, instances of unlawful deprivation of liberty and the impact caused by delays in the implementation of Liberty Protection Safeguards. Nine professionals engaged in the field of DoLS participated.

Evidence in this report, alongside our annual report and accounts, enables us to fulfil our legal duties to report on equality issues and on the operation of DoLS.