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People Scrutiny Committee	17 March 2026
Report of the Corporate Director, Adult Social Care and Integration

Care Quality Commission (CQC) Local Authority Assessment

Summary

1. This report outlines the outcome of the CQC Local Authority Assessment, and the subsequent actions being taken.

2. The CQC local authority assessment is a new assessment framework under Health and Care Act 2022, to assess how well Local Authorities deliver their duties under Part 1 of the Care Act 2014. It does not consider how local authorities are carrying out their functions in relation to the Mental Health Act 1983. It covers 9 Quality statements in 4 categories and all Local Authorities are due to be assessed by April 2026.

3. Reports published to date: 111, as at end February 2026.

a. 3 Outstanding

b. 2 Inadequate

c. 38 Requires Improvement

d. 68 Good

e. 42 yet to publish 

4. Adult Social Care supports the wider City of York Council Plan commitments, and it also supports two of the four Council Plan commitments, Health and Equalities and Human Rights. Some examples of these are:

Council Plan	Adult Social Care Strategy
Our vision of a healthier, fairer, more affordable, more sustainable and more accessible city where everyone feels valued.	· Use our resources fairly and wisely · Value carers
Health Inequalities	· Prevent reduce and delay the need for care and support · Make sure homes support independence · Work with health services to improve care · Promote wellbeing at every stage of life · Support people to live well at home and in their community · Work together for better care and support · Provide high quality and flexible support
Equalities and Human Rights	· Use evidence and insight to make the best decisions to understand what is working well and where gaps or inequalities remain.

Background

5. The local authority is assessed under the following 9 quality statements:

a. Assessing needs

b. Supporting people to live healthy lives

c. Equity in experience and outcomes

d. Care provision, integrity and continuity

e. Partnership and Communities

f. Safe systems, pathways and transitions

g. Safeguarding

h. Governance, management and sustainability

i. Learning improvement and innovation

6. Measured against the following 4 evidence categories:

a. Peoples experience (5 case files audited)

b. Feedback from staff and leaders

c. Processes

d. Feedback from partners

7. The CQC assessment process for CYC began in January 2025 when the council received notification of assessment. 

8. The process required the council to provide a range of data, policies, processes and documents to support the assessment process.

9. CQC also requested a reference number for 50 anonymised people who met the criteria for case tracking. 

10. CQC selected 10 individuals’ cases to request consent to speak with them around their experience of care and support. 

11. CQC subsequently spoke to 5 of those people with lived experience as part of the case tracking. The purpose of case tracking was to understand people’s journeys through the social care system, their experiences of how care and support decisions were made by commissioners and social work teams, how they were communicated and implemented, and the impact this has on their lives.

12. The assessment included an on-site visit on 17th, 18th and 19th June 2025.

13. As part of the process, the assessment team met with front line staff, corporate colleagues, co-production groups, providers, key partners, key councillors and community and voluntary sector groups.

14. A draft report was received in October 2025 and the final report published on 5th December 2025.

Report Findings

15. There were many positives outlined in the report; areas of mixed feedback; as well as areas for improvement:

a. People were mostly positive about the staff that supported their assessment and care and support planning. They described staff as helpful, kind and considerate.

b. There was mixed feedback and findings from people and unpaid carers about the quality of assessments and care planning that took place.

c. People gave mixed feedback about the effectiveness of the local authority’s processes for assessing and charging adults.

d. People and unpaid carers told CQC about their care and support and the quality of services in York. Some people said they had no concerns about the care they received, and had heard how services supported people to remain as independent as possible and made people feel safe. In contrast, CQC heard how timings of care could be cut short or be unreliable, meeting peoples specific needs could be challenging and training needed to be improved.

e. Staff were committed to serving people in the City of York, there was an ethos of wanting to learn through people, staff, partners feedback and analysis so that Care Act duties could consistently be delivered safely and effectively.

f. The current DASS had the passion, commitment, expertise and energy to deliver what was required but there was more to do collectively within the senior leadership team to deliver and embed developments, learning and ensure staff, people and partners were an integral part of changes.

g. There were developing foundations in place with partners to strengthen relationships

h. Processes had begun to improve, for example duty staff were starting to work more closely with call handlers.

i. There were ambitions for improved strategic direction particularly around how the local authority gathered and acted on feedback, learning and a need to embed coproduction with people with care and support needs to deliver Care Act responsibilities.

Scoring & Key Findings

16. The CQC ratings are as follows:

· 88% & above = Outstanding

· 63-87% = Good

· 39-62% = Requires Improvement

· 25-38% = Inadequate

17. York outcome is Requires Improvement 39%. 

18. The following areas fell into the 39%-62% score range, ‘evidence shows some shortfalls’

· Partnerships and Communities – 57%

· Equity in experience and outcomes – 50%

· Supporting people to live healthier lives – 50%

· Governance, management and sustainability – 50%

· Learning, improvement and innovation – 50%

19. The following 4 areas fell into the 25%-38% score range, evidence shows significant shortfalls

· Safeguarding – 38%

· Safe systems, pathways and transitions – 38%

· Assessing needs – 38%

· Care provision, integration and continuity – 32%

20. The key findings of the report were as follows for the areas showing significant shortfalls:

a. Delays in assessments and provision.  Waiting lists for all types including carers, safeguarding, OT assessments, Care Act assessments

b. Communication about eligibility including sending out copies of plans

c. Advice, information, and communication including use of ‘jargon’

d. Effectiveness of front door, out of hours, and safeguarding systems

e. Some gaps in provision – in-area care homes; supported living; mental health; carer respite

f. Lack of clear contingency plans (in people’s support plans)

g. Inconsistent risk management across teams – no service level reports

h. Arrangements for hospital discharge

i. Audit/quality assurance processes – safeguarding, learning from SAR (Safeguarding Adult Reviews).

j. Training compliance for Safeguarding & Mental Capacity across the sector.

k. Responsiveness/partnership work on safeguarding including quality of referrals and communication/feedback 

Improvements already made

21. Adult Social Care already had a Service Plan in place to make improvements to operations, and this has been worked on during the assessment period.

22. Outlined below are the areas where improvements have already been made in the last 12 months:

a. Stable leadership with visible, regular engagement and clear messages, involving staff and people in changes needed - be part of the solution.

b. Operating a rights-based approach to social work embedding CYC core values, social model of disability and Home First principles.

c. Positive results to staff wellbeing and reduced staff turnover

d. New workforce development lead and training matrix monitoring system in place. Mandatory training compliance is significantly improved.

e. Commitment to embed evidence-based practice and expertise in the organisation.

f. Co-produced ASC strategy

g. Co-produced - Co-production and Research strategy

h. Co-produced Learning Disability Partnership board; increased support to self-advocates 

i. Improved working relationships with partners, including the police, hospital partners, primary care and providers

j. Re-designed commissioning team with a new structure, roles, and integrated leadership with ICB Place

k. A shifted mindset for commissioning around being more provider led with a new process with active engagement and consultation on fee rates and new commissions.

l. Development of mental health hubs and a frailty hub designed with people and partners to connect people to services to enhance early intervention and strengthen people's support networks

m. Housing First model and Homelessness and Rough Sleeping strategy

n. Working towards Domestic Abuse Housing Alliance accreditation

o. Reablement outcomes are measurable and above the national average for keeping people at home 60 days after discharge

p. New supervision policy, training and guidance

q. Direct Payments project co-producing a new procedure and the information that is provide to Direct Payment recipients.

r. A new and expanded multi-disciplinary review team for planned reviews

s. New hospital discharge model and integrated team 

t. Safeguarding Adults Board (SAB), new chair and manager; evidence of strong leadership and multidisciplinary attendance at board. SAR learning events. SAR process improved.

u. Joint transitional protocol with the Children’s Safeguarding Partnership.

v. Making Safeguarding Personal - leaflets, posters, animations and videos to raise awareness and understanding of safeguarding using simple terminology.

w. Timely allocation of DoLS (Deprivation of Liberty Safeguards)

x. Plans for 2025-2026 are clear and have mechanisms to monitor progress this included: delivering the vision for an integrated neighbourhood model, and revised partnership agreement with a joint committee to plan and commission services together.

y. New management structure now in place to support improved oversight. New roles created for workforce development and Adults Safeguarding Board manager which had been in place less than a year at time of CQC assessment. 

Steps following the publication of the final report

23. For the areas of significant shortfall, the council is required to produce an improvement plan.

24. This work has been prioritised and incorporated into the existing Service Plan while also carefully considering what resources are needed to make essential improvements.

25. The DASS has worked with the Department of Health and Social Care and shared the improvement plan. An Improvement Advisor has been assigned to support City of York Council, and to report back to the DHSC.

26. Additional support is being offered by the Local Government Association to carry out case files audits, test out current audit process and improve staff confidence in undertaking Case File audits.

27. Additional capacity is being put in place to enable people to be assessed and appropriately supported sooner, reducing waiting lists.

28. Practice Development Leads are being deployed to standardise practice across all teams adopting a learning and reflective culture.

29. Support provided to ensure that data and evidence collection methods are effectively demonstrating the work completed in Adult Social Care.

30. New governance arrangements are being put in place in the form of an Improvement Board, with new Terms of Reference and the recruitment of an independent chair to support the improvements required.

31. As part of the response to the CQC report the following actions have been taken:

a. Adult Social Care is working together with all directorates across CYC to ensure the provision of safe, effective and efficient services. Adult Social Care cannot provide the required improvements alone, and indeed many aspects of support that adults with care and support needs require are provided across many council departments. Supporting people to live safely, independently and well requires a whole council, whole system, whole city approach.

b. Improved oversight of risk, with active risk rating of all incoming work and waiting lists, weekly reporting in place to monitor changes. 

c. Recent SAR learning event re self-neglect had led to changes in practice and at the front door

d. Audits are taking place for all aspects of Safeguarding at Assistant Director level. 

e. Improvements to the Adult Social Care access point to ensure an effective audit trail for all safeguarding enquiries that are received.  Additional staff have been assigned to support the triaging of work in a timely manner.

f. Practice change is underway within the safeguarding adults' team to ensure improved responsiveness to those raising concerns, this will be further supported by changes in the case management system to enable reporting that feedback has been given to referrers.

g. Safeguarding training across the adult social sector. Significant work has been undertaken to ensure compliance for social work staff with mandatory social work training. Work to better manage compliance with training and refresh the offer across the council and sector is planned.

h. In recognition of the need to improve practice, including with safeguarding adults, practice development roles are being deployed within the service. Within safeguarding adults there is focus on using this role to ensure that learning from Safeguarding Adults Reviews (SARs) is being consistently understood and acted upon in practice. Additional focus on consistency of s42 criteria and defensible documentation and recording of intervention and support.

i. There is a revised and re-prioritised Transformation and Improvement programme in place that covers almost all aspects of Care Act delivery.

Consultation

32. The outcome of the report has been shared widely, with staff and mangers across the council, with specific sessions held for Adult Social Care Staff; and with voluntary and statutory sector partners.

33. 145 adult social care staff attended in person sessions to review and contribute to the improvement plan.

34. Further engagement sessions are planned with partners and colleagues, and this will continue in order to support involvement in the on-going delivery of the plan.

35. The Improvement board will as one of its functions support the involvement of people with lived experience and the workforce.

Options    

36. This report is for information. Scrutiny members are invited to consider the role for the committee and how members can support on-going scrutiny and support of the improvement work. It is suggested that the committee might receive regular update reports and briefing sessions, and consider if a task and finish approach might support particular projects in the programme or aspects of the work. 

Analysis

37. This report is for information.

Council Plan

38. Adult Social Care supports the delivery of the Council’s priorities, as set out in the Council’s Plan. The strategy promotes equality, diversity and inclusion and the delivery of a social model of disability. Through the fair use of resources, Adult Social Care aims to reduce health inequality. The emphasis on partnership between housing, social care, NHS and community colleagues is intended to enable people requiring support to continue live in their communities, in housing suited to their needs

39. Implications

· Financial (Steve Tait – Finance Manager, ASC & PH)

The investment required for the resource to deliver the improvements will be met from Adult Social Care growth allocated in the 2026/27 Council Budget.

         The estimated cost of the current improvement resource is detailed in the table below with the final value depending on when employment/contracts start. The resources required to deliver the plan will be kept under review. Most of the spend is non recurrent and therefore can be recycled once the improvements have been achieved.

Figures in £000	2026/27	2027/28
Total Investment	1,578	877
Business analyst and project management – Improvement (provided free by Partners in Care & Health)	0	0
Case file audits – assessment of practice and practice assurance framework (provided free by Partners in Care & Health)	0	0
Assistant Director/senior programme manager plus support – to lead on transformation and improvement with learning disability and autism	315	161
Assistant Director level – Customer Service and Practice performance	83	113
Co-production and Engagement lead	75	0
Practice development worker/social work consultant	536	549
Social work and Occupational Therapy resource to reduce waiting lists	500	0
Improvement Board Chair	18	0
Communications Officer	52	53

· Human Resources (HR) - There are no specific HR implications associated with the action plan. A key part of the implementation of improvements is staff awareness, training, engagement and empowerment to both the day-to-day practice requirements and the additional requirements identified. Additional temporary resources are being deployed to aid the changes in a swift and effective manner, these have been created following existing HR practice and processes.

As the plan is progressed, any workforce implications will be identified and associated actions will be taken in accordance with the council’s policy and procedure.

· Equalities - There are no direct equalities implications, although the improvement work has positive impacts for those cohorts of people accessing social care who are protected under equalities legislation.

· Legal - Section 46A Health and Social Care Act 2008 (as amended by the Health and Care Act 2022) requires the CQC to assess and report on how local authorities are meeting their duties under Part 1 Care Act 2014 (the legal framework for provision of adult social care in England).

· Under s50 Health and Social Care Act 2008, if, following assessment, the CQC considers that a local authority is failing to perform its functions under the Care Act to an acceptable standard (ie. achieves a score of 1 or ‘inadequate’ in any of the scores assessed, except leadership), then they must inform the Secretary of State for Health and Social Care and recommend any special measures. The DHSC will then provide guidance and co-ordinate any improvement or intervention activity with the local authority.

· The Secretary of State (‘SoS’) has the power to direct the local authority to address the failings identified. This may include requiring the local authority to act in accordance with advice given by the SoS or their nominated person, to take steps specified by the SoS/their nominee, or provide the SoS/nominee with specified information. Directions may also, if considered necessary to address the failures identified, include provision for specified functions of the local authority to be exercised by the SoS/nominee for a time period the SoS considers appropriate, or require the local authority to act in accordance with instructions issued by the SoS/their nominee.

· A local authority’s key duties under Part 1 Care Act include assessing adult and carer’s needs for care and support, meeting eligible needs, preparing and maintaining care plans and safeguarding adults in its area. The requirement to adhere to those duties remains, regardless of the outcome of the CQC assessment process. Failure to do so risks increased complaints and potential for legal challenge, as well as potentially inadequate care and support for the individuals concerned.

· Adult Social Care have developed an improvement plan addressing areas of concern identified in the CQC assessment and are working closely with relevant organisations and the improvement advisor. There are no statutory interventions currently.

· Crime and Disorder – N/A

· Information Technology (IT) - No comments to make

· Property - No implications unless there are any recommendations or impacts regarding accommodation needs

· Economy – NA.

· Communications – The team will continue to focus communications resource on supporting the action plan, where appropriate.  This includes developing a longer-term campaign around recruitment to the service, to support the right skills and capacity to deliver this improvement work.  A range of engagement was carried out with local and regional media, and via the communication channels the councils owns, at the point the report was originally published.

· Data Protection and Privacy – NA

· Affordability – NA

· Health and Wellbeing – Meeting duties under the Care Act includes promoting the wellbeing of individuals and considers people’s health can care needs and the provision of appropriate support to meet eligible needs.

Risk Management

40. Should implementation progress be slow; the quality of implementation be poor or CYC fail to sustain the changes, there is a risk that the current informal support arrangements could be stepped up to statutory intervention.

a. Intervention Power: The Act introduced a specific power for the Secretary of State to intervene if an LA fails its statutory duties, with CQC providing the independent assessment evidence.

b. Secretary of State Action: If CQC identifies significant failures, the Secretary of State can then use their powers to mandate improvements or take further action, informed by CQC's findings

Recommendations

41. Members are asked to support the action plan and approach.

Reason: So that members are aware of the outcome of the CQC Local Authority Assessment and support the subsequent actions being taken.

Contact Details

Author:	Chief Officer Responsible for the report:
Anne Howgate AD Access Prevention and Improvement Adult Social Care and Integration	Sara Storey Corporate Director, Adult Social Care Adult Social Care and integration
	Report Approved	ü	Date	5 March 2026
Wards Affected:					All	ü
For further information please contact the author of the report

Background Papers:

Care Quality Commission assessment of adult social care services – City of York Council

Annexes

None