County Durham: local authority assessment

The local authority worked with local people and stakeholders using available data to understand local needs for care and support. County Durham expanded their Joint Strategic Needs Assessment to include assets (JSNAA). This meant they were able to see their assessments of needs within the context of the strengths of their communities. Communities were seen as integral stakeholders to understanding specific needs. For example, the ageing well workstream of the health and wellbeing board expanded their work to people aged 50 and over to take a more preventative approach, with more focus on veterans, carers, and dementia. This activity tended to focus on public health than specifically for people using adult care services. Services used the information available to understand potential future needs for services.

The local authority made information available from their JSNAA through Durham Insight. This was an online tool that provided information through infographics to support people in the county to use and understand the key challenges identified. For example, life expectancy and healthy life expectancy was identified as significantly lower in County Durham than England for men and women, and more so in deprived areas of the county. The data was used to inform the health and wellbeing strategy and the approach to prevent, reduce, and delay need. Data was regularly updated and used to understand impact and performance in relation to long term public health intervention. Some information about communities who were more likely to experience poorer outcomes was identified, such as for deprived areas. This recognition did influence how services were designed and delivered, for example, where locality services were based in order to have most impact for people in the county. There was limited information that identified how people’s protected characteristics affected their experiences, though the local authority did identify some instances, such as domestic abuse, learning disability and mental health services in which this had taken place. However, this was not reflected in a specific focus on how people’s experiences were fully considered into outlined commissioning intentions, such as in the Market Position Statement.

The local authority worked with another organisation and linked this work with Durham County Carers Support. They had identified 48,000 carers in the county who required low level support and had developed a service to understand and deliver support. There were regular events in which carers were able to feedback and shape future care provision.

Commissioning teams maintained good relationships with frontline staff who felt they were able to feed into gaps in services and where there were local needs that the care market may be able to fill. Staff were not always sure how resolutions to gaps in services were progressing. Staff were not sure they would be able to source culturally competent care and that provision was fully able to meet people’s cultural needs.

People had access to a range of local support options across the county including for nursing, residential, supported living, extra care, and day opportunities. National data indicated that 67.48% of people felt they had choice over the services they used. This was in line with the England average of 69.81% (Adult Social Care Survey, published October 2023).

The local authority worked with health to jointly commission services for adults, children, and young people. The local authority’s Market Position Statement and Market Sustainability Plan highlighted joint priorities and approaches. This included being a key contributor to the development of the draft housing strategy principles and market position statement to ensure local alignment. For example, the local authority was able to demonstrate that their coordinated approach had supported people to remain at home with appropriate care and support in place. This had increased the age when people were being admitted to residential care due to this approach. This integrated approach also enabled services to plan for young people’s transition to adult services, supporting continuity and reducing families’ anxiety about transition. Services were able to view capacity, quality, and sustainability across a broad range of factors.

Where gaps were noted, commissioning strategies were developed. Staff predominantly liaised with providers and frontline services and used data to understand issues. People who used services were generally only involved in service changes at the point of contract reviews and were not actively involved in many early discussions about new provision. People had limited involvement in helping the local authority understand and shape the care market. Survey results from people who moved into care or nursing homes were collected and used to support developments. The local authority had recognised they needed to develop their approach to co-production, for example of the monitoring of quality and design of new or alternative provision. There were plans in place to further involve people with commissioning activity.

Commissioning strategies and market shaping activity supported prevention and delaying people’s need for care and support. They focused on developing recognised good practice and supporting the market to deliver person-centred care as a standard for the county. Commissioning approaches were integrated and maintained a focus on the objectives of partner agencies.

The local authority commissioned homecare mainly through their framework arrangements, as a shortlist of preferred providers. Spot purchasing from providers who were not on the framework was available. This approach supported people’s choice and control regarding their preferred provider or to support their needs.

There were delays in mental health service provision linked to mixed diagnosis of people or provider breakdown whey they felt they could no longer meet people’s needs. Commissioners were working together with a local health trust to source placements. There was a recognition that hospital environments were not effectively able to support people but a lack of providers willing to work with this group of people was affecting people’s experiences. People had less choice about their placement or were unable to live as independently as they wanted with appropriate care and support. The local authority recognised that their commissioning approach prioritised filling vacancies within existing provision and choice was supported where possible. The local authority was expanding their range of single person and dispersed properties at the time of our assessment.

The JSNAA had identified mental health and suicide as a significant challenge in County Durham. Approximately 1 in 5 people in County Durham have poor mental health and the suicide rate for people aged over 10 is significantly higher than the region and England averages. In response, the local authority developed the Durham Mental Wellbeing Alliance as a collective of voluntary, community and faith sector agencies and providers. They recognised issues regarding mental health and suicide and collaborated with commissioners to bring in a different way of commissioning that responded quickly to changing need, including through low need mental health and wellbeing in a preventative approach.

Developments were ongoing regarding supported living services, where gaps had been identified related to the availability of single person accommodation for people with mental health needs or people with a learning disability. There was an ongoing shift from shared housing to smaller bungalows or flats that supported this area in line with people’s preferences. Commissioning staff were exploring social rehabilitation models within this provision and identified that they had creativity within the design approach and budget arrangements to make this work for the future.

There was specific consideration for the provision of services to meet the needs of unpaid carers. Durham County Carers Support was commissioned to provide support services for carers in the county. National data indicated that 13.6% of carers were accessing support or services allowing them to take a break from caring at short notice or in an emergency, which was higher than the England average of 10.76% (Survey of Adult Carers in England, published June 2022). The same data indicated that 20.51% of carers were able to take a break from caring for more than 24 hours, which was better than the 13.56% England average. Carers, partner agencies, and frontline staff told us this was still an area that should grow, specifically where carers were supporting people with learning disabilities.

The local authority was aware of challenges related to bariatric care and had worked with providers to increase available beds and equipment. This was ongoing work, as equipment and adaptations were in place but not all providers felt care plans reflected the additional care workers required to support bariatric patients and it could be hard to ensure they were paid for this.

Information provided by County Durham indicated that they had no waiting lists for homecare provision or care homes. People had no delays in hospital discharge due to capacity issues within the market. There was sufficient capacity for intermediate care beds, which were effectively spread across the county to ensure people were able to remain local.

Staff groups and organisations told us that there was not sufficient respite provision in the county. This included bed-based provision and short term generally and specifically for people with a learning disability, partly linked to the temporary closure of internal provision for refurbishment. Access to mental health crisis beds and more general mental health provision was a key area staff felt needed more provision. Staff felt there was also a gap in provision of community services for older people and people with a learning disability. The local authority told us that they were developing future service delivery based on these issues.

There was minimal need for people to use services or support in places outside of their local area. When support was being accessed from outside of the area, this was predominantly due to personal choice or to be close to family. The local authority placed 38 people in the last 12 months outside of the area. Reviews for people placed outside of the area were robustly managed. Six monthly assurance updates were provided to Durham Safeguarding Adults Board concerning people with learning disabilities in out of area placements. All out of area placements had been reviewed. For those who were assessed as potentially having their needs met in County Durham, each person’s circumstances were monitored through a Provisions Development Group which met monthly. Plans were at various stages of development to identify opportunities in County Durham to meet individual needs.

The local authority’s joint commissioning arrangements were well established and integrated providing a county wide view of provision. Staff within commissioning carried out quality assurance and contract monitoring as part of their roles. The integrated commissioning structure had sufficient oversight of services across the county. There were sometimes challenges for voluntary, community and faith sector organisations who may be funded by other parts of the organisation or through arrangements outside of the integrated commissioning function with conflicting or challenging monitoring requirements. Organisations reflected that alignment here would support them to deliver services to people in the county. The local authority was aware of this and looking at ways to improve it through the County Durham Together Partnership working group.

The local authority had clear arrangements in place to monitor the quality of commissioned care and support services. Commissioning teams had oversight of quality and used a quality band assessment tool that was developed and adapted by the county council to the different provider sectors. The tool provides a robust and detailed scoring benchmark across 16 areas including nutrition, environment, medication, and risk. A threshold for further support was applied. According to our information on regulated services, 86% of care providers in the county are good or outstanding.

The practice improvement team worked closely with commissioners to identify patterns in safeguarding contacts and enquiries and support quality and practice improvement. There were links between safeguarding practice and overall quality improvement for a provider. The quality band assessment tool used by commissioning staff also covered safeguarding. Practice improvement staff were involved following an incident or pattern of incidents.

Internal teams communicated well regarding suspended providers. At the time of our assessment, 16 providers had been at one of the stages within the local authority’s executive strategy process that identified concerns around providers. In total 5 had been suspended throughout the year, with only 1 active at the time of our assessment. Themes included medication errors, safeguarding concerns, staff culture and environment. The local authority had a robust process in place to work with providers to improve. Managers and leaders recognised how changes in quality within the care sector could quickly affect other parts of the system and were well sighted on information.

The local authority had established a Supporting the Provider Market (STPM) team to collaborate with partners and providers to further improve quality of services and support market stability and sustainability. The STPM team supported social care providers with recruitment, retention, training, and development through the County Durham Care Academy and assisting providers with digital developments and opportunities and service improvement, including funding for technology initiatives, for example.

The local authority used the Market Sustainability and Improvement Fund to increase fee rates to social care providers and to increase the adult social care workforce. As the fund was not available for the integrated care and hospital funded provision, the local authority recognised a potential risk that the fee uplifts to part of the market only would destabilise system provision. Temporary workforce payments were released ahead of expected demand in the run up to winter 2023 to mitigate any market destabilisation. Fee rate uplifts were applied for all domiciliary care agencies commissioned through the integrated commissioning team to support continued operation and rurality payments were available to maintain the market.

The local authority proactively engaged with providers on their cost of care exercise to understand pressures and main areas of concern. For example, recognising a significant factor was increasing costs for building-based services, the Council agreed a revised model, in partnership with provider representatives to reflect these factors. This created a targeted and market specific approach to support providers to meet the challenges of rising costs. A similar approach was seen in homecare services. This enhanced uplift was seen as having significant impact on market stability.

The local authority worked with providers and stakeholders to understand current trading conditions and how providers were coping with them. Staff maintained good relationships with providers and provider forums were in place, tailored to the type of services commissioned, to support open discussion. Providers told us they felt listened to and the local authority was transparent.

Information from the local authority indicated at the time of our assessment that 7 providers were either decommissioned or handed back contracts over the previous 12-month period, affecting around 80 people, across nursing, residential care, day care for older people and people with a learning disability or mental health needs, supported living and home care. Predominantly reasons for closure were financial viability and leaseholder changes, but recruitment of nursing staff was also a factor. In this case, the residential care home side of the provider remained open, and the local authority worked with the provider to reassess each residents needs to ensure appropriate provision. There was a good understanding of the factors that cause provider failure, as evidenced by market sustainability plans and the cost of care exercises. Providers and commissioners described good working relationships, alongside the quality band assessment tool that allowed them to manage and share any risks.

Recruitment and retention of staff within the local authority was seen as a key concern for partner organisations and they did not feel they knew about any actions and further developments in relation to this. The local authority recognised workforce risks, particularly in meeting increasing demands for services within existing budgets. The strategy set out induction, learning and apprenticeships as mitigating factors. Many of the staff we spoke to had worked at the local authority for a long time and retention was generally seen as good. It was seen as positive that the mental health team had been fully staffed when this had previously been a challenge.

The recruitment of Personal Assistants was described as challenging and a possibly contributing factor to the low take-up of Direct Payments in the area. We were unaware of any plans that supported the increase of the number of Personal Assistants in the area and they were not included in the existing local authority workforce development strategy. The local authority told us they planned to include Personal Assistants in their Commissioning Workforce Development Strategy that was in development at the time of our assessment.

The local authority used its quality band assessment to ensure care sector staff were working in safe environments and with appropriate working conditions. An inflationary uplift to the local authority’s hourly rate was provided to domiciliary care providers to ensure a minimum pay rate above the national living wage and to support retention and recruitment. A requirement to pay staff travel time was not covered in their quality band assessment tool and the local authority chose not to monitor this in any other way. Local authorities have a duty under the Care Act 2014 to foster a workforce whose members are able to ensure the delivery of high-quality services (because, for example, they have relevant skills and appropriate working conditions). The local authority felt that their contractual terms were sufficient to ensure this was the case.

The local authority had developed the Care Academy as a local solution to challenges with recruitment in the sector. This included the development and delivery of training courses from entry level through to management qualifications. The service recognised gaps in terms of care workers being unable to drive, that affected provision in more rural areas of the county. The Care Academy supported individuals to complete their driving tests and reduce the impact of this issue across the county and ensure more people in rural areas were supported. The local authority told us that the work through their Care Academy was instrumental in removing any waiting lists for homecare and that the Care Academy had supported the recruitment of over 100 care workers in the county in the last 2 years. This is reflected in improving national data, where 56.03% of sector staff had completed or were in progress of completing the care certificate, which was better than the England average of 49.65% (Skills for Care, published October 2023). The area had a lower job vacancy rate in the sector of 8.4% compared to the 9.74% England average (Skills for Care, published October 2023). The local authority felt the Care Academy was integral to the quality and sustainability of the care market which was an important factor in people’s experience of care and support in the county.