Northumberland County Council: local authority assessment
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Care provision, integration and continuity
Score: 3
3 - Evidence shows a good standard
What people expect
I have care and support that is coordinated, and everyone works well together and with me.
The local authority commitment
We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.
Key findings for this quality statement
Northumberland had a good understanding of the local needs for care and support, used data insight, and worked with academic partners to understand its current and future needs in relation to preventing, reducing and delaying the need for services; the delivery of services; and effective commissioning both currently, and in the future. The local authority has a Joint Strategic Needs Assessment which gave insight into the current and future health and social care needs of the people in Northumberland, providing an understanding of the population statistics, including demographic information and levels of poor health and deprivation. The view was shared across external partners which supported and facilitated joint person-centred working in the county.
The Place Standard Tool developed by the Scottish Government involves a community conversation. It had been used in 4 areas in Northumberland to understand and provide the evidence of what people wanted in their communities. Using a targeted approach to ensure it is inclusive, the tool asks a range of questions about how people feel, whether there is a sense of belonging, and what their experiences are of the built environment. The next step is to plan how to meet those needs.
As a Marmot local authority, tackling inequalities was a key feature of Northumberland’s overall strategic plan, and the ambitions of adult social care were closely aligned to this objective. Challenges included an ageing population, digital inequality, dementia, poor transport links, the shortage of social care staff, a shortfall in qualified nurses, the rurality of the county, housing, and financial constraints. Service and commissioning plans and practices were in place to address and support with most of these challenges. The adult social care plan ‘Next steps for adult social care in Northumberland 2024 – 2027’ was a position statement describing what senior leaders saw as the main issues they need to address and says what they are doing to address them.
The corporate perspective and insights of the community were consistently understood and applied within adult social care, enabling the service to leverage the shared understanding of the needs of the community to be met in the delivery of wider statutory services. For example, the Chair of Health and Wellbeing Board identified the challenges of the ageing population and increasing levels of people living with dementia, housing, social isolation and deprivation. The housing function highlighted there was a lot more cross service communication, engagement, and mutual involvement needed in schemes and planned to meet current challenges in strategic housing, for permanent and temporary housing. There was increasing complexity in people’s presentation and in finding the right, safe accommodation for people in the county. The need for community resources to support populations, particularly in rural areas and the need to work in partnership with the VCS, was shared across partners. The local authority was also able to forecast issues with the increasing ageing population due to younger people moving to rural area.
Providers told us delayed discharges were an issue, but many areas had proactive plans in place to address these, such as providing staff and drivers at very short notice. There was an emergency care hospital (Northumbria Specialist Emergency Care Hospital - NSECH) which had a rapid response team who also improved the discharge process. However, this rapid response service ended after 12 months due to a lack of funding.
Northumberland had a commissioning plan, which set out its intentions in response to emerging needs, and clearly highlighted where there was sufficient service provision, taking into account issues such as geographical limitations when highlighting need. The ASCS 2023/24noted 78.81% of people who used services felt they had choice over services, higher than the England average of 70.28%.
The local authority had commissioning plans in place for 2023-2024 which split down into different service provisions. This included, older persons care homes, homecare, specialist accommodation for people with mental health conditions, people with learning disabilities and autistic people, day services, and direct payments/personal assistants.
However, there were areas identified for development, and others, which did not always meet the needs of people who had care and support needs or their unpaid carers. Feedback from carers told us only half of those we spoke with knew about the Carers Forum. The SACE 2023/24 noted 12.33% of carers were accessing support or services allowing them to take a break from caring at short notice or in an emergency, although there was no variation compared to the England average and indicates that 87.67% of carers were not accessing care allowing them to take a break at short notice. The same survey found 25.69% of carers were accessing support or services which allowed them to take a break from caring for 1-24hrs and 20% of carers accessed support or services which allowed them to take a break from caring for longer than 24hrs. Both figures broadly reflect the national average.
The local authority and its partners recognised in Northumberland's changing population, people's needs and conditions, employment, transport, and access to services were all impacted by the county’s rurality and had aligned their strategies to address the challenges presented by recent and future change. For example, CNTW, the acute mental health trust, and the local authority were aware of the lack of housing capacity and accommodation demand to enable people to be discharged safely and supported in the community. Access to housing as a barrier to care and support was also noted by the DASS. Steps had been taken in areas such as housing, where they had undertaken a strategic property asset management (SPAM) review to look at opportunities to develop affordable housing and supported accommodation. The Targeted Accommodation Programme (TAP) Board had ensured the inclusion of the development of several potential extra care, supported living, and learning disability and/or mental health accommodation plans in line with the local authority's strategy.
We also heard that age-appropriate services, giving opportunities for people to develop and sustain their social life outside of services, was an area of development with providers working in partnership with training and educational organisations. People being given support to be part of local communities, flexible support for evenings and weekends, and activity-based services for people with a learning disability and/or mental health needs was also a gap in provision. While it was outlined the local authority wanted to address these areas, working through community hubs and alongside providers, there was not a clear commissioning plan around this.
The commissioning plan also noted behaviours which challenged services, and dementia placements were areas where more provision was needed in Northumberland. This aligned with needs assessments recognising the rise in numbers of people living longer with dementia, and the complexity in responding to the needs of people needing specialist care and support. For example, frontline teams noted inequities in dementia nursing home placements. If people had behaviours which challenged services, it was more difficult to find appropriate placements and the local authority often had to seek an out of county option, posing significant challenges for the individual and their relatives.
The gaps in provision were recognised operationally and politically and were made more challenging by the geography of the county and the variation in deprivation. The carers organisation commissioned by the local authority stated they were now at capacity and would need to think about how they could fulfil their duties and continue to support carers in the future. However, the local authority evidenced the steps it was taking to shape the market to meet current and future needs in areas such as age appropriate services and flexible support for evening and weekends for people with learning disabilities.
Northumberland demonstrated how they worked to ensure there was sufficient capacity to meet the care and support needs of the people of the county. Data submitted by the local authority stated there was no waiting time for residential or nursing care as of February 2024 and aligned with the commissioning plan which highlighted no gaps in the current level of provision but contradicted operational experience.
There were 22 supported living providers in the area across 3 levels of complex need. The highest level, which included autistic people, people with complex learning disabilities, and people with emotionally unstable personality disorders, was an area in need of development. These placements were most likely to be out of area.
Data provided by the local authority showed 272 people were placed out of the area of Northumberland. 84 of those placements were made within the last 12 months. The majority of the placements were due to the requirement of specialist services such as mental health, learning disability, dementia, physical disability and brain injuries. Mental health specialist services made up almost a third of all out of area placements. Plans were in place to address these challenges in the local authority's strategy for extra care and independent supported living services.
Homecare packages were impacted by where people lived. As of 17 November 2023, 73 people were waiting for a homecare package (either a full care package or an increase). On 23 February 2024, 59 people were waiting for homecare. 24 of these people were in receipt of a care package which met their assessed needs, but they were supported by a provider outside of the local authority's normal contracting arrangements. Although the waiting time to start homecare had reduced, there was a variation in the length of wait, depending on which part of the county a person lived in, with greater waits in the more rural north. By the time of our assessment, the number of people waiting for homecare had continued to decline, and we were told by the DASS actions taken to ensure people could access homecare in a timely manner, such as workforce availability, had been successfully implemented. Outstanding packages of care were monitored and managed by the brokerage team, who retained oversight of the waiting list on a tracker.
The rural nature of significant parts of Northumberland was consistently cited by leaders, staff and providers as impacting on enabling sufficient capacity for commissioned services. Staff stated one of the challenges they faced was the location of provision. Also access to resources during out of hours periods could be challenging. The mixture of urban and extremely rural areas over a very large geographical area meant staff could, at times, find it hard to find services which covered specific parts of the county, as not all services were available throughout Northumberland to all residents. This resulted in an inequality of access to services, which was compounded by longer travel times to reach rural populations.
Hospital discharge was led by the Homesafe social care teams based in each of the acute and community hospitals. The Homesafe team was made up of social workers and social work support assistants who worked closely with occupational therapists and discharge nurses, employed by Northumbria Healthcare Foundation Trust, as part of a wider transfer of care hub.
The teams also worked with the Short Term Support Service, an integrated therapy and reablement service based in four localities across the county which provided a seamless transition from hospital to home with a focus on Discharge to Assess model.
The challenge in ensuring consistent high-quality provisions across the county was well understood. Some providers told us they felt some drug and alcohol needs, in relation to unpaid carers were not fully understood or resourced to a sufficient level. However, we also noted work undertaken in commissioning, and with partners, to ensure as far as possible, people and populations were not adversely impacted by the distribution of provision. For example, providers working with people with mental health needs were flexible with support hours, however many of the locality homecare support providers were not skilled to support people with mental health conditions.
The local authority was confident in its approach to managing the quality of services, with clear quality monitoring processes and systems in place to ensure people had the best possible outcomes. Despite a mixed relationship with providers, the local authority had continued to work with providers to deliver services to the county.
The local authority demonstrated a strong contract management process, with an effective quality tool, which served to identify gaps in the market from providers, and from peoples' feedback from a variety of sources, for example, at provider forums, through surveys, and during training. This included speaking to people who used services, relatives and staff whilst on-site at a contract monitoring visit to inform their judgement.
Officers highlighted a quality assurance framework and tool, and how the approach linked into the local authority’s values and collaborative approach. The tool was an in-house spreadsheet which was analysed monthly, looking at themes and trends. The key gaps, themes and trends were shared with providers at their forums, with follow-up training given where required.
In Northumberland; 76.74% of nursing care homes;72.55% of residential care homes; 72.09% of home care services; and 84.62% of Supported Living are rated good or outstanding by CQC. Between 2023-2024, there were 7 contract suspensions in place, 3 care homes and 4 home care agencies. Six of the suspensions were voluntary following concerns and one enforced. Agreed actions were responsive and appropriate, and the local authority put in place support for providers. Feedback received from one care home provider was positive and the support given by the local authority ensured they improved.
In older persons care homes, the fees paid by the local authority are linked to the home's CQC rating. This approach was contentious with providers. However, the local authority told us where changes to the home's CQC rating is delayed because there has been no follow up inspection, there is provision in the contract for the provider to ask for council officers to determine the quality of the home and the fee levels.
Contracted social care providers and their staff had access to the Council’s training courses to improve the quality of the services they delivered. An 'Excellence Course' had also been developed to enhance the skills and knowledge of care service managers and increase resilience. The effect of this was the local authority could be confident in practices and standards linked to its practice framework, with services being strength-based and equitable for people receiving care and support in Northumberland.
The principle of partnership was a key feature of the quality monitoring activity in the local authority, with an example given of a residential service, which the local authority had concerns about, developing a joint action plan with clear timescales to improve. People’s experiences of services were generally positive. In addition to being part of the quality monitoring process, compliments received by the local authority during 2022-23 about services were mainly about how helpful, kind, and professional staff had been; or about the quality of the services commissioned or provided.
Strategically, the local authority was working with regional partners to ensure people placed outside of the county, who tend to have more complex needs relating to areas such as dementia and mental health issues, were monitored and supported. A process was in development with other local authorities in the Northeast for the monitoring of out of area placements. This was a reciprocal approach where the commissioning authority would be informed about any concerns with prospective or current placements.
Northumberland had a plan to ensure local services were sustainable. The local authority understood what the challenges and risks were to deliver sustainable services in the local market. Areas such as workforce availability, the availability of specialist independent supported living services, and the modernisation of day services were recognised as areas for development.
The market position statement made clear its ambition to commission services and to support a good quality of life for people in Northumberland. The local authority had sought to address sustainability issues through policies and how it prioritised commissioning activities. As such, any provider entering the market in Northumberland had a clear understanding of the expectations of the local authority and its challenges in delivering sustainable services. There had been no contracts handed back early to the local authority by providers in the last 12 months.
The local authority used several mechanisms to ensure quality and sustainability. For example, through the Market Sustainability and Fair Cost of Care Fund 2022 to 2023. The local authority had considered the return of the 'fair cost of care survey' from care home providers as part of their grant allocation to support market sustainability, and in response the local authority had proposed plans to use the fund to support both care home and homecare providers with the acute pressures they were facing to support the sustainability of the local market.
Through the Provider Development & Quality Assurance Team a workforce strategy had been developed with providers and supported by an external group across the northeast. Activity included supporting providers in the recruitment of care staff in rural communities, to schemes that encouraged staff return and retention.
The local authority worked with partners to jointly commission services. Through public health, micro-grants were offered to the VCS rather than through more complex contracts, and performance indicators were agreed to address community needs. Providers and commissioners spoke of the positive working with specific teams including forensic services, brokerage, complex housing, independent supported living, MASH and safeguarding teams to ensure services met the needs of the people who used them. As such the work to ensure services were sustainable was holistically considered and acted on beyond the commissioning and contract management function alone.
However, we also heard from the VCS in Northumberland that the relationship with local authority commissioners could sometimes be difficult. The commissioned sensory service noted that the level of funding offered for what was expected in delivery was not always consistent. Some contracts were short-term and feedback on performance was not always available. Parts of the VCS felt there was a lack of strategic direction. As the local authority did not always commission on time, the sector had challenges in managing the uncertainty in relation to both staffing and the service offer, which impacted on the sustainability and security of delivery.