CQC published State of Care 2025/26 on 23 October 2026 and summarised the system in two words: flux and fracture. There are real improvements in it, but the thread running through the report is unwarranted variation, and the provider-level finding worth most attention is leadership. This is a horizon scan, not a new checklist.
The Care Quality Commission published its State of Care 2025/26 report on 23 October 2026.
CQC's description of the system is unusually concise: "flux and fracture".
There are signs of improvement. CQC points to more GP appointments, greater use of digital services, shorter waits for elective care and examples of local innovation. But improvement is not keeping pace with demand everywhere, and the experience people receive still varies significantly according to where they live, who they are and which part of the health and care system they need.
That variation is the thread running through much of this year's report.
For providers, however, State of Care needs to be read carefully. It is not a new inspection framework and it is not another checklist to complete.
It is CQC telling Parliament, providers and the public what it is seeing across the system and where it believes risks are developing.
That makes it worth reading.
Variation is the bigger message than pressure
Health and care services being under pressure is not new.
What stands out in State of Care 2025/26 is how often CQC returns to unwarranted variation in access, quality and outcomes.
More than 80,000 children and young people have been waiting over a year for a community health appointment, almost 11 times the number of adults waiting that long. The number of children waiting for their first contact with mental health services has risen by 31% in two years.
CQC also highlights large geographic differences in primary care staffing, variation in annual health checks for people with severe mental illness, inequalities in maternal outcomes and markedly worse dental health among children living in deprived areas.
An individual provider cannot solve national inequality. But there is a very practical governance point here.
An average can hide the problem.
A service may have a good overall patient satisfaction score while one group of patients consistently reports a worse experience. Access figures may look acceptable overall while people with particular communication needs wait longer. Complaint numbers may appear reassuring while one pathway, clinician, location or patient group repeatedly produces the same concerns.
That last pattern is its own subject, and what an empty complaints log tells a CQC inspector covers it properly.
The question is not only whether the headline number looks good.
It is whether your governance can see the variation underneath it.
Social care is changing shape
The adult social care section is one of the most significant parts of this year's report.
CQC describes a market being reshaped "by accident rather than design".
Homecare is becoming more fragmented, with increasing numbers of smaller providers, while care homes are moving in the opposite direction. The number of care homes has fallen by 8% since April 2019 while the overall number of beds has remained broadly stable, fluctuating by 1% or less, meaning a greater proportion of beds is now concentrated in larger homes.
The change is particularly visible at the small end of the market. The number of care homes with 10 or fewer beds fell by more than 1,500 between April 2012 and April 2026.
Ownership is concentrating at the same time. The number of homes held by the five largest providers rose by 26%, driven mainly by transactions involving one US-based real estate investment trust whose homes now account for 9% of all CQC-registered care home beds in England. The Competition and Markets Authority opened an investigation in January 2026.
Most of that sits well beyond the control of an individual registered manager.
But the provider-level question is still important.
Has the governance structure changed as the service has changed?
A system that worked when a provider was small may not remain adequate after growth. More staff, more people using the service, more locations, more complexity and more external relationships all create additional information that leaders need to see.
CQC's analysis also suggests that leadership structure and management stability matter. Inspectors observed a high turnover of management staff in medium-sized care homes, while larger homes may have a bigger leadership structure supporting governance. Smaller services, meanwhile, often performed well.
That should not be read as evidence that one size of care home is inherently safer than another.
The more useful point is that governance needs to be proportionate to the organisation it is supposed to control.
Leadership is the provider-level finding I would pay most attention to
CQC is not saying that adult social care is generally poor. Its headline position is that almost three-quarters of the sector is rated Good or Outstanding.
But in the same report, CQC identifies leadership as the area most in need of improvement.
That distinction matters.
In CQC's care home analysis, shortfalls in standards were identified in 55% of the assessments that looked at the Governance, management and sustainability quality statement.
That is not 55% of all care homes. It is 55% of the relevant assessments in which that quality statement was considered.
The report's inspector evidence helps explain what sits behind the figure. Concerns included leaders not having enough time or support to maintain effective oversight, and services not consistently listening to staff or acting on what staff were telling them.
That pattern will be familiar to anyone who has worked around regulated services.
A service can provide compassionate care and still have weak systems around it. Staff can know people extremely well while actions remain open, audits identify the same issue repeatedly, risks are not reviewed, staff feedback disappears into meetings and governance depends heavily on what one experienced manager happens to know.
Those are not simply paperwork problems.
They are leadership and assurance problems, and the duty they sit under is Regulation 17: good governance.
The purpose of governance is not to create documents around good care. It is to make good care dependable when the service gets busier, people change, something goes wrong or the manager is not in the building.
Some of the greatest risks sit between services
Another strong theme in State of Care is how connected different parts of health and social care have become.
CQC's Chair, Julia Neuberger, points directly to challenges in social care provision contributing to delays in hospital discharge, and gaps in community mental health provision pushing more people towards crisis care.
The discharge data gives this a practical scale, and it is worth quoting precisely because the denominators differ.
Around one in eight (12%) of people who had been in hospital for 14 days or longer were ready to be discharged but delayed because social care services did not have the capacity to take them, roughly 1,000 people a day on average.
Separately, 12% of delayed discharges nationally happened because transfer arrangements between hospitals and social care were still being negotiated, affecting nearly 1,100 people a day, and a further 8% were caused by a lack of suitable care home places. London had the highest share of transfer-related delays at one in five.
That does not mean social care is responsible for every delayed discharge. Capacity, commissioning, rehabilitation, housing, hospital processes and other factors all interact. Hospital discharge is a governance problem, not just a flow problem takes that argument further.
The important governance point is that risk does not stop at the provider's front door.
A referral leaves one organisation and reaches another. A patient is discharged. Medication information moves between teams. Transport is arranged. A safeguarding concern is handed over. A care provider receives somebody whose needs may have changed considerably during admission.
Those interfaces are exactly where responsibility can become blurred.
For an individual provider, the useful questions are straightforward.
Did we identify the risk? Was responsibility clear? Did the right information move with the person? Did we escalate when the handover failed? Did repeated failures become a governance theme, or did we record each one as an isolated problem caused by somebody else?
External dependency does not mean external risk.
If it affects the people using your service, it belongs somewhere in your oversight.
Workforce improvement does not remove the competence question
There are some signs of improvement in the adult social care workforce.
CQC says vacancy and turnover rates have continued to fall slightly, although they remain a concern. Care home vacancies sat at 4.6%, close to one role in twenty standing empty, with turnover just over 23%. Homecare vacancies had fallen to 9% and turnover to 19%. That improvement sits alongside a substantial reduction in international recruitment, which more than halved between 2023/24 and 2024/25 and fell by a further 40% across 2025/26.
The report also links poor safety with staff capability. In services rated inadequate for Safe, providers did not always ensure staff had the necessary skills, knowledge or competence to meet people's needs, and CQC records training that was incomplete, not aligned to people's needs, or not translated into safe practice. In one service a newly recruited worker administered medicine before any recorded competency assessment.
That distinction is important.
A green training matrix tells you that training has been recorded.
It does not automatically tell you that somebody is competent.
For a provider, workforce assurance therefore needs to go beyond course attendance. It needs to answer whether there are enough people, whether their skills match the needs of the people receiving care, whether competence has actually been assessed, and whether supervision identifies where support is still needed.
Regulation 18: staffing has always made that distinction.
State of Care gives another reason not to lose it inside a spreadsheet.
Be careful with the headline ratings
State of Care contains a large amount of assessment data, but this year's numbers need some discipline when they are quoted.
For example, CQC's analysis covers 2,121 homecare services assessed under its current framework between January 2024 and August 2026, of which 80% were rated good or outstanding, 76% good and 4% outstanding.
That sounds like a useful description of homecare quality nationally.
It is not quite that simple.
CQC's assessment activity has been largely risk-based. Services were not selected as a random or representative sample of every provider in England. CQC itself cautions that the results may not be representative of all services across the sector.
This is a point worth remembering whenever a State of Care percentage is repeated.
Ask:
What is the denominator?
Who was assessed?
Why were they assessed?
How current is the evidence?
Does the percentage describe all registered services, or the services CQC happened to assess under that part of its programme?
More assessment activity gives CQC more current evidence.
It does not automatically turn a risk-selected sample into a representative one.
State of Care should be a horizon scan, not another action plan
I would not respond to this report by creating a 40-line action plan simply because CQC published it.
The more useful approach is to use it as a horizon scan and ask whether the patterns CQC is seeing nationally are visible inside your own service.
Can your averages hide variation? Look beyond the organisation-wide figure. Are particular groups of people experiencing poorer access, outcomes or feedback?
Can leaders see risk without reconstructing it? If the registered manager or nominated individual is asked what the main risks are today, can they see them from the governance system, or do they need to ask three people and search several spreadsheets first?
Does training translate into competence? Completion is useful evidence, but does the service know whether staff can actually perform the work safely?
Are handovers you do not own still visible? Where another provider, hospital, commissioner or professional controls part of the pathway, are recurring failures still being captured and escalated?
Do you check whether the fix worked? An incident was investigated. A complaint produced an action. An audit found a problem. Staff were retrained. What happened afterwards?
Those questions are not new regulatory duties created by State of Care.
They are questions prompted by what CQC says it is seeing.
What State of Care 2025/26 tells us about CQC's direction
State of Care is a system report, not an inspection manual.
But it does tell providers what is occupying the regulator's attention.
The direction this year is clear: growing and increasingly complex demand, inequalities in access and outcomes, variation between places and populations, leadership and governance, workforce capability, failures at the interfaces between services, and the sustainability and changing shape of adult social care.
None of those themes can be answered simply by producing another policy.
They require providers and systems to know what is happening in practice.
That means joining information together.
Incidents with actions.
Complaints with learning.
Audits with follow-up.
Training with competence.
Risks with controls.
Staff feedback with management decisions.
Patient experience with outcomes.
A governance system should help a service see those relationships while they are happening, not reconstruct them when somebody asks.
My reading of State of Care 2025/26
Having worked as a CQC inspector, the part of this report I would pay most attention to is not any individual percentage.
It is the repeated gap between activity and assurance.
There is a great deal of activity across health and social care: more appointments, new service models, digital tools, improvement programmes, assessments, restructures and initiatives.
But the harder question is whether those activities lead to consistent outcomes for people.
That is also the question providers should keep asking themselves.
Not simply:
Did we do something?
But:
Did it make things better, for whom, and how do we know?
State of Care 2025/26 is, at national level, the same governance question.
Sources
The principal source for this article is the Care Quality Commission's The state of health care and adult social care in England 2025/26, published on 23 October 2026.
Supporting CQC material includes the 23 October 2026 press release Flux and fracture: CQC warns of fast-changing social care market while inequalities persist across health and care, together with the report's own sections on adult social care ratings, consolidation of the care home market, the adult social care workforce and adult social care and the wider system.
Figures on homecare assessment coverage and on hospital-to-social-care transfer delays are drawn from those sections and should be read alongside CQC's caveat that much of its assessment activity has been risk-based. Where this article gives a percentage, it names what the percentage is of, because the discharge figures in particular use more than one denominator.