Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission.

Three big things happened in the health and social care world last week — at CQC we published our latest State of Care report; social care gathered together in Bournemouth for the National Children and Adult Services annual conference (NCAS) and the inquest into Connor Sparrowhawk’s death ended on Friday.


I will start with Connor, described by the Justice for LB campaign as:

“A much loved son, brother, family member and friend who loved buses, London, Eddie Stobart and speaking his mind. Connor had autism, a learning disability and, like 1 in 4 people with learning disabilities he also had epilepsy.

“On 19 March 2013 he was admitted to the Short Term Assessment and Treatment Team Unit (STATT) run by Southern Health NHS Foundation Trust. 107 days later, on 4 July 2013, he drowned in the bath as a result of an epileptic seizure.”

The inquest jury concluded by finding that Connor’s death was contributed to by neglect.

You can read more about the inquest here.

Having given evidence at my own brother’s inquest I have some small understanding of what Connor’s family have gone through but we didn’t have to wait two and a half years nor were such significant failings in care identified.

There is so much that the health and social care world needs to act upon from Connor’s experience — perhaps first and foremost, listen and don’t ignore what people using services and their families are telling us. And that includes CQC.

A powerful and poignant reminder in this animation Rights and Colour.

Sadly, what happened to Connor also serves to reinforce why regulation and inspection continues to be necessary and important. You would have thought that Connor’s death would have encouraged the Trust to reflect on what had gone wrong and put it right, yet two months later we inspected and had to issue 10 warning notices — actions which led to the closure of the unit in December.

State of Care

More evidence was presented in our State of Care report — bringing together the findings from our inspections across adult social care, hospitals and primary medical services. Read the full report or take a look at the fab infographics.

The newspaper headlines inevitably focused on what is happening in the NHS but the messages for social care were fully explored by some great questions at the launch and in a really helpful summary of reactions by the Guardian Social Care Network. A short summary in this blog will fail to do justice to the wealth of information in the report but key points include:

  • Our concern about the fragility of the social care sector and the variation in quality that we see.


These themes of concern echoed loudly on the platforms at the NCAS conference — platforms that were shared to a much greater extent by people using services than ever before. This started with a witty but powerful opening address from Isaac Samuels.

In his brilliant speech, ADASS President, Ray James, spoke passionately about the importance of working together to make real improvements in the sector. It was also fantastic to hear such positive mentions about CQC’s progress in our co-production work! You can read Ray’s speech in full here — a must for anyone involved in adult social care.

My speech

On Friday it was my turn to take to the main stage and I spoke about CQC, the progress we had made over the past year or so and shared the findings from State of Care. I was joined by Sarah Reed, one of our Experts by Experience, who provided a real person centred perspective on our work and why it matters so much to people using services. The presentation was well received and generated a good buzz in the room and over the internet on twitter.

The summary of tweets below gives a flavour of what was covered.

And last but not least, Sarah read Gill Phillipspoetry challenge to the conference which ended with:

“Real action. Words are no longer enough.”

I think Connor would agree.

Originally published at

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