The state of health care and adult social care in England 2024/25

Demand for adult social care

Analysis of NHS England data shows that the demand for local authority-funded social care support continued to rise in 2023/24. New requests for adult social care were 4% higher in 2023/24 compared with the previous year, and 8% higher than in 2019/20.

While older people still make up the majority (68%) of requests for local authority-funded social care support, there has been a large growth in demand for support from working-age adults in recent years. The rate of requests for support from older people per 100,000 population was less than 1% higher in 2023/24 than it was in 2019/20. However, the rate of requests from working-age adults increased by over 14% in this period, equivalent to nearly 100,000 additional requests for adult social care from adults of working age.

The King’s Fund partly attributes this increase to more disability among working-age adults, with 23% reporting a disability in 2022/23, compared with 16% in 2012/13 (with mental health the most prevalent impairment among this age group).

The proportion of requests that were met by providing long-term care or a package of short-term care designed to maximise independence has also increased slightly in the latest year’s data, from 20.7% in 2022/23 to 21.4% in 2023/24. However, working-age adults are less likely to be supported by this type of provision. In 2023/24, around a quarter (26%) of new requests for support from people aged 65 and over were met with long-term care or a package of short-term care designed to maximise independence, but only just over 1 in 10 (11%) new requests for support from adults aged 18 to 64 received this form of support.

The data also shows a recent increase in requests for social care from working-age adults who were subsequently advised to contact universal services (which includes GPs, community health services and voluntary and community groups) or other services: 35% of new requests from this age group were directed in this way in 2022/23, increasing to 37% in 2023/24. Although people can be supported well without formal social care services, it is important that the right care is given to those who need it.

Although we note these recent differences between the level of demand and provision of support for working-age people compared with older people, there has been a longer-term trend of reducing access to publicly-funded social care, particularly for older people.

Analysis published by the Institute for Government shows that the proportion of older people receiving council-funded long-term social care has reduced over the last 20 years from 8.2% of the population in 2003/04 to 3.6% in 2023/24. This analysis also shows that geographical variation in older people’s access to local authority-funded social care is not only tied to levels of deprivation, prevalence of disability or by how many older people live alone, but also by the size of the older population in the area. Local authorities with a larger older population have lower rates of access to publicly-funded long-term social care.

Adult social care workforce and capacity

Staffing capacity

Overall, staff vacancy levels are reducing across the adult social care sector. Estimates from Skills for Care show that vacancy rates across adult social care have fallen back in line to where they were before the COVID-19 pandemic (7%) and turnover levels have also reduced.

Every year, we collect information from registered adult social care providers through our provider information return. Data for care homes shows that staff vacancies have continued to reduce throughout 2024/25, with the vacancy rate just under 5%. This is around half the rate recorded in 2021/22 (10%). The turnover rate for staff in care homes is now 25%, which is 8 percentage points lower than in 2021/22.

While this has improved, vacancy rates in adult social care remain higher than in the wider job market, and Skills for Care’s data highlights that in March 2025, vacancy rates in homecare were just over 10%, which is more than double that of care homes.

The improvements in rates of vacancies and turnover of social care staff follows a period of increased international recruitment, which has helped ease staffing pressures. However, recent policy changes, such as restrictions on overseas recruitment and the cessation of new care worker visa applications, pose challenges to sustaining this progress, as we describe below.

We have heard through our local authority assurance assessments that there are still delays for some people in getting access to care due to shortages of homecare staff and shortages in the workforce delivering reablement services. Pressures around staff shortages are also reflected in the ADASS Spring Survey 2025, which found that 55% of directors of adult social services were ‘quite’ or ‘extremely concerned’ about increased costs due to the high level of vacancies in the adult social care workforce for older people.

People told our Experts by Experience that they were noticing how care workers are leaving the sector due to being overworked and undervalued:

I think it all comes down to salary, the wages, the minimum wage. It's a really hard job. They've got so many different things to remember. Like one person might be blind, the next person might have paraplegia, the next person dementia, so that it's very difficult for someone who's getting £12.50 an hour who might only have a half an hour call to have the skills to look after your mum and your dad, your auntie.

(CQC Expert by Experience)

We commissioned research on workforce equality in health and social care, which highlights how discrimination in the workplace can affect staff wellbeing, capacity and delivery of care. This work found that nearly a third (32%) of the 130 adult social care workers who responded to the survey had experienced or witnessed race or ethnicity-based discrimination at work. Over 80% of these staff said this affected their working environment and relationships at work, while more than 40% said this affected the quality of care provided to people using services. The individual attitudes of leaders and managers was noted as the biggest contextual factor behind inequalities in adult social care services.

International recruitment

In February 2022, a change in policy enabled care home and homecare workers to be added to the government’s Shortage Occupation List visa route. Subsequently, applications for the Health and Care Worker visa rose steadily, peaking at 18,300 in August 2023 – a 395% increase from January 2022.

However, from late 2023, the volume of applications declined sharply. This was likely due to more scrutiny applied by the Home Office to employers in the health and social care sector, and compliance activity taken against employers of migrant workers. Further reductions in applications followed after new policy measures were introduced, including restrictions on the eligibility of dependants, higher qualifying salary thresholds and increases in visa sponsorship fees.

By March 2024, the number of monthly applications had reduced to 2,400 and a year later it was even lower at 1,700 (figure 5).

Figure 5: Health and care worker visa applications, January 2022 to April 2025

Source: Adapted from Home Office: Monthly entry clearance visa applications, March 2025

This pattern in visa applications is reflected in Skills for Care's 2024/25 report on the size and structure of the adult social care workforce. This shows that international recruitment into adult social care has more than halved, falling from 105,000 recruits in 2023/24 to around 50,000 in 2024/25.

In May 2025, the government announced it would end overseas recruitment for new care workers, citing concerns over the abuse and exploitation of migrant workers. Given the sector’s reliance on overseas workers, the change in policy causes concern, as it could result in reduced staffing levels.

In our statutory Market Oversight scheme, we assess the financial sustainability of care providers that have a large local or regional presence, which local authorities could find difficult to replace if they fail and become unable to carry on delivering a service. Providers of care homes for older people in the scheme have told us that services in some regions have relied heavily on staff recruited from overseas to reduce their staff vacancy rate and reliance on agency staff. If these overseas workers leave and cannot be replaced by domestic workers, there is risk of a return to the social care workforce pressures that peaked in the aftermath of the pandemic, limiting the delivery of care and having wide-reaching impacts for the health and care sector.

The impact of staffing issues on people’s experiences

Even as the overall trend for staff turnover and vacancy rates is improving, our inspectors continue to hear the challenges around recruitment and retention of staff, with providers reporting high numbers of staff vacancies and citing low pay and an increased cost of living as the main contributing factors.

People who use adult social care services tell us about the impact on them when they experience issues with staffing. For example, in our focus groups with CQC Experts by Experience, we heard how staff turnover can lead to uncertainty for people receiving homecare:

One man said to me, ‘I don't know who's coming through the door, and if that's in your own home and you've got strangers turning up all of the time, it's not very nice for you’.

People also told our Experts that they often receive rushed care, or that care workers are late due to staffing pressures. This could affect their health, wellbeing, dignity, and independence in different ways, for example if they do not:

• get people up, washed and dressed
• give people their medicine on time
• have enough time to talk to people, to benefit their overall wellbeing
• supervise mealtimes
• tidy up after themselves.

Issues with staffing are also highlighted in our inspections of care homes. For example, we inspected a care home in response to concerns regarding the safety and quality of care, where people and their relatives told us that there were not enough staff. One person told us, “Staff don’t get time to sit and chat... I get lonely.” Staff at the service also told us that they needed longer to get to know people, and understand each person’s needs, with new staff having only “3 days training and then they are thrown into a shift.”

In this inspection, we also found that processes to ensure there were enough competent staff on duty were not always effective, and staffing was not reviewed following incidents of concern or falls to ensure that staffing levels were at the required level. After our inspection, we took urgent action to prevent the provider from taking further care packages without our agreement. As well as rating the service as inadequate, we placed it in special measures, which means we will keep it under close review to ensure people are safe while sufficient improvements are made.

By comparison, an inspection in 2024 of a homecare agency found that it fostered a culture of learning, improvement, and innovation to make sure its staff were trained well to meet people’s needs. The service used a ‘Time off to train policy’ for professional development, which had a positive impact on staff and people. For example, one member of staff said they had completed a chiropody and foot care course and had shared their new-found knowledge with colleagues and people using the service. In another example, an outstanding supported living service for autistic people and people with a learning disability introduced quick response (also known as QR) codes, which enabled staff to access short information videos to promote learning.

We continue to support the work of Skills for Care’s Workforce Strategy, which seeks to ensure that, over the next 15 years, there are enough people working in social care who feel valued and have the right training, skills, qualifications, and pay to meet the changing and increasing needs of our population.

Adult social care provision and capacity

Care homes

Although the number of care home beds in services registered with us has remained static over the last year, as a rate per 100,000 population aged 65 and over, the number of beds has reduced by nearly 2%. Additionally, our analysis of information submitted by services through provider information returns shows a steady rise in the proportion of care home beds that are occupied – from 78% in 2021/22 to 84% in 2024/25.

London not only has the fewest care home beds per population aged 65 and over (just over 3,000 per 100,000 population), but the region also continues to show the highest bed occupancy rates in 2024/25, at 87%.

Data from our Market Oversight scheme provides insight into the association between occupancy levels and funding: care homes for older people with a higher proportion of residents receiving local authority-funded care also have higher occupancy levels compared with care homes that have more self-funded residents.

With continued rising costs, local authorities may not only have less funding to provide social care, but also fewer care home spaces available to them. We are concerned that this could leave a reduced range of options for people whose care is funded by a local authority.

Supported living

In our State of Care report for 2022/23, we reported on our collaborative work to drive the improvements needed to change outcomes for people who access supported living services. These can enable adults to live as a tenant in suitable accommodation that is treated as their own home, with the help they need to be independent.

This year, we note that the number of adult social care locations that offer supported living services has increased by nearly a half in the last 2 years from 2,612 locations to 3,823 locations. The greatest increase has come from services offering homecare services alongside supported living.

While increased provision in supported living is positive, as it can enable adults to live independently in their own home, we are still concerned about the inconsistent quality raised in our previous report.

Homecare

In the last year, we have seen the number of new homecare services registered with us increase by 11%.

The area with the largest increase in the number of services per 100,000 adults aged 65 and over was London, which saw 13% growth compared with the England average of 9% (figure 6). The North East saw the lowest growth in homecare services, at 3% in the last year, as well as having the fewest homecare services per 100,000 adults aged 65 and over (69 compared with the England average of 116). The change we’ve seen this year has widened the gap in the number of homecare services available for people living in different areas of the country, which may have implications for their choice of service.

Figure 6: Increases in homecare services in the past year by region

Source: CQC HSCA Register snapshots as at 9 April 2024 and 1 April 2025

The growth in the homecare market is also reflected in ADASS Spring Survey 2025. It shows the total number of homecare hours delivered between January and March 2025 was over 5% higher than in the same period in 2024, reaching just over 47.5 million hours of care delivered.

These changes reflect the policy shift in local authorities to aim to commission more community services to support more people to stay in their own homes for longer. We are also seeing this policy shift reflected in our work on local authority assurance, with most authorities aiming to commission more community services for this reason.

However, despite this overall increase in the number of registered homecare services and hours of care delivered, we see factors that could limit the growth needed to support the shift towards increasing care in community settings, set out in the government’s 10 Year Health Plan for England.

The data we gather to determine our annual fees for providers shows that the volume of the homecare market made up by very small services (providing care to 4 people or fewer) has grown by 7 percentage points in the last 2 years – making up more than 28% of the market in April 2025.

Our concern is that these small providers may be less financially resilient (through a lack of reserves or diversification of services, for example) or may be more likely to come and go from the market, which has implications for people receiving care.

Additionally, using ‘EBITDARM’, a high-level measure of profit that excludes key expenses such as rent, depreciation and interest charges, our Market Oversight scheme data shows that profitability in homecare providers within the scheme has decreased slightly to 16.2%, and at the end of March 2025 was down nearly 1 percentage point compared with one year earlier.

We analysed data for a subset of homecare providers in the scheme for whom we can make a like-for-like comparison over time (these providers account for 40% of care hours delivered by providers in the scheme). This also shows that the total number of hours of care delivered reduced by just over 3% between the beginning of 2023 and beginning of 2025. This is equivalent to a reduction of over 13,000 hours of care delivered.

Providers in the scheme give various reasons for this reduction – including declining or handing back contracts in the context of rising costs and fees that do not cover these costs. They also say that some local authority commissioning practices are slow to use available capacity, which is being split between more providers.

Spotlight on people’s experiences of homecare

Our Experts by Experience have their own lived experiences of care, and regularly speak with people using services as part of our inspections. They told us about some of the implications of limited adult social care provision, as described above, with a focus on homecare.

Living in a rural area can affect the choice of homecare providers available. People have found that when the services are at capacity, alternative options are unavailable so people can become stuck receiving poorer quality care or having no care at all:

The only other agency down the road hasn't got any space for me. Where do you expect me to go? I'm telling you what's wrong and the things I'm not happy with, but I don't feel like I've necessarily got a choice to change that.

(CQC Expert by Experience)

Due to staff shortages or poor communication, people also experienced a lack of choice when voicing their preference for a care worker of a specific gender. For some, this had implications for their health and wellbeing:

A lady would not let a male give her care or wash her, but was happy for him to take meals. Family asked not to send men, but this had not happened. Sometimes he comes 3 days in a row, so the lady doesn't wash for 3 days. As she is incontinent, she gets sore and smells; she is therefore ashamed and refuses visitors.

(CQC Expert by Experience)

By contrast, a homecare service that provides support to autistic people and people with a learning disability, as well as those living with physical disabilities or sensory needs, was recently rated as outstanding. The inspection report describes how people can be supported to make informed choices.

The service considered people’s strengths, abilities, aspirations, culture, unique backgrounds, and protected equality characteristics. When people were due to move into the service, a detailed, comprehensive transition plan was developed with them and those important to them. One person was extremely anxious about receiving support, as they had not previously received formal support. Staff empowered them by seeking their input into a job description and advertisement for a suitable care worker who could support their specific needs. They were also invited to hold interviews, with the support of senior staff, and as a result found a new member of staff who the registered manager described as a “100% match.” The person’s relative told us:

The relationship is brilliant. They are really good mates. It's definitely 100% person-centred care. Staff encourage (the person) to also try out new things. Their confidence has really improved in going out and doing things.

Our Experts also told us how poorly-organised homecare, and late or missed calls, could have a negative impact on people who are incontinent, with some people sharing that they had been left to sit or lie in soiled or wet clothing for hours while waiting for their care worker to arrive. Delivering care in an untimely way can significantly affect people’s health and dignity, reducing their ability to live independently and comfortably:

One family had an elderly relative who was [cared for in bed], and they had requested certain visit times throughout the day, including one last thing at night and one first thing in the morning because the elderly relative needed incontinence pads and couldn't get out of bed by herself. The care company couldn't meet the times for the lady’s needs so the family said they'd come in and put her to bed at 4pm and then nobody would visit until 11am, by which time the bed was soaked.

People and their relatives gave us feedback about a specific homecare agency that provided services for older people, people with dementia, and younger adults with a range of needs, including people with physical disabilities. Although they said that staff were kind and caring, some raised concerns with the agency’s leaders that staff were not arriving at the scheduled time or staying for the full duration of the allotted visit.

Our inspection of this service in February 2025 resulted in a change of rating from good to requires improvement. During the inspection, we found that the provider failed to ensure that its management team had effective oversight of the Electronic Call Monitoring system. We found that care staff were logged into different locations simultaneously, showing ineffective oversight of care worker allocation or whether staff were staying at their calls for the right length of time. This placed people at risk of harm. We discussed this with the provider and served a Warning Notice to ensure that it took immediate action.

Conversely, effective care leaders promote a culture of openness and learning. An inspection of a homecare service in London in 2025 resulted in a rating of outstanding. We noted how the provider shared lessons learned with staff through weekly structured online sessions. This gave staff a platform to ask questions and receive advice, which was shared on the provider’s intranet for transparent communication. Staff involved in incidents were required to complete a specific reflection exercise to ensure lessons were learned for the future. The provider also shared examples of good practice with staff, including from other services.

Experts by Experience highlighted that continuity of care – including having one consistent care worker – is a key aspect of good homecare. However, they heard that some people do not receive support from one regular care worker, with one person saying they have around “10 different carers come in to support them.”

When an individual care worker supports people regularly, they can become ‘part of the family’, which has a positive impact not just on the person receiving care, but on their families and significant others.

Having the same regular care worker helps people feel safe. They foster a sense of familiarity, which helps people to trust their care. Additionally, regular care workers often know and understand the person who they are visiting, so can more quickly notice when they are unwell:

Regular carers [are] really important because.. [they notice] when somebody is not themselves… or they notice something about their skin and act on it.

Adult social care and the wider system

Causes of delayed discharges from hospital

Last year we reported in State of Care that “waits for care home beds and home-based care accounted for 45% of delays in discharging people who had been in an acute hospital for 14 days or more”. New definitions introduced by NHS England in 2024 present a different perspective of the causes of delayed discharges.

NHS England data for March 2025 shows that lack of capacity in social care services, or delays completing transfers to social care services accounted for 23% of delayed discharges of people who had been in an acute hospital for 14 days or more. However, 26% of delayed discharges were due to the same issues affecting access to rehabilitation, reablement or recovery services. Specifically, the monthly data shows that capacity within bed-based rehabilitation, reablement or recovery services is consistently the biggest cause of delayed discharges nationally.

Although rehabilitation, reablement or recovery services may be delivered within social care settings, this type of care is also often provided in community hospitals and specialised facilities. There is a need for increased investment to expand capacity within services, including in the workforce, to ensure people can move out of hospital efficiently and be supported to mobilise and regain independence in appropriate settings.

Our survey of 144 people aged over 65 carried out by National Voices highlighted the importance of care provided in the community after people are discharged from hospital after a stay as an inpatient. The majority of respondents who had received care agreed that the follow-up care they received had allowed them to recover fully, regain or maintain their independence and reduce the amount of support they required from family and friends. We talk more about this survey in the section of this report about ‘Health and care for frail and older people’.

A&E emergency admissions and adult social care

Across England there is variation in the rates of attendance for urgent and emergency care, emergency hospital admissions (including avoidable admissions), and emergency readmissions of older people. Health and social care services are interdependent – challenges in one sector have an impact on other sectors. We have started work to investigate how variation in the capacity, accessibility, and funding of social care services can affect the volume of hospital attendances and admissions.

The initial stage of this work focused on a correlation analysis using a range of publicly available data on adult social care and Hospital Episode Statistics data at local authority level. This explored which indicators are associated with higher or lower rates of hospital activity for older people aged 65 and over. We also considered a range of contextual factors, such as deprivation, population age and distance to health care services.

The findings show strong associations between levels of self-funding of social care, local authority expenditure on social care, costs per unit of social care and levels of hospital activity for older people (this includes rates of A&E attendances, emergency admissions, avoidable admissions and emergency readmissions):

• In areas where a greater proportion of people self-fund their care (such as homecare or a care home) there are lower rates of attendance at emergency departments, emergency admissions (including avoidable admissions) and readmissions within 30 days for older people.
• In areas where the gross expenditure of local authorities per population on social care is higher, there is increased attendance at emergency departments for older people.
• The lower the rate that local authorities pay per unit of care (such as a week in a care home or an hour of homecare), the higher the rates of emergency department attendance and emergency admissions (including avoidable admissions).

These associations are likely to be best understood in the context of deprivation, which also showed a strong association with levels of hospital activity.

Areas that are more deprived typically have fewer people self-funding their care and higher local authority expenditure on social care services. People living in more deprived areas are also more likely to live in poorer health and face a higher risk of A&E attendance and emergency admission – in part due to issues with accessing primary care, as highlighted elsewhere in this report. As reported in last year’s State of Care, “in 2023/24, attendance rates for urgent and emergency care for people living in the most deprived areas of England were nearly double those for people in the least deprived areas”, and this has continued in 2024/25.

The 10 Year Health Plan acknowledges the impact of deprivation on health and proposes a range of measures to try to counteract its effect with a view towards halving “the gap in healthy life expectancy between the richest and poorest regions”.

Collaborating to improve the quality of life for people in care homes

In last year’s State of Care, we highlighted the launch of the Vivaldi social care project. The project, which was co-produced with people who live and work in care homes, is a collaboration between University College London and organisations in the care sector, such as The Outstanding Society, Care England, Skills for Care and the Care Provider Alliance. The project is transforming the way social care-led research is carried out in care homes to improve people’s quality of life.

Since January 2025, the care homes involved in the Vivaldi social care research study for older adults in England have begun to share data on their residents with the NHS, making it possible to track important events like hospitalisations and rates of infection by care home. This data sharing between health and social care for research is enabling evidence-informed decision making between these sectors.

Adult social care pressures and reform

Additional budgetary pressures are affecting adult social care services this year, such as the increase in employers’ national insurance contributions and national living wage, on top of increases in the cost of living. This means it is unlikely that local authorities will be able to sustain the current provision of care. Through the ADASS Spring Survey 2025, directors of adult social services have also warned that the need to make substantial savings to adult social care budgets will have an impact on the choice and quality of care and support that people can access at a local level.

As local authorities around the country increasingly look to make savings, it seems likely more will signpost people to support in the community, ration the care they do provide, and reduce the provision of other statutory and non-statutory services. As well as negatively affecting the health and wellbeing of those in need of social care support, this could increase the pressure on the health and care system and the voluntary, community and social enterprise sector, and further increase the burden on unpaid carers. It is also likely to incur wider societal costs, as outlined in the Health and Social Care Committee’s report, Adult Social Care Reform: the cost of inaction, published in May 2025.

There is a lot of activity taking place to drive change in adult social care, with examples including:

• the independent commission into adult social care chaired by Baroness Casey
• the fair pay agreement
• the 10 Year Health Plan
• the adult social care workforce strategy, led by Skills for Care.

But it is important that these initiatives are connected across government and the wider sector. To help this, we are bringing people together to improve our understanding and planning on key topics.