West Berkshire Council: local authority assessment

The local authority worked with public health to create a digital tool from the Joint Strategic Needs analysis data to understand the demographic and other factors impacting on people’s health and wellbeing in West Berkshire. This included people who were most likely to experience poor care and outcomes as a result of one or more protected characteristics. The data was used to inform the health and wellbeing strategy and the approach to prevent, reduce and delay needs for care, as well to inform the Adult Social Care Strategy. West Berkshire is a relatively healthy and prosperous place to live with an index of multiple deprivation of 1 which is the lowest score. However, the local authority noted within the largely affluent area, there are areas of deprivation and health inequalities. In particular, they noted a digital divide resulting in inequalities in access to opportunities, knowledge, services, and information. This particularly impacted older people over 75 and disabled adults. There was very little strategic assessment of need in relation to some of the seldom heard groups such as the migrant populations and ethnic minority groups as these were small populations below the level of analysis of the demographic data.

People had access to a range of local support options in West Berkshire. The available services were safe, effective, and generally high-quality with CQC ratings above the regional average. In a survey of Adult Care in England 71% of people who use services felt they had choice over services. However, staff and leaders told us there were limited available spaces within residential care which meant people sometimes were placed out of the area. For most people this was still within their local area, just over the border in a neighbouring authority but 30% of those people placed outside the West Berkshire border had to travel further, particularly if they had complex needs. This represented 13% of the total number of people in nursing or residential placements. The local authority was also facing issues in relation to adverse outcomes in relation to decisions for Continuing Health Care funding that impacted people with more complex nursing needs.

The local authority was in the process of updating their market sustainability plan. While the local authority was aware of where there were gaps and pressures in services, market shaping by commissioning was responsive to demand, rather than proactively shaping the market to anticipate and manage future needs within budgets. The commissioning team sat outside of adult social care and therefore were responsible for commissioning across the local authority. While the commissioning team worked closely with adult social care in the provision of care, it was not apparent how they were taking a more strategic approach to deliver on the adult social care strategy.

There was little evidence of working with partner agencies to consider the data in relation to the population and needs for care now and in the future as a basis for actively shaping the care market. There was a recognition that there was a need for more services to support independence as numbers of people with complex needs wanting to stay in their own homes increased, but this was a response to current demand, rather than a proactive consideration of the data for a plan now and over the next 5 – 10 years. They were working to adapt the market for example, by working with providers to repurpose and adapt buildings in communities or change models of care to meet people needs. They had recently opened 3 new Extra Care services but recognised that there was a need for more as the population aged.

The local authority had considered provision for unpaid carers. They had worked with the carers partnership and voluntary organisations in producing their carers strategy. They had a focus on improving the identification of carers to enable them to access support and wanted to improve the availability of support to improve the health and wellbeing of carers as well as the provision of respite support to enable carers to take breaks. They provided voluntary sector grant funding for the provision of services for unpaid carers and a separate voluntary organisation had been identified to support young carers. However, the feedback from the voluntary organisations was that they didn’t feel there was ongoing involvement and use of their experience to understand needs and develop services.

The local authority commissioned care based on outcomes rather than tasks. Contracts with providers focussed on person centred care, involvement of people in their care plans, and supporting social inclusion and wellbeing. However, these were largely delivered through traditional models of care such as care homes, nursing homes and home care. The local authority acknowledged a need to innovate and develop new models of care supporting independence and person-centred approaches such as Extra Care and more supported living.

There was not always sufficient care and support available to meet demand. There were very few vacancies in residential care. There were not always suitable services available for people with a learning disability and autistic people, especially when people had complex and multiple needs such as physical disabilities requiring adapted environments. Similarly, there was a lack of services for people requiring complex dementia care. The demand for these types of services was increasing as people aged. This issue was compounded because the cost of care in West Berkshire was high. The local authority had a flexible approach to funding care placements which allowed them to be responsive to local market rates. Decisions about care placements were based on value for money, quality of care and people’s choice. However, staff told us often cost was a driver and where people had complex needs this often resulted in out of area placements. People did not have to wait for services to start. Where there was not provision in West Berkshire there was close working with neighbouring authorities and people could be placed out of the local authority area, but close to the border and therefore close to home. For those with complex needs it was more likely the placement would be out of the area but also at a distance from their home. Of the 218 people placed outside the border of West Berkshire, 70% were local to the geographical boundary. There was a recognition along with public health that there was a need to integrate plans for housing and plans for social care investment, to improve provision within West Berkshire. However, progress was slow, with barriers because of the local costs of housing and poor relationships with planning. The local authority was starting to address this and building relationships with planning to plan for the future development of services. Further work was needed with partners to work toward joint commissioning, this included ongoing work with the integrated care board in relation to Continuing Health Care funding.

The local authority had worked effectively with the local care market to build the workforce in the home care sector, supporting with sponsorship, recruitment, and training. As a result, there were no longer delays for home care or in discharging people from hospital. Staff said there was good access to intermediate care beds for hospital discharge and if they weren’t available there was an easy spot purchase system they could use.

Carers feedback indicated there was sufficient capacity for unpaid carers to have access to replacement care for the person they cared for in both planned and unplanned situations. In the survey of adult carers in England, 18% of carers reported accessing support or services allowing them to take a break from caring for more than 24 hours, which is slightly above the England average of 14%. We had feedback from organisations working with carers that carers told them the support was positive, and carers felt they could access support and respite when needed. Other support for unpaid carers included provision of information and support, social groups including a dementia café providing support for people caring for someone with dementia, respite breaks and help with transport for health appointments.

The local authority had a care quality team placed within commissioning that monitored the quality and impact of care and support services being commissioned. Resources within this team meant they could not always be proactive in the way they monitored services across the local authority. However, West Berkshire had the second highest number of services rated good in the region with 88% of residential care and 73% of homecare rated good or outstanding. 62% of home care was rated good or outstanding and 69% of supported living services. 1% of nursing homes, 1.5% of care homes and less than 1% of home care and supported living services were rated inadequate. The local authority worked closely with partners in neighbouring local authorities in Berkshire West to share intelligence about any concerns relating to services. Services were requested to complete an annual self-assessment survey on the quality of care they provided, but most of the time this did not include an onsite review by the care quality team, unless there were specific concerns raised about a service. When concerns were identified, the local authority worked with providers to produce an action plan to bring about the necessary improvement, but again resources limited the amount of support it was possible to give to individual providers. In the past year the local authority had one service where they had used their ‘place with caution’ protocol due to poor care. This was a relatively new policy under which the local authority would place people in services rated requires improvement and was implemented to open the market to more affordable care. Staff told us this was used where they knew of improvement in a service since it was rated requires improvement. Prior to placing someone in such a service the protocol required them to assure themselves of the quality of care based on the work they had been doing with the service to improve.

The local authority collaborated with care providers to ensure the cost of care was transparent and fair. There was a flexible approach to paying for care which allowed the local authority to adjust for the market rate. However, the high costs of care in West Berkshire did impact on the ability of the local authority to place people locally. Providers described their relationship with the local authority as collaborative. They were given opportunities to discuss issues and concerns and the local authority had supported with issues such as recruitment. They said the local authority was aware of the market and the barriers providers faced, and they felt the local authority had confidence in providers.

In the past year there was one embargo placed on a service that had now closed. The local authority had systems in place in case of provider failure and poor services. However, resources were limited to enable their own proactive monitoring to anticipate provider failure and service disruption, so they were reliant on intelligence from partner local authorities and provider self-assessment. Due to the resource levels in the team if there was a failing service this took away resources from the general monitoring of quality across all providers. However, the good quality of care across the authority meant that this was not a frequent event.

The local authority had an awareness of workforce pressures. They had recently supported providers in developing the homecare workforce to successfully meet demand, where there had been delays in being able to access care for people in their own home. However, there was less evidence of proactive work to foresee pressures in the market and develop a workforce to support future market shaping and new models of care.

Their contractual arrangements placed expectations on providers in relation to the training and development of staff. Providers were able to access training through the local authority. The local authority had an expectation of standards for working conditions including payment of the living wage, sick pay, and travel time for home care staff in provider services. They told us they advised providers through forums about their expectations and also include sources of support for safer recruitment practices and training etc. However, they told us they had limited capacity for proactive monitoring of the terms and conditions for carers employed by providers. Wherever they were made aware of concerns, they linked with relevant partners and colleagues such as Home Office, His Majesty’s Revenue and Customs etc.