Shropshire Council: 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 expanded their Joint Strategic Needs Assessments (JSNA) to include locality based JSNAs. They were in the process of undertaking an additional 18 neighbourhood JSNA’s to get a more detailed understanding of the areas of need for care and support in each locality. JSNA is an ongoing process by which local authorities, integrated care boards and other public sector partners described the current and future health inequalities affecting people, the wellbeing needs of its local population, and its identified priorities for action. Senior leaders told us all the localities within Shropshire were very different and this approach would ensure all needs are being met. In Shropshire over 60% of people lived in small hamlets, villages and isolated rural locations. A challenge of this was the long waiting and travel times for transport and how it affected people attending health appointments, social and leisure activities. A senior leader told us they were learning more about the communities through the neighbourhood based JSNA approach. At the time of our assessment approximately 9 of the JSNAs had been completed and there was a written ambition to publish all 18 JSNAs by autumn 2024. Action plans were formed from the JSNAs which the local authority used to inform the 'Shropshire Plan' and the work of the Health and Wellbeing board. Improvement activity was underway and an example of an initiative that came from a neighbourhood based JSNA’s was the development of a Community Health and Wellbeing Hub.

At times, people living in rural areas had to wait longer for their care than people living in urban areas. The local authority recognised this and worked with care providers and the voluntary and community sector to address this. For example, by looking at technology-enabled care and only accrediting new providers who evidenced they could supply care in the areas they were needed in. They were working with providers to redesign the domiciliary care market to ensure growth, flexibility and coverage and to increase the use of technology and digital solutions.

The local authority also extended their ‘two carers in a car’ scheme, which was a system that used 2 care staff to work overnight to visit and provide care and support. This arrangement allowed them to reach more rural areas. The feedback the local authority had received from people indicated that this had a positive impact on their well-being.

The local authority’s Market Position Statement (2024-2027) had a strong emphasis on community-based commissioning within localities and recognised the strength and contribution of communities in prevention and early intervention for supporting people’s wellbeing. This meant reducing the reliance for services to support people to remain independent at home. 

The local authority had a new commissioning structure in place comprising of 3 elements: start well, live well and age well. The objective of commissioning across the age groups was to improve pathways and provision for people moving between different parts of the system, for example from children to adult services. The local authority planned to look at a model of commissioning for aged 0-25 years in the future for further strengthen its pathway for care and support of young people.

The local authority worked with stakeholders and people in the community to ensure co-production and delivery of strategies, and they had several boards including the Making it Real, Learning Disability, Mental Health and Autism Partnership Boards who influenced strategy development. Providers told us they were not always directly involved in co-production, however the local authority worked with an organisation who represented care providers, and they met with this organisation regularly. Working with partners through the Joint Commissioning Delivery Board ensured the local authority’s strategic objectives aligned with national and local agendas to drive their commissioning intentions. There was a priority focus on provision of domiciliary care services to support people to remain living in their homes for longer, as opposed to moving into residential care.

To understand people’s views of care at home services, to drive up quality and to inform the wider transformation programme, the local authority undertook a survey of people who received care at home, care workers, and other stakeholders. The results were published in the Care at Home report, January 2024. Despite effort from the local authority, responses were limited with 70 individuals, 44 carers and 15 stakeholders taking the surveys, which is less than 1% of the populations of interest in this consultation. Despite the low response rate, the survey provided useful insight into people’s experiences of care at home which the local authority is using in its transformation work, for example feedback on the importance of consistency and communication from care providers, increasing the ease of finding and arranging care, improving the quality of carer’s training for frailty, dementia and mental health, and the impacts of rurality on the care sector.

The local authority had used the Market Sustainability funds to increase the hourly rates for domiciliary care by 12% and which had a positive impact on provision, for example 27% more people were supported at home in January to April 24, than between July and December 2023. The local authority told us the 12% increase also brought some providers back into the market and recruitment was improved through overseas sponsored workers. However, some care providers told us that more financial support was needed to cover travel costs.

There were mixed responses from providers regarding whether the local authority consulted with them effectively. Some providers said their feedback was ignored and felt the provider forums they attended were not collaborative. Others told us once the local authority had published their JSNA’s and market position statement, they were then invited to webinars and remote meetings to share their thoughts on proposed changes, which they had welcomed.

A draft strategy for Independent Living and Specialist Accommodation 2023-2028, was currently out for consultation and it identified several priorities including addressing diverse housing need, delivering accessible and adaptable housing, providing specialist accommodation and preventing homelessness.

A partner organisation told us that Shropshire supported refugees but there was a gap in service provision, and some challenges in accessing provision such as housing. The organisation worked with the housing team to address this and secured housing for 400 refugees and supported them into employment.

The local authority had dedicated Commissioning Officer roles for Mental Health (all-age) and Autism (all-age) to ensure they had the right level of expertise to identify what was needed to overcome any gaps in the market and to maximise opportunities for joint working for complex needs.

The carers support team provided support to young carers and were developing a young carers group that would offer young carers activities such as cooking classes and basic life skills. There was a dedicated carer support worker in the hospital, who gave support and advice for new unpaid carers when they were leaving the hospital setting. An unpaid carer told us the support worker had been valuable for them.

Staff told us respite was available for people and unpaid carers and this included support during a crisis. The local authority block booked respite provision, and they spot purchased from this according to need. National data showed that in Shropshire, 14.29% of carers accessed support or services allowing them to take a break from caring at short notice or in an emergency. The England average was 12.08% (ASCS). 34/92% of carers accessing support or services allowed them to take a break from caring for 1-24hrs. The England average was 21.73% (ASCS).

The local authority had 102 supported living properties and had identified a need to increase the number of providers with a focus on supporting people with more complex care and support needs. They were keen to develop more diverse models for supported accommodation, and they were working with the Housing Learning Innovation Network (LIN) to develop a needs assessment to inform future developments and models. Feedback from staff and partners indicated there was a need for more supported living, but we were not advised of people waiting for supported living placements due to a lack of capacity at the time of our assessment.

National data shows that in Shropshire, 87.77% of adults with a learning disability live in their own home or with their family, this is somewhat better than the England average of 80.42%, (SALT) October 2024.

Some staff said there were some gaps in services for people with a learning disability and autistic people, for example they said for people with more complex needs it could be difficult to find care due to the rurality of the area. However, they shared person centred examples of how they have supported people with more complex needs with 24-hour support in the community. 

The local authority had a monthly accommodation forum for supported living to look at individuals needs and to match with other people where there were vacancies. Staff used the forum to assess whether a property and the people living there would be a good match for the person they were supporting.

There was some use of out-of-area placements. For people with more complex needs the local authority worked with commissioning and partners to explore bespoke services to facilitate people to come back to the county if appropriate. In total the local authority had 114 people placed out of area with 76% of these placements being made in neighbouring counties. Personal choice and geographical location were the most common reasons for an out-of-area placements, and the geography of Shropshire meant that some placements in neighbouring authorities could sometimes be closer to a person’s home and their networks.People who were in out-of- area placements were continually monitored and 98% of out of county placements had been assessed or reviewed in last the 12 months.

The local authority struggled to get paid carers in rural areas due to the distances they had to drive. The local authority had specific recruitment drives in areas where they needed staff. A senior leader told us that by working with providers and community partners, the local authority had increased capacity for domiciliary care which reduced the need for residential care.

There was a commitment to develop models of support for people needing complex nursing care and people with dementia to enable them to remain living independently for longer.

Data provided by the local authority showed there were waiting times for services to start across residential, nursing, home care and supported living services. When formal services did not start immediately, interim care arrangements were made to keep people safe. Where care did not start within 3 months, the main reasons included people were admitted to hospital (20), care was declined (19), care was being sourced (18) and people were awaiting direct payments (16). This information was being used to direct improvement actions.

The local authority was also working with health colleagues to implement alternatives to admission to hospital by providing a 2-hour rapid response service in the community, and by implementing an integrated discharge team to support discharge from hospital with the right support within the community. The local authority told us they had seen a significant reduction in delays in hospital discharge as a result of this. The average discharge time in April 2023 was 2.02 days. The average discharge time once a person was ready to go was 1 day in April 2024, which included discharge times for people with complex needs.

The local authority had clear arrangements to monitor the quality and impact of the care and support services being commissioned for people and it supported improvements where needed. The local authority told us the supported living market was a key area of focus that they needed to support and work with.

In spring of 2023, the local authority reviewed and identified risks in its provider quality monitoring and assurance processes. As a response, a draft Provider Quality Assurance Framework for commissioned care and support services was created. This outlined the local authority’s approach to ensuring the quality of care and support services. Quality standards and expectations were clearly communicated and with the aim of building positive and supportive relationships across the range of agencies, care providers and people using services to foster a culture of continuous improvement.

The local authority used a risk dashboard which allowed partners to feed in data from many sources including CQC, monitoring of organisational quality concerns and financial stability to risk rate commissioned care providers. The Market Quality Assurance group maintained oversight of this and worked in partnership with other stakeholders including health partners.

CQC ratings of regulated providers, showed that at the time of our assessment, Shropshire had 6.58% outstanding, 67.11% good, 18.42% requires improvement and 2.63% inadequate residential services. The nursing homes had 81.58% rated as good 13.16% rated as requires improvement. Homecare had 9.76% outstanding services, 62.20% good, 9.76% requires improvement and 1.22% rated inadequate. Supported living was rated 7.69% outstanding, 53.85% good and 23.08% requires improvement.

Staff told us if a provider was identified as high risk or had received a CQC requires improvement or inadequate rating, there were a number of visits to the service along with an action plan set and the monitoring of improvement actions.

Data provided by the local authority showed that they had suspended commissioning with 5 providers in 2023 due to quality concerns. The common theme was high turnover of staff with poor management and leadership in place. A provider told us the local authority had been supportive and nurturing when they had come out of a period of suspension. This included the provider having 3 monthly meetings with the local authority to monitor progress and improvements.

There were 200 active adult social care providers in Shropshire with 11 locations who deregistered in the last 12 months.

Whilst the local authority had arrangements to collaborate with care providers, including to ensure that the cost of care was transparent and fair, some providers felt the provider forums they attended did not always achieve this.

The local authority acknowledged that domiciliary care was the market area that presented the greatest risk to Shropshire in their ability to deliver statutory services. Providers were given a contract uplift of 12% to reflect increasing costs. The impact of this had been a reduction in waiting lists for domiciliary care and an increase in the number of providers. The local authority told us they would be prioritising Supported Living Providers uplifts for 2024/25 to mitigate instability within that market.

The local authority understood that different areas of the market required different uplift solutions and other areas received a 7% uplift on a ‘cap an uplift’ basis. Providers received the uplift if their rates were at or below their average rates at that point. This approach was designed to standardise fee rates and support a sustainable market.

The local authority told us they held quarterly forums with care providers. Providers we spoke with had attended a recent forum, but they were not aware of those in the previous year.   Providers told us they were well supported with operational matters.

The local authority had a Joint Training Team which offered specialist training to care providers. Providers told us bespoke training was available for example, if a person using the service had specific moving and handling needs and equipment needs, the local authority would arrange this with an occupational therapist.

The local authority recognised that recruitment for its own workforce was challenging due to its geographical location. National data showed that there were 8.06% of adult social care job vacancies in Shropshire. The England average was 5.66% (Skills for Care Workforce Estimates).

To address workforce challenges, the local authority had developed a Workforce Strategy which identified the capacity, capability and diversity of the workforce and how it needed to operate to deliver outcomes for the residents of Shropshire. The workforce priorities were to attract, recruit and retain skilled workers and reduce reliance on agency and interim workforce in addition to developing apprenticeship and career pathways. Apprenticeships and social work student placements provided a positive way of attracting staff to social care that had helped to address recruitment issues.

The Adult Social Care Provider Failure and Service Interruption Policy set out how Shropshire would work with adult social care providers in the event of risks or issues that affected providers service delivery.

We were told that for care homes 2 contracts that were handed back in the last 12 months due to care home closures, with 2 homes closing in the last 12 months, due to quality and financial issues, and a provider changing their business. We were told that 1 supported living service had handed their contract back in the last 12 months which was supporting 31 people. The local authority negotiated and mitigated the risk for the people who had used this service to retain continuity in their care.