London Borough of Hounslow: local authority assessment

Hounslow Council used an electronic data hub for their Joint Strategic Needs Assessment. This meant the data used for decision making was always as up to date as possible. Hounslow used the hub to prepare their State of the Borough Report. They looked at what the data told them and considered options. This provided a rich picture of what was going on in the borough, in terms of people’s lived experience. They reviewed demographic projections not just regarding population growth but also about the nature of society, what was changing with caring and kinship groups, to understand what changes they needed to make to ensure services would be accessible.

They analysed the population data and projections, as well as current and expected use of services to inform their future planning. Hounslow had an ageing population, including unpaid carers and it was expected there would be more demand for care services, in particular support for people to remain independent for as long as possible. Asian people constituted 37.4% of the population in 2021 and are projected to be 39% by 2040. Currently this population is significantly underrepresented in residential and nursing care, but it was anticipated this pattern might change in future, which would impact on demand for this type of provision.

The local authority worked with local people and stakeholders to understand the care and support needs of people and communities, including those who are most likely to experience poor care and outcomes, people with protected characteristics, unpaid carers and people who fund or arrange their own care, now and in the future.

There was a Mental Health and Wellbeing Forum which was regularly attended by 50 people including representatives for excluded groups such as homeless people, and those experiencing poor mental health and substance misuse, but not engaging with traditional services. The Forum ran a consultation exercise and heard from 1500 people who had an interest in Mental Health and Wellbeing services. Commissioners also asked Healthwatch to do ‘deep dive’ studies where new services were to be commissioned.

Hounslow Council commissioned work from an advocacy organisation to engage with people with a learning disability for feedback about services and what was needed, which they used to shape commissioning practice.

Hounslow also commissioned work with a focus group of carers to gather views to inform their Carers Strategy. A carer who had been involved told us they did not know what had happened with their information.

People had access to a diverse range of local support options which were effective, affordable, and high-quality to meet their care and support needs. There was a variety of providers, including for care at home, residential and nursing care. The council had a good range of care providers.

All adult social care commissioning in Hounslow was undertaken through an integrated strategy and pooled budgets between the integrated care board (ICB) and the local authority, and for the whole life course (children and adults). A key health partner told us there was strong partnership working with the local authority, and Hounslow were looking into how this could be developed further. Together they were planning services for the next 10 years to serve the population and looking at the need to try and keep the increasing numbers of older adults well and in their own homes. This had driven the development of three Extra Care services and plans for an increased range and capacity in supported models of accommodation, such as significant investment in Supported Living services and expanded use of Shared Lives services.

Hounslow used their pooled budgets to target resources where they were needed. For example, using funding to provide additional psychological support to people with mental health needs, as this was identified as a local gap, and the most cost-effective way of preventing hospital admissions.

There was a focus in commissioning on the prevention and reduction of care needs through earlier intervention. The Director of Public Health reported to the joint Director of Commissioning, which reinforced the alignment of the two functions.

Commissioning services for people with learning disabilities, autistic people and those with mental health needs focused on outcomes rather than commissioning ‘tasks’ or services which is recognised as good practice; more traditional domiciliary care providers and residential care home settings were more task and/or time oriented. Commissioners allowed providers to flex where and how they targeted their resources when necessary to manage challenges with capacity and provided an example regarding advocacy provision. The way in which providers delivered services were not usually flexible to meet people’s preferences unless the contract was bespoke for an individual, and the specification developed to meet their particularly complex needs.

There were some examples of newer models of care provision. For people with learning disabilities and complex needs Hounslow had developed Supported Living with positive behavioural support. They had also created adaptive models of support and accommodation for people with mental health and substance misuse support needs, who would not typically accept help. They told us they had developed a new service which felt like a bed and breakfast hotel but had security, to which they added in reach services who engaged people in a supportive dialogue, whilst they were there. Hounslow were proud they were able to minimise use of long stay and secure provision in mental health wards because people felt more able to engage with this model.

Some of the models of care being explored for expansion were more traditional arrangements such as Shared Lives. The best practice guidance staff we spoke with cited as the basis for service design of services for people with learning disabilities, was published in 2001 and updated in 2009. It was not clear how the models of service design being considered for people with learning disabilities and autistic people took account of more recent best practice guidance. This means there were potentially missed opportunities to support people to reach for ambitious outcomes facilitated by optimum service design.

People were usually able to access care when and how they needed it, but for residential or nursing care this might be out of area. The market was at 90% occupancy/capacity based on current demand. This meant there was little flexibility for increases in demand. The average waiting times for the start of a package of care were 55.97 days from the point of referral to social services, although this reflects the assessment period as well as any delay for support. Hounslow told us there were very few delays in securing packages of care, although placements in Extra Care could be slow due to a lack of vacancies.

Hounslow were aware of the gaps in capacity to meet growing needs, these related to recruitment and retention of workforce, insufficient beds for adults with mental health needs including dementia, and increased need for Supported Living and Extra Care facilities. In response to this, three new Extra Care Schemes had opened to add more choice and independence for people. Other proposed developments such as an expansion of Shared Lives, and more Supported Living were being evaluated.

At the time of our assessment, 364 people were placed out of area, 225 of which in residential or nursing homes and 139 in Supported Living. Of these 174 had been set up in 2023. Of the 225 residential placements, 63 were for people with a learning disability or autistic people, 36 had mental health needs. The remainder were older adults requiring social support, physical support, or support with memory & cognition. Placements out of area, occurred due to a lack of capacity in borough, client needs and/or requests i.e. closer to family. Neighbouring London boroughs had block contracts with some of Hounslow’s care homes to meet the needs of their own people, which also absorbed some capacity.

The 139 out of area Supported Living placements were exclusively for people with a learning disability or autistic people (73), or people with mental health care and support needs (66). People were placed out of borough either through personal choice, availability of appropriate provisions (Forensic female only accommodation) or mitigating risk for the individual i.e. removing them from social networks. Some of these placements were much further away than over a borough boundary, which staff told us was because of prior working practices for example young people being sent to residential colleges out of area and settling there. To mitigate the risk of out of area placements for people with learning disabilities, a new Supported Living service for people with learning disabilities and autistic people was developed in Feltham in Hounslow, and more similar schemes were being considered.

The Commissioning team led a review of 131 out of area placements which were more than just beyond the borough boundary. Some people chose to remain out of area, but Hounslow were able to bring 35 people back to their home borough. They were working to increase options for younger people to remain in borough, rather than moving away for further education.

Hounslow told us people with mental health needs were split equally in or out of area. They had developed over 200 beds in the borough, so people were given the choice for where they would like to go, unless there were safety reasons for them to move out of area. They told us they developed new services for individuals or where a gap is identified.

The council made some specific provision for services to meet the needs of unpaid carers, but carers told us this was not adequate, and the council acknowledged this. There was a Short Breaks provision for short periods only (usually up to 3 hours), with a maximum standard offer of 20 hours per four weeks. Since August 2023 Hounslow had allocated one bed at each of two care homes for respite, and during 2023/24 they had made 15 respite placements. 33 further episodes of respite in nursing homes had been commissioned in this financial year. National data from the Survey of Adult Carers in England (SACE – published June 2022) showed that 10.75% of carers accessed support to allow them to take a break at short notice or in an emergency; 18.09% of carers accessed support or services allowing them to take a planned short break from caring of 1-24 hours and 9.68% of carers accessed support or services to allowing them to take a break longer than 24 hours These figures were all lower than the average for England.

The uptake of unpaid carers having replacement care for the person they care for, in both planned and unplanned situations was relatively low. It is therefore difficult to know whether there would be capacity if more people either wanted or needed respite on a planned or unplanned basis.

The local authority reported no hospital discharge delays were caused by lack of service availability/capacity. This was principally because they developed a bridging service in November 2023 to ensure people could be discharged safely home following physical health difficulties, pending more substantive care arrangements being put in place.

Some services such as the Community Recovery Service and the Care Home Support team were commissioned jointly with other agencies such as the NHS. In these instances, there were clear roles and accountabilities for monitoring the quality of the services being provided and the outcomes for the people using them.

The local authority had very clear arrangements to monitor the delivery of care and support services being commissioned for people Hounslow suspended contracts with homecare providers where they were rated less than good. Where quality or compliance issues were identified, contract managers had access to the PAMMS (Provider Assessment and Market Management Solution) tool to undertake audits. This was not used proactively, but in response to issues only. More systematic use of outcomes-based audit tools would support earlier identification of actions needed to improve care and support achievement of outcomes, rather than outputs. The majority of service providers in Hounslow are rated either good or outstanding by CQC;

There were 107 services in registered in Hounslow providing CQC Regulated Activity.

• Residential Homes: 15.79% rated Outstanding, 57.89% rated Good, 21.05% rated Requires Improvement.
• Nursing Homes: 9.09% rated Outstanding, 81.82% rated Good, 9.09% rated Requires Improvement.
• Homecare: 2.86% rated Outstanding, 52.86% rated Good, 18.57% rated Requires Improvement, 1.43% rated Inadequate. 24.29% have not yet been formally inspected and rated by CQC.
• Supported Living: 60% rated Good, 13.33% rated Requires Improvement. 26.67 have not yet been formally inspected and rated by CQC.

Hounslow told us they aimed to commission with providers who were rated at least good and intervene with providers if there were quality issues using their Care Home Support Team, and contract monitoring meetings to address issues. This no doubt contributed to people’s experiences. National data shows (Adult Social Care Survey) that 64.76% of people who use services were satisfied with their care and support and 71.94% of people who use services felt they have choice over services (neither metric was statistically different to the England average).

The local authority had quality monitoring systems in place to manage the care people experienced from providers, including surveys. Hounslow Council commissioned Healthwatch to do ‘Enter and View’ visits to registered providers in their footprint, either routinely or in response to concerns.

We heard very positive feedback from some people, about the services they or their loved ones used, for example one carer told us "I want to say they have been fabulous. They were "very happy with the placement.” "They are caring and look after (relative) well.". We also heard from some people who were not happy with the services provided to them, for example in relation to support to access the community.

The local authority imposed 4 suspensions across the 11 contracted homecare providers. 3 of these have been due to the suspension of the providers Visa Sponsored Status by the Home Office. All these providers were reinstated to the Visa Scheme and have since had their suspensions lifted. One provider was suspended for shortened call times, which had been monitored. This had been in place since September 2023, and was the only suspension due to performance concerns in the last 12 months. No homecare contracts had been handed back. This was the only framework contract the local authority had with providers, all other placements/relationships with providers are through Spot Purchases. Only one provider who was not on the framework chose to hand back all packages of care in the last 12 months and exit the borough. The local authority told us keeping an open dialogue with providers helped avoid crises or provider breakdown in most cases. They gave examples of where the local authority intervened with a provider due to safety concerns, but worked with the provider to give options about how this was addressed.

The local authority collaborated with care providers to ensure the cost of care is transparent and fair. They also consulted providers about the cost of care and met with each provider monthly. They told us “We use the funding calculator as a tool, but it is very subjective... We use our knowledge and use negotiations with providers. They met weekly with finance colleagues and took requests for uplifts seriously. These were carefully considered on a case-by-case basis. Staff told us they had “a collaborative relationship with providers and understand the challenges they face.”

5 Registered Care Providers (only 1 of which was commissioned by the council), out of 107 active Registered Providers, left the market in the last 12 months. The local authority noted that the decision to pay the London living wage was to support workforce stability to providers.

The local authority told us they worked closely with providers and stakeholders and a co-produced Care Home Forum, regarding fee rates and issues. They spoke of close management of provider contracts, oversight of challenges, and invested in support, such as additional capacity in a joint NHS/local authority Care Home Support team. Engagement and monitoring arrangements, including monthly contract meetings, enabled the local authority to get early warnings of potential service disruption or provider failure. Hounslow were able to give examples of action taken both to support providers, and to ensure safety of people who use their services.

Provider organisations spoke highly of their relationships with commissioners, although some domiciliary care agencies reported concerns about the inflexibilities of a call monitoring system which fed back directly to the local authority and was used to inform payments and contract monitoring. Some homecare providers told us they were paid by the minute above 30-minute calls, and their delivery was closely monitored.

Hounslow is the location for Heathrow Airport, which is the largest employer in the area. Partly in response to the workforce challenge this presented, Hounslow Council was a London Living Wage employer and commissioner. This meant all contracts commissioned by Hounslow stated that workers must be paid the London Living Wage, and the rate paid to the provider is on that basis. The most recent domiciliary care contracts issued by Hounslow explicitly stated that travel time between care calls should be considered as working time and paid accordingly. Commissioners told us that they encouraged providers to minimise travel distances/time for each member of staff through the call monitoring system, to ensure they didn’t effectively reduce the individual’s hourly pay.

The local authority understood its current and future social care workforce needs. It worked with care providers, including personal assistants and other agencies, to maintain and support capacity and capability and told us they were actively engaged in addressing workforce recruitment and retention.

Recruitment and retention in Adult Social Care was a challenge in Hounslow. At 16.11% Hounslow had above average levels of Adult Social Care job vacancies (all jobs, all sectors) (Skills for Care Workforce Estimates). To counter this, they were conducting an international recruitment campaign with partners in London Association of Directors of Adult Social Services London (ADASS). A significant number of homecare staff had been recruited through the UK Immigration Sponsor Scheme, and proposed changes to this may impact on recruitment and retention.

Hounslow had developed apprenticeships and development opportunities to increase staff skills and support progression to qualified roles, especially in social work and Occupational Therapy. They were also part of a London wide strategy delivered by (ADASS) to help with apprenticeships, professional networking to support best practice and tackling inequality in the London workforce for adult social care. This had similar priorities to Hounslow’s own strategy. As part of this, there were retail discount schemes, a London wide website promoting social care as a career, and support for people to access Social Care Academies.

Through this, Hounslow encouraged providers to support training for their staff, and data from Skills for Care Workforce estimates 61.49% ASC staff have completed, partially completed or are in progress with the care certificate (all jobs, all sectors).