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State of Care 2013/14

  • Public

In 2013/14 we began to introduce a new, tougher approach to inspecting care services. Our more rigorous, expert-led inspections are starting to give us a deeper understanding of the quality of health and social care than ever before.

We've found many examples of good and outstanding care. But we've also found wide variation in quality. There are big differences in the quality of care that people experience from different providers, in different places and sometimes at different times of the day or day of the week.

What we've found: unacceptable variation in quality

We have seen widespread, unacceptable levels of variation in the quality of care.

There are five key questions that we now ask of all the services we inspect:

  1. Are they safe?
  2. Are they effective?
  3. Are they caring?
  4. Are they responsive to people’s needs?
  5. Are they well-led?

We began applying our new inspection approach to NHS trusts in September 2013. We've seen some outstanding care – but we've also seen examples of care that requires improvement or that's inadequate. We have found differences in quality from one trust to another, from hospital to hospital within trusts, and between different services within hospitals.

Basic safety and leadership are key issues

Across health and social care, we've found that staff provide compassionate care. But there are two aspects of quality that stand out: basic safety and leadership.

Variation in basic safety is a serious problem, particularly:

  • a lack of effective safety processes.
  • the lack of a culture that truly learns from mistakes and near misses.

Strong, effective leadership at all levels of an organisation is vital. In our new inspections of NHS trusts we have found that:

  • good leadership drives up quality and safety overall.
  • in more than 80% of cases, the rating for 'well-led' was the same as the trust's overall rating.

Well-led organisations have strong and effective leadership, an open and supportive, values-driven culture and stable management. They are committed to ensuring safe, effective, caring and responsive care.

CQC is calling time on unacceptable variation in the quality of care. In our report, we are challenging every health and care provider in England, and every commissioner and oversight body, to deliver the high standards of care that each person has a right to expect.

We are also issuing an invitation to the public: to become empowered consumers, to use CQC's inspection reports and ratings to make decisions about your care and the care of those close to you.

Adult social care

We saw many examples of excellent care being delivered up and down the country. Providers of poor care need to look at those who are doing it well and learn from them.

Adult social care: in detail

Overall, there was a slight improvement in the quality of adult social care in 2013/14.

  • There was a significant improvement in performance on the 'care and welfare' standards.
  • However, performance on safety and safeguarding was slightly weaker than last year.
  • Services were better at treating people with dignity and respect than ensuring they were safe or that staff were suitably skilled.

Variation in quality

We found that people living in nursing homes continued to receive poorer care than those living in residential care homes with no nursing provision.

Smaller residential care homes tended to perform better than larger ones.

What affects quality?

Workforce recruitment is a major issue. We're particularly concerned about the shortage of nurses in care homes. Encouraging more nurses to work in the care home sector should be a higher priority.

Good leadership is vital to delivering good quality care.

Our inspections have shown that care homes with a registered manager provide better care.

  • We identified care homes that had no registered manager in place for at least six months.
  • Performance against quality standards was 10-15% higher for care homes with a registered manager than for those without.
  • Care homes without a registered manager were more than twice as likely to be non-compliant than other care homes.

Hospitals, mental health care and community health services

We have found examples of good and outstanding care. We awarded the first outstanding rating to a hospital trust in September 2014: Frimley Park in Surrey. But most of the first hospitals we inspected under our new tougher inspections needed to improve to be considered safe. However, it's important to note that the first inspections under this approach have focused on hospitals that we consider to be higher risk, so our findings are not a fair representation of the quality of care across England.

Hospitals, mental health care and community health services: in detail

Variation in quality

We found variation across hospitals, within hospitals and within the core services provided by each hospital.

  • We saw high levels of compassionate care, delivered by caring doctors, nurses and other staff.

Safety was the area where we had the most concerns: four out of every five of the first safety ratings were inadequate or requires improvement.

Problems across core services

Where we rated core servicesThese are the eight services that we will always inspect at every NHS acute hospital where they are provided. They include urgent and emergency services, maternity and gynaecology, and end-of-life care. inadequate, we often found problems with:

  • Staffing: shortages, workforce planning, training and knowledge of guidelines.
  • Culture: fear of reporting concerns, poor leadership.
  • Poor management of access to services, waiting times and appointments.

A&E had the highest number of inadequate ratings. The most common problems we found were:

  • overcrowding
  • long waiting times
  • inadequate staffing levels

Medical care services had the fewest ratings of good. Of all the core services, critical care had the most ratings of good.


Of the first hospitals we inspected under our new, more rigorous inspections, we gave only 40% a rating of good for being well-led. The remainder were rated as requires improvement or inadequate. Weaknesses we found included a lack of vision or strategy, and poor staff engagement.

NHS mental health services

Our new inspections have revealed areas of good practice, including caring and committed staff, multi-disciplinary working and person-centred care. However, we also found areas of poor practice:

  • Unsuitable physical environments – poorly maintained buildings, ligature points, some failures to meet requirements for same-sex accommodation.
  • Unavailability of admission beds.
  • Unavailability of intensive care.
  • Inappropriate response in a crisis – many people experiencing a mental health crisis not having a health-based place of safetyThis might be a mental health service or an emergency department at a general hospital. People experiencing a mental health crisis should only be taken into police custody in exceptional circumstances. available to them.

NHS community health services

Our inspections showed most community health services were providing a caring service. However, some recurring issues included:

  • Staffing levels – either staff shortages or an unsuitable skill mix.
  • Inconsistent training.
  • Multidisciplinary working – while mostly good, some services struggled to bring everybody together to work in a coordinated way.

Primary medical services and integrated care

In 2013/14 we carried out our first inspections of GP practices. Our biggest concern was about safety and safeguarding. The first inspections of GP out-of-hours services showed most services were safe, effective, caring, responsive and well-led.

Primary medical services and integrated care: in detail

Our biggest concern is about safety and safeguarding

On inspecting both GP practices and dental practices, our biggest concern was about safety and safeguarding.

  • Almost one in five GP practices did not meet at least one of the standards of safety (although the impact on patients was mostly minor).
  • Among dental practices, one in 13 did not meet at least one of the safety and safeguarding standards.
  • However, dental practices present a lower risk to patients' safety than other sectors we regulate.

Variation in quality

  • GP practices with larger patient lists tended to be deliver higher standards of care.
  • GP practices in areas with the highest social deprivation tended to provide a lower quality of care than practices in other areas.

GP out-of-hours services

Most of the out-of-hours services we inspected were safe, effective, caring, responsive and well-led. We found no examples among those we inspected of out-of-hours services offering very poor care.

Integrated care

We also explored a number of themes across services.

  • We found wide variation in the delivery of diabetes care and deficiencies in the way people with diabetes are cared for in hospital.
  • We've found variation in the quality of dementia care in care homes and hospitals. A person with dementia is likely to experience poor care at some point along their care pathway.
  • Our report into children and young people with complex physical health needs and their transition to adult services found the system to be fragmented, confusing and difficult to navigate.


Last updated:
7 October 2015