London Borough of Hillingdon: 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 communities. This included people who were 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.

The local authority had collected data about demographics, health conditions and mortality rates, and the impact of behaviour on health in their Joint Strategic Needs Assessment (JSNA). They also reported on the wider determinants of health and wellbeing, such as deprivation, employment and housing or homelessness.

Understanding of these contributing factors was evident in the initiatives the local authority put in place, either singly or more often in partnership with health and other partners, such as work to support people to access benefits, to cope in cold weather when experiencing fuel poverty, and to intervene in the housing market to increase the availability of affordable homes. The local authority demonstrated it understood these measures contributed to wellbeing, and to reduce, delay or prevent the need for care and support, for example in response to people with mental health needs.

Staff and partners in the voluntary, community and social enterprise sector VCSE told us they worked closely to identify and respond to the needs of community. Local authority staff told us they were forming much closer relationships by commissioning directly. They were co-producing a specification with the VCSE and had also talked to people at different events about what matters to them - being safe, independent, in control of their lives, and what their best life looked like. A provider also noted the local authority were very focused on local partnerships. They gave an example where the local authority had contacted them about available space for a café for one of their outreach partners, in the ground of their property. Due to the good working relationship between the provider and the local authority, the space was utilised for a café, providing a drop-in service, advice and support to individuals with mental health needs.

People had access to a diverse range of local support options which were safe, effective, affordable and high-quality to meet their care and support needs. There was no strategic commissioning function for adult social care. The corporate procurement team were responsible for identifying and understanding the impact of changes in the social care market, and for market shaping. There was no specific focus however on the market for people with more complex needs such as learning disabilities and communication and behavioural support need.

The local authority had a framework for domiciliary care. There were 2 lead providers, one each for the North and South areas of the borough, and 8 smaller contracts on a framework. Lead providers were expected to take 70% of referrals. We heard this had worked well to date, and there was a constructive relationship between partners which meant the provider could say no if they did not have capacity. We heard there were always conversations around numbers, and the local authority worked with them to understand capacity challenges.

Staff in the local authority felt it was better to have fewer providers as it was easier to manage contracts and assure quality. With closer relationships, they could reduce the risk of unexpected provider failure. They felt having a smaller framework also gave resilience, as those on the framework were more likely to be offered work more often.

Whilst the lead provider and smaller framework potentially limited choice, people could express a preference and if appropriate use direct payments to pay the agency of their choice. National data (ASCS Oct 2023) showed 67.74 % of people who used services in Hillingdon felt they had choice over services which was consistent with the England average of 69.81%.

Commissioners had moved from grant funding of the multiple organisations in the voluntary and community (VCS) sector to commissioning fewer, longer, large contracts. There were 10 larger VCS organisations commissioned. A VCS organisation told us however they were given a significant period to seek alternative funding, which they appreciated.   

Staff understood flexibility needed to be built into longer contracts, so providers could respond as people’s needs changed. They felt they had become more person-centred, and outcome focused in their commissioning approach.

Commissioning strategies were aligned with the strategic objectives of partner agencies, across the local area. The local authority commissioned a “Bridging Care” service to ensure patients who were medically fit for discharge, and only needed a simple home care package, could go home the same day.

The local authority considered specific services to meet the needs of unpaid carers. Local carers described the carers support service, commissioned by the local authority as “gold standard”. This provided a sitting service and many other support services. Carers could access bed-based respite via a Care Act Assessment completed by the local authority. Carers in Hillingdon fared better than the average across England in terms of respite. SACE data (March 2024) showed 21.82% of carers surveyed in Hillingdon reported accessing support or services which allowed them to take a break from caring at short notice or in an emergency. This was almost twice the England average of 12.08% Similarly, 33.93 % of carers in Hillingdon accessed support or services to take a break from caring for >24hrs which was significantly better than the England average of 16.14%. Almost a third of carers (32.73%) said they had accessed support or services to take a break from caring for 1-24hrs. Whilst better than the England average, this was still at best 1 in 3 of carers who were able to access support as and when they needed it to take a break from caring, and the data also showed only 1 in 8 carers had time to do things they enjoyed.

The local authority commissioned a range of models of care to reflect the breadth of needs and preferences in the community in line with recognised best practice. They commissioned extensively in models which supported independence, and the least restrictive option for people – such as extra care and supported living. They were commissioning additional supported living accommodation, which was suitable for people with more complex needs, with staffing skilled in positive behavioural support.

Staff told us they were intending to increase their shared lives scheme where a person lives with a family in their own home and is cared for by them.  Staff told us they currently had limited capacity in shared lives due to staffing.

Staff supported new and innovative approaches to care provision, where this led to better outcomes for people. The local authority was shown a flexible, homecare service provided in another borough to support people with mental health needs in the short term after they were discharged from hospital. Staff welcomed the information and commissioned it in Hillingdon. Feedback from frontline staff was that the model was working very well. We were also told of an example where a person with complex needs was supported to stay in their family home, with a package of support. This was jointly funded through health and direct payments. The local authority also worked with partners to make the most effective use of resources and facilitated connections between different stakeholders.

The local authority commissioned for outcomes with both the VSC sector, and for independent providers of domiciliary and residential care. The VSC sector were commissioned for outcomes such as connecting people, addressing fuel poverty and wellbeing. Providers told us case studies to understand outcomes formed part of the contract monitoring process. The reablement service was measured against the number of people who achieved their personal reablement goal.

The local authority had the second highest number of care home beds in North-West London. There were 44 care homes in Hillingdon, 60 domiciliary care agencies and 50 supported living providers which is a high number compared to other local authorities. There was not always however sufficient care and support available to meet demand in borough. This was because of the numbers of people from inner London Boroughs placed in these homes due to lower unit costs, capacity was purchased by the integrated care board and the number of people who were self-funders. Most people could access the service they needed when and how but not always where they needed it.

Of the current 44 active homes 26 were residential and nursing care homes for older adults and 18 were working age residential care homes, focused on mental health needs or people with learning disabilities. The care home market was at 96% occupancy. The local authority’s Market Sustainability Plan exercise identified demand for an additional 20 beds for nursing & nursing dementia.  Staff told us they had a strategy for bed-based services and community services. There were no delays in securing domiciliary care packages. The local authority had invested in extra care provision, and there were 243 apartments to which the local authority had exclusive nomination rights. We were told there were no waiting lists for extra care, although we had also heard there was a lack of suitable supported living for people with more complex needs. Staff reported an extreme example where one person waited 5 years in a care home.

Based on the SACE data cited above, the capacity for unpaid carers to have access to replacement care for the person they cared for, in both planned and unplanned situations was better than in other places, but still only met the needs of a proportion of carers. 

There were some gaps in the availability of residential care for people with more complex needs, such as dual diagnosis of learning disabilities and mental health needs in the borough. People with these needs, or with complex behavioural/communication needs resulting from dementia, were more likely to be placed out of borough. The local authority was aware of this issue and had plans for specialist care home capacity including dementia nursing care. They were also working on a proposal to develop a short-term provision to meet the accommodation-based needs of people with dementia.

The Market Position statement 2024-27 for the local authority specified there were no plans to increase the supply of supported living accommodation in self-contained flats, despite acknowledging an apparent mismatch between demand and supply. Between March 2023 and February 2024 51% of placements were made out of borough, some of which were based on supply rather than complexity of need or other requirement. The local authority told us updated data analysis shows that now only 26% of supported living placements for people with learning disabilities are being made out of borough. There was an expressed intention to collaborate with people who use services, their families, providers and NHS partners in 2025/26 to develop a supported housing strategy, in accordance with national requirements.

Staff told us there was reasonable capacity in the domiciliary care market, and there were no delays to hospital discharge for people who needed domiciliary care or reablement. Where a person needed a non-complex residential or nursing placement staff told us placements happened very quickly, and always placed people within the borough unless people actively wanted to move out of borough.

The local authority told us 418 people were currently placed in out of area placements, of which 111 had occurred since March 2023. Of these 164 were long term placements markedly further away than a neighbouring borough, and 41 were supported living placements for people aged 18-64 outside the London area. The local authority said for the majority, it was personal choice, for legal reasons or safety. There were occasions where urgent out of borough placements were needed to ensure people’s care and support needs were met in a timely fashion.  Being placed out of area when it wasn’t personal choice, meant that people were further away from their families, friends and communities.

Staff told us they had a strong relationship with the Care Home Support Service which was managed by primary care and health partners.  The local authority’s quality assurance team met monthly with a care home matron which all care homes had access to. They helped avoid hospital admissions through a range of support to the care homes including falls prevention, hydration and nutrition.

The local authority had clear arrangements to monitor the quality and impact of care and support services being commissioned for people, and supported improvements where needed. Staff told us the Quality Assurance team did in-person monitoring visits, shared intelligence with other local authorities and where appropriate liaised with the CQC. If the host authority of an out of borough home identified concerns, a Hillingdon social worker would attend to review people’s needs.

Providers told us the monitoring and evaluation of services were conducted through the quality and monitoring service using both announced and unannounced visits and examining the people’s journey. One provider told us the contracts and monitoring team referred to both qualitive and quantitative data, such as the achievement of outcomes for people, and how satisfied they were with their care as well as timekeeping and lengths of visits. This demonstrated that the local authority were concerned about the quality of care.

There was a provider risk panel which met monthly, and the local authority had recently invested in a risk scoring tool to support this. The panel considered any concerns arising from reviews, quality assurance visits, safeguarding, complaints or anything else. This would include intelligence from another local authority, or where a problematic pattern had been noted. These were discussed at the panel and recommendations made to the Care Governance board about the measures which should be taken regarding the provider.

Staff provided an example whereby they had worked with a provider under the concerns process, to uphold the standard of care required.  The local authority sought improvements in their supported living service. The provider also ran a residential care home, but this was not implicated in the concerns. After a period of discussion and support from the local authority, the provider decided to leave the market completely in Hillingdon citing operational and financial pressures. The local authority brought the supported living service for 4 people under their control, so that care for those people was not disrupted. 

The only other provider who handed back their contract in the last 12 months, was a homecare and outreach framework provider, who gave notice on cost / affordability grounds.

Other evidence of the operation of the local authority’s robust approach to quality is seen in the following data. In the last 12 months, they had suspended new referrals to 4 providers on the Provider Concern list for a period. These included the Care Provider referred to above, 2 Supported Living Providers, and a Day Care service. There were also 7 care provisions within the borough footprint placed on a ‘Do Not Place’ embargo due to quality concerns and issues.

Staff told us they would not issue a contract to any provider rated less than good by CQC. If they were a new and not yet inspected provider, they would be prioritised for an assessment by the Quality Assurance team and intelligence would be gathered from other local authorities, who might be aware of them. Being as yet unrated would trigger more due diligence. Where a provider subsequently received a rating lower than good, this would trigger the local authority to work with the provider to support them to address concerns.

Care home ratings by CQC in Hillingdon were slightly better than the England average, with 82.14% of residential homes rated Good, 14.29% rated Requires Improvement and 3.57% are rated inadequate. 82.35% of nursing homes were rated Good, 17.65% were rated requires Improvement.

Ratings for supported living providers in Hillingdon were lower than the England average with 46.72% (compared to 63.79%) rated Good, 23.81% (compared to 10.24%) rated requires improvement, and 28.57% currently have no overall rating, which is higher than the England average.

58.57% of homecare providers in Hillingdon were rated Good, 10% were rated requires improvement and 31.43% currently have no overall rating. This is similar to the England averages.

Staff told us the quality assurance team would also go to services they did not directly contract with, and all providers were invited to the providers forum. The local authority invited speakers and offered training for providers. We were told the local authority worked with Skills for Care to facilitate a quarterly registered managers’ network which was open to all providers in Hillingdon. Meetings were in person rather than held virtually, because they had feedback this was providers’ preference, and they had good attendance.

Providers we heard from were very positive about the way in which the local authority worked with them. One provider said the local authority played a vital role in empowering them to deliver high quality services to meet the needs of vulnerable people. We also heard the local authority acted as a supportive intermediary with health and other partners on behalf of their contracted providers. 

The local authority collaborated with care providers to ensure the cost of care was transparent and fair. There was a framework rate for different provisions set by an external organisation, but only 20 care homes were on this framework and due to demand the local authority often paid significantly above these rates. The supplier relationship team worked with corporate procurement, safeguarding and quality assurance teams and had a quarterly two-way meeting with domiciliary care, residential and nursing homes, and supported living providers to share information and address issues or concerns.

The local authority recognised longer contracts of up to eight years, gave providers financial stability and allow for longer-term planning, which in turn helped secure better service quality for residents.  To ensure contracts remain appropriate and effective, they built in scrutiny within this time and the opportunity to consider whether both parties wanted to continue. This was articulated in the local authority’s Market Position Statement and was the default approach unless there was a good reason not to.

Staff told us they had worked with providers and analysts employed at a NWL regional level to look at care home fees. We heard providers put in requests for uplifts, which were considered under the uplift procedure. The local authority had discussions with them based on submitted business plans and individual need.  Providers confirmed it was possible to have discussions and negotiations about rates, and there was room for negotiation, but it was usually about meeting an individual’s needs, rather than generic uplifts. Providers acknowledged the local authority might not always agree to their requests, but listened, was responsive and supportive, and made and communicated decisions in a timely manner.   

One provider told us 95% their invoices were paid within 5 working days, and disputes were responded to and dealt with in a timely way.

The local authority collaborated with the North-West London Alliance (NWLA) about providers who worked across the region. NWLA engaged with large private care home providers to talk about the costs process and Hillingdon used the information to inform their costings. Staff told us they felt it helped to know what other local authorities were paying.

Staff said they incorporated what providers said about their wages when they set the fees framework. The provider’s annual contract monitoring review included consideration of the annual level of pay, and quality assurance monitoring looked at how staff were paid. Providers weren’t contractually obliged to pay the London Living Wage, but the local authority expected them to pay the National Living Wage and for homecare providers to pay travel time between appointments. Providers confirmed this was their experience.

Staff said sponsorship licences had been a big issue in the provider concerns process and there had been several licence suspensions. When the local authority was notified about a suspension, they reviewed the service and talked to the provider about contingency plans in case the licence was not reinstated. They worked closely with other local authorities to support each other if a provider in their footprint was impacted. Most of the providers commissioned by the local authority were not involved, but across the wider domiciliary care market, there was 16% of international recruitment. The local authority collated data about all providers who were part of the scheme to conduct a risk assessment and had suggested they formally address this collectively at the wider NWLA. When a provider’s licence was revoked the local authority helped workers to secure other employment if needed. Providers also reflected when they had been affected, the local authority had supported them to provide the information they needed for assurance, whilst being patient and understanding.

Providers told us the partnership approach the local authority took with them resulted in improved outcomes for individuals. They said they had demonstrated their commitment to supporting care businesses by streamlining communication channels, providing access to resources and information relevant to their industry, and offering guidance on best practices in care provision.  They told us this continuity fostered effective partnership working and facilitated co-production and co-creation. While there was always room for improvement, the local authority consistently worked towards addressing areas of concern identified by the providers.

Engagement and monitoring arrangements enabled the local authority to get early warnings of potential service disruption or provider failure. Providers were expected to have contingency plans, and the local authority was confident and could demonstrate most departures from the market were planned and managed, although occasionally individuals might be impacted by a short notice move. The local authority had a good understanding of current trading conditions and how providers were coping with them.

Staff understood the risks in the health and care sector market. They acknowledged competition from Heathrow meant providers had to pay more. The data about the adult social care workforce in Hillingdon showed mixed results compared to other places.  According to the Adult Social Care Workforce Estimates (ASC-WE Oct 23), the sickness absence rate in Hillingdon was 4.11 days which was slightly better than the England average of 6.24 days, and the rate of turnover in adult social care (all jobs, all sectors) in Hillingdon was 0.15 which was significantly lower than the England average of 0.29. However, staff vacancy rates in Hillingdon were 14.89% - significantly higher than the England average of 9.74%.

Staff noted the workforce was ageing which meant people would potentially retire, leaving a shortfall. A new workforce strategy had just been published. They also recognised the age of care homes was an issue, for example being built to an earlier standard, so not all rooms had ensuite facilities. This was something individual providers needed to address but the local authority recognised it was a challenge in the medium and the long term for the market.

A provider told us the local authority had actively supported them by providing training opportunities for staff such as diabetes awareness, safeguarding adults, and a North -West London medication event through Skills for Care. The percentage of ASC staff with a care certificate in progress or partially completed, or completed in Hillingdon was 58.48% as compared to an England average of 49.65% which was tending towards a positive variation (ASC-WE, October 2023).