Hertfordshire County Council: local authority assessment

The local authority worked with local people and stakeholders, and used available data, to understand the care and support needs of people and the communities they live in, including those from seldom heard groups. The Joint Strategic Needs Assessments clearly show the situation relating to people with a range of need, including those who were most likely to experience poor care and outcomes, as well as unpaid carers and those with protected characteristics.

The local authority had eight co-production boards which were all co-chaired by someone with lived experience. These covered a range of needs and all linked into the overall strategic co-production board. People with lived experience were involved in the development of specific strategies, such as the Dementia strategy. In addition, the co-production board for people with a learning disability recognised that they were not fully meeting the needs of autistic people who did not have a learning disability and so a separate co-production board was set up to address this.

There were plans for further development of co-production focusing on the groups and communities who had more recently been identified as being at risk of not having equal access to services as others.

People had access to a range of diverse local services that were safe and provided good quality care and support. There was a variety of providers of residential, nursing and homecare services. National data indicated that 66.4% of people who used services felt that they had choice over the services they used. This was in line with the England average (ASCS).

The local authority worked closely with Public Health to ensure there was a good understanding of the population of Hertfordshire. Data was also obtained from the Joint Strategic Needs Assessments (JSNA). Generally, Hertfordshire is a fairly wealthy county with a score of 2 on the Indices of Multiple Deprivation (where a score of 10 is the most deprived areas). However, the local authority were aware of areas in the county where there was considerable deprivation and the causes of this. The local authority’s Market Sustainability Plan and Market Position Statements reflected this understanding of the current population and were clear about the planning required for the services predicted to be needed. For example, the JSNA for people living with dementia predicted that the diagnosis rate for people in Hertfordshire was in line with the England average. Recommendations arising from this JSNA included the need for equitable access to diagnostic treatment and for an improvement in screening in care homes and extra care services. The local authority’s Dementia Strategy was developed from information in the JSNA and involved co-production with people with lived experience.

Another example was that the JSNA for people with a learning disability predicted that in the next 10 years there will be a higher number of adults with a learning disability aged 65 years and over and less of working age. This information had influenced the development of housing strategies and commissioning strategies, including the development of supported living accommodation and support.

Commissioning strategies and market shaping activity supported the sustainability and further development of services specifically focused on the needs of people now and those predicted over the next few years. The local authority’s strategies were aligned with the strategic objectives of partner agencies such as housing and health. There was clearly partnership working in relation to the development of services for people with specific needs which the local authority had identified were going to be needed in the forthcoming years.

The local authority worked closely with the District and Borough Councils with regard to housing strategies and the need for good quality housing and the impact on social care was clearly understood by all involved. This work was incorporated in the 10 Year Supported Housing Strategy (2017-2027) and the Extra Care Housing Strategy.

This collaborative approach to commissioning and market shaping was also reflected in the strategies relating to the needs of unpaid carers. The JSNA for unpaid carers included recommendations. These were considered as part the consultation which took place in 2020 involving carers through Carers in Hertfordshire. Following this consultation the Carers Strategy was published in 2023. The strategy involves a five-year plan to develop and improve services for unpaid carers. This includes taking steps to find out the needs of carers from communities in which they may not have been identified as carers. One of the key priorities of the strategy is the provision of respite care. National data shows that the percentage of carers able to take a break in an emergency or for a period of over 24 hours was in line with the England average. However, the percentage of carers able to take a break for a period of between 1 and 24 hours at a time was 37.54% which was considerably higher than the England average of 27.61% (SACE). 

Commissioned care was based on recognised good practice. The commissioning strategies and market shaping plans were focused on, wherever possible, preventing and delaying people’s need for more formal support. As a result, work had taken place on a partnership basis to increase the availability of supported accommodation with a new extra care housing service having opened in 2023 and a further one planned for 2024. In addition to this, there had been a recognition of the need for more nursing provision, including for those people living with dementia, and less reliance needed on residential provision. Again, partnership working was in place which had seen the opening of one new nursing home and further work planned in 2024.

The local authority commissioned homecare mainly through a number of preferred providers. Spot purchasing from providers who were not on the Framework was available where those providers were unable to meet the need or when a person’s choice was to use another provider.

The local authority was proactive in identifying where services were required to meet people’s needs and in working in partnership with health, providers and the voluntary and community sector to provide those. For example, the Framework for Community Opportunities for people with disabilities was developed through co-production with people with lived experience in recognition that what had been provided was no longer meeting people’s needs. This led to a range of new services being commissioned and provided which are more flexible and accessible at a range of times across the day/week.

Commissioning and market shaping strategies were focused on those areas where it had been identified that there was a need to further develop services. These included nursing homes, including for people living with dementia, supported housing including extra care housing and also services for working age adults with more complex needs and/or co-morbidities. The waiting lists for services reflected the challenges that the local authority was aware of. For example, in a three month period there had been 21 referrals for residential care for working age adults, all of whom had complex needs. At the time the data was collected there were 11 people waiting and the average wait was 39 days. There were 7 people on the waiting lists for supported living, out of a total of 46 referrals in that three month time period. The average wait was 37 days and was longer where people also had mobility needs.

The average wait for a homecare service was 14 days out of 1889 referrals during the three month period. The longer waits were all due to the specific locality where people lived as in some areas, for example rural areas, it was harder to recruit staff. The upcoming recommissioning of the homecare contract was expected to improve this.

Out of 262 referrals for residential or nursing homes for older people the average wait was 16 days and there were 10 people on the waiting list. The reason for 4 of the people waiting was a lack of preferred homes at the local authority rate. People gave us mixed views about how easy it was for them to find a suitable service for themselves or a relative.

The local authority worked very proactively with the Hertfordshire Care Providers Association (HCPA) with regard to market shaping and developing new models of care. This includes the current development of further nursing home provision.

Hertfordshire Partnership Foundation NHS Trust provides the commissioning and provision of adult social care services for adults with a mental health need. The Trust used the same quality tool as the local authority to assess the quality of the services and reports concerns through the Hertfordshire Safety and Improvement Process. The local authority has oversight of commissioning through the Section 75 agreement that is in place. A Section 75 agreement is an agreement the local authority and an NHS body which includes arrangements for pooling resources and delegating certain functions to the other partner.

There were 618 people who lived in the local authority area receiving a service from outside of Hertfordshire. Many of these were receiving a service from a provider very close but over the county border. The local authority had agreements in place with other local authorities which set out each authorities’ responsibilities, this included the commissioning team’s monitoring to include out of county placements. The frontline staff teams were responsible for carrying out reviews of people’s needs as part of their Care Act duties.

The local authority had carried out a thorough review of the 80 people who had been placed out of county in the previous year. This showed that over half of the decisions to move out of county were due to the person’s choice, mostly to be nearer to family and friends. Five people moved out of county as they felt they would receive more culturally appropriate care. There were 12 people whose needs could not be met in Hertfordshire. These people had complex needs and the local authority had already identified this type of provision as an area in need of improvement.

There were six people placed in out of county hospitals due to the complexity of their needs, including learning disabilities and mental health needs. There was a team responsible for reviewing the needs of these people and ensure their needs were being met.

There were clear arrangements in place to monitor the quality of the services provided and to take action where concerns were identified. In September 2023 the revised Provider Monitoring and Assurance Framework was introduced which incorporates the Provider Assessment and Market Management Solutions (PAMMS) which had been in place previously. The provider monitoring and assurance team gathered the views of people using the service as part of their PAMMS assessment.

The local authority had been one of the first to use the PAMMS Risk Profile and Landscape Tool which brings together information about quality of services from a range of sources, including Care Quality Commission (CQC) ratings. It also includes information about local services and cost data to give a picture of adult social care across the county which enables the commissioning teams to make key decisions.

The number of CQC registered adult social care services rated as Good or Outstanding was around the same as the England average with ratings of nursing homes being slightly lower (74.7%) than residential care services (82.6%). 14.81% were rated as Requires Improvement and 2.22% rated as Inadequate. Almost 10% had not yet been rated. The local authority had already identified the issues relating to the quality of care in nursing homes and these had influenced the commissioning strategy for nursing homes.

The CQC ratings of home care services were 4.5% rated as Outstanding, 53.82% rated as Good, 10.07% rated as Requires Improvement and .35% as Inadequate with approximately 30% of home care services not yet rated.

The local authority had invested considerably in the provider market to support them to develop and maintain a good quality workforce. Providers were required to agree to the Hertfordshire Care Standard as part of their contract agreements. This set out the expected working conditions for care workers. This included ensuring a sustainable wage was paid which was competitive with local service industries. Also, that staff should receive sick pay, holiday pay and that travel was paid in addition to the staff salary. 

The local authority paid a rate to providers which ensured that their staff were paid above the Real Living Wage. Any recent fee increases to providers was with the express intention that staff wages would rise. The Hertfordshire Care Standard was monitored through routine contract compliance visits by the local authority.

All commissioned regulated providers were required to join the Hertfordshire Care Providers Association (HCPA) which worked very closely in collaboration with the local authority. The association channelled information to all providers and gathered information on behalf of providers to feedback to the local authority. Providers told us that there were very good relationships with the local authority and that they felt that HCPA, and therefore providers, were considered a key partner in terms of market shaping and ensuring standards of care and support were of a good quality. The regular engagement ensured that the local authority had a good understanding of the challenges facing the provider market and were able to consider these as part of their strategic planning.

Providers were involved in the Market Sustainability and Fair Cost of Care exercise. Providers had benefited from the local authority’s commitment to ensuring that care workers were paid fairly and at a rate that was above the Real Living Wage. This helped to support providers to remain sustainable as they were better able to recruit and retain staff.

The provider monitoring and quality assurance team used a risk matrix approach to monitoring care services. There was a good understanding of the factors that cause provider failure and plans were in place to prevent this wherever possible. Partners told us that the local authority worked proactively with them to share information about risk and particularly in circumstances where there was provider failure and a need to find alternative services for people. For example, in the last year a provider of a large service for adults with a learning disability had closed with a high number of people needing to move within a short period of time. Partners told us the local authority worked well with them with a real focus on assessing people’s needs and finding the right place for them that was of their choosing.

In the previous 12 months, 6 supported living and 7 residential services had handed back contracts which affected 41 people. Again, the local authority worked with HCPA and partners to ensure suitable alternatives were found for people.

The HCPA said that the local authority has invested strongly in training for the wider social care workforce. On behalf of the local authority in 2023/2024 they provided training to 3,500 members of staff. This included working with the local authority to be one of the first areas in the country to roll out the Oliver McGowan training programme which is recognised as being a requirement for all providers/staff working with people with a learning disability.

This commitment to training of the adult social care workforce was reflected in national data which showed that 56.7% had completed the Care Certificate compared to an England average of 49.65%. The level of vacancies and rate of turnover was in line with the England average (Skills for Care Workforce Estimates).