Quality challenge

Service quality continues to be a significant concern within Norfolk. Norfolk has the lowest care quality in the eastern region and is one of the lowest nationally.

Our aim is for at least 85% of all services to be rated 'good' or 'outstanding'.

The position reported on 31 March 2023 highlights the percentage of services with a 'good' or 'outstanding' rating in Norfolk, East of England, similar local authorities (family groups) and England:

Norfolk

All services

Percentage of all services with a 'good' or 'outstanding' rating:

69.8% of services for all users
71.9% of services registered for older people
68.7% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Home support care

Percentage of home support care services with a 'good' or 'outstanding' rating:

77.4% of services for all users
76.4% of services registered for older people
73.4% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Residential care

Percentage of residential care services with a 'good' or 'outstanding' rating:

66.4% of services for all users
71% of services registered for older people
66.2% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Nursing care

Percentage of nursing care services with a 'good' or 'outstanding' rating:

67.8% of services for all users
64.8% of services registered for older people
63.2% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Similar local authorities (family groups)

All services

Percentage of all services with a 'good' or 'outstanding' rating:

83.6% of services for all users
82.5% of services registered for older people
85.5% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Home support care

Percentage of home support care services with a 'good' or 'outstanding' rating:

88.6% of services for all users
88% of services registered for older people
88.9% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Residential care

Percentage of residential care services with a 'good' or 'outstanding' rating:

81.8% of services for all users
79.7% of services registered for older people
83.1% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Nursing care

Percentage of nursing care services with a 'good' or 'outstanding' rating:

78.2% of services for all users
77.7% of services registered for older people
81% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

East of England

All services

Percentage of all services with a 'good' or 'outstanding' rating:

82.2% of services for all users
81.5% of services registered for older people
83.5% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Home support care

Percentage of home support care services with a 'good' or 'outstanding' rating:

86% of services for all users
85.4% of services registered for older people
85.9% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Residential care

Percentage of residential care services with a 'good' or 'outstanding' rating:

79.5% of services for all users
78.1% of services registered for older people
80.8% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Nursing care

Percentage of nursing care services with a 'good' or 'outstanding' rating:

78% of services for all users
77.1% of services registered for older people
80.5% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

England

All services

Percentage of all services with a 'good' or 'outstanding' rating:

83.2% of services for all users
82.1% of services registered for older people
84.4% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Home support care

Percentage of home support care services with a 'good' or 'outstanding' rating:

85.8% of services for all users
85.3% of services registered for older people
85.9% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Residential care

Percentage of residential care services with a 'good' or 'outstanding' rating:

82.7% of services for all users
80.5% of services registered for older people
84.4% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Nursing care

Percentage of nursing care services with a 'good' or 'outstanding' rating:

78.1% of services for all users
77.8% of services registered for older people
76% of services registered for people with learning disabilities and/or mental health, or physical/sensory disabilities (without older people)

Norfolk services are performing against all comparator groups. The most relevant comparison being those local authorities that are identified as 'family group' as these are the most similar in geography and demographics for example.

However, when the ratings are analysed into services registered for older people and services registered for people with a learning disability, mental health, and physical disabilities without older people there are fewer services rated 'good' and 'outstanding' in working age adult provision than for older adults.

Nursing care

The quality of nursing care appears to be an issue for most local authorities with the percentage of 'good' and 'outstanding' being lower in all comparator groups than other registered provision. This could be due to the difficulties of recruiting and retaining nurses.

Skills for care reports that during 2021-2022, there was a turnover rate of 50.2% for registered nurses in Norfolk. The vacancy rate for nurses reported in 2021-2022 was 11.5% which was 50 posts. Most recruitment for nurses is from within the adult social care sector (63%).

A transient workforce means that staff will not be gaining the training and qualifications to deliver the qualitative service required. This is also applicable to direct care staff.

Well-led and safe

'Well-led' and 'safe' continue to be the key domains that providers are failing against with 38% of all services inspected being rated 'requires improvement' or 'inadequate' in 'well-led' and 33% in 'safe'.

Visit the care quality commission website for more information about the five questions they inspect and rate all services on.

Services with restrictions on admission and new referrals

A review of services with restrictions as at 4 April 2023 highlights that there are currently 70 services that are subject to restrictions accounting for 9.4% of all registered services.

Restrictions can range from a need to consult before placement to no new placements allowed. The impact of restrictions by service type varies massively with the percentage of different services having some form of restriction being:

31% of care home services
8% of older adult care homes
1% of supported living services
8% home care services
1% of day services

Types of restrictions by service type

Working age adult residential care services

10 homes have a 'contact quality assurance team prior to placing new people' restriction - affecting 90 registered beds
3 homes have a 'restriction on the number of placements' that can be made each month - affecting 57 registered beds
27 homes have a 'no new placements' restriction - affecting 159 registered beds

Working age adult nursing home services

1 home has a 'restriction on the number of placements' that can be made each month - affecting 32 beds
2 homes have a 'no new placements' restriction - affecting 71 registered beds

Older adult residential care

3 homes have a 'restriction on the number of placements' that can be made each month - affecting 141 registered beds
7 homes have a 'no new placements' restriction - affecting 196 registered beds

Older adult nursing care

1 home has a 'restriction on the number of placements' that can be made each month - affecting 29 registered beds
5 homes have a 'no new placements' restriction - affecting 287 registered beds

Supported living

1 service has a 'contact integrated quality service (IQS) before placing' restriction - affecting 6 registered tenancies
1 service has a 'no new placements' restriction - affecting 3 registered tenancies

Shared lives

1 service has a 'contact IQS before placing' restriction

Home care

2 services have a 'restriction on the number of placements' that can be made each month
5 services have a 'no new placements' restriction

Day services

1 service has a 'contact IQS before placing' restriction

Number of care providers with suspensions on all placements

The number of home support and care home providers with suspensions on all placements from December 2017 to December 2022:

2017

Number of care providers with suspensions on all placements at the end of:

December 2017:

Home support: 3
Care homes: 14

2018

Number of care providers with suspensions on all placements at the end of:

March 2018:

Home support: 3
Care homes: 11

June 2018:

Home support: 2
Care homes: 9

September 2018:

Home support: 2
Care homes: 20

December 2018:

Home support: 2
Care homes: 21

2019

Number of care providers with suspensions on all placements at the end of:

March 2019:

Home support: 3
Care homes: 12

June 2019:

Home support: 5
Care homes: 14

September 2019:

Home support: 3
Care homes: 12

December 2019:

Home support: 2
Care homes: 15

2020

Number of care providers with suspensions on all placements at the end of:

March 2020:

Home support: 3
Care homes: 16

June 2020:

Home support: 3
Care homes: 15

September 2020:

Home support: 3
Care homes: 8

December 2020:

Home support: 4
Care homes: 9

2021

Number of care providers with suspensions on all placements at the end of:

March 2021:

Home support: 2
Care homes: 15

June 2021:

Home support: 3
Care homes: 25

September 2021:

Home support: 10
Care homes: 29

December 2021:

Home support: 5
Care homes: 34

2022

Number of care providers with suspensions on all placements at the end of:

March 2022:

Home support: 4
Care homes: 28

June 2022:

Home support: 2
Care homes: 35

September 2022:

Home support: 3
Care homes: 33

December 2022:

Home support: 3
Care homes: 34

There has been an increase in the number of providers with some type of restriction from June 2021, which will correlate to the creation of the integrated quality service.

District level service quality ratings

The quality-of-care provision varies across Norfolk:

There is no area that has 'good' quality in all service types
North Norfolk, South Norfolk and Norwich have the highest service ratings overall with North Norfolk particularly strong in home support services (92% rated 'good' or 'outstanding').
North Norfolk does, however, have the highest level of unmet needs with insufficient capacity available to meet demand
East Norfolk is the poorest performing area in relation to the quality of all regulatory services with only 62% of home care, 59% of residential care and 57% of nursing care rated 'good 'or 'outstanding'
Comparing the quality ratings for each district against similar local authority averages, highlights that North Norfolk has more home support services rated 'good' or 'outstanding' (92%) compared to 88.8% for other similar authorities.
The average ratings for nursing homes which are 'good' or 'outstanding' in Norwich is 81% compared to 77.4% in other similar local authorities
The average rating of 'good' and 'outstanding' in local authorities for residential homes is 81.6%. South Norfolk has the highest rating in Norfolk, but this is only 75% of residential homes rated 'good' or 'outstanding'.

Our ambition to address the quality challenges identified

In the 2021-2022 market position statement, we said that to achieve our aim of at least 85% of regulated services in Norfolk being rated 'good' or 'outstanding' we would:

Engage people who use services (experts by experience) in our reviews of service quality
Develop and implement a system wide strategic framework for care quality improvement across Norfolk, with a focus on system wide drivers. This included:
- Individual, family and carer feedback
- Provider led change
- Workforce
- Commissioning and contract management
- Quality monitoring and improvement
- Health services to support care provision and operational measures
Identify further key themes relating to poor quality, share these with providers and support them to achieve the improvements required
To review and amend processes and procedures that directly impact upon provider quality
Implement our integrated quality service (IQS) improvement and escalation policy
Achieve ambitious key performance indicators for published provider assessment and market management solution (PAMMS) and quality monitoring visits (QMV) audits

What we have achieved

We have:

Worked with our partners within the integrated care systems to develop a wide-ranging programme to drive care quality improvement in Norfolk. New tools, support models, approaches and engagement are being rolled out as part of the programme to deliver change, oversee progress, and improve data.
Norfolk care association (NorCA) is leading work to increase shared learning from 'outstanding' and 'good' providers and to support the focus on best practice
Initial research has been completed on delegated health tasks with next steps to deliver new protocols for Norfolk
Healthwatch Norfolk has launched engagement to get people's views on how they provide feedback about the care they receive and how this could be improved in the future. The next steps will be to increase the level of feedback about social care we receive and ensure this is reviewed and used to steer actions.
The quality improvement and escalation policy has been implemented and is being used to ensure a consistent approach to the work of the IQS, support to achieve quality improvement and where needed contractual measures
The development work has been completed to enable experts by experience to support the reviews of service quality. The pilot is being launched this spring.
The work of the IQS is continuing to develop, with data starting to be available showing the progress following PAMMS re-inspections for some care provision. This demonstrates how the work of the IQS is supporting more providers with improving their ratings.

In addition to the above the following was also delivered or is in train:

The IQS has worked with the Capital and Housing Programme Team, together with providers who are supporting victim-survivors of domestic abuse in safe accommodation to develop and pilot a new quality assessment framework which provides a review process to audit care quality in these settings
The team continues to work with partners across health and with Norfolk and Suffolk care support and NorCA to ensure new legislation, best practice and policy is communicated to care providers across Norfolk