Surrey County Council: local authority assessment

The local authority worked with local people and stakeholders to use available data for example the Joint Strategic Needs Assessment (JSNA) 2022 to understand the care and support needs of people and communities. Senior staff told us the JSNA was effective in the way it described key populations in Surrey, as in some of the neighbourhoods there were some pockets of real deprivation and specific areas identified where they needed to work with people with most inequalities. This included people who were most likely to experience poor care and outcomes, people with protected characteristics, unpaid carers and people who funded or arranged their own care.

The largest borough in Surrey by population was in Guildford. Most Surrey residents spoke English as their first language, most common other languages spoken in Surrey were Polish and Chinese languages. Priority populations were identified by Surrey Public Health Intelligence and Insight Team. These included people with a diagnosed learning disability, serious mental illness, people with a long-term condition and people belonging to minority ethnicity groups.

The local authority strategy for understanding people’s care and support needs focused on everyone living their best life, then considering do they understand this locally and how this works in practice. For example, in Woking they had high numbers of people with mental health needs and addiction, with some complex cases, so capacity was being reviewed in this area to try to better support people’s needs. Community prevention officers did complex community planning where people were struggling to work with the local authority.

Unpaid carers were considered to be a top priority for the local authority. Staff told us without them the entire social care system would struggle. Carers advisers were embedded within local authority teams to support this work further. Their role was to drive and uphold best practices in working with unpaid carers including understanding the legal requirements and the personal experiences of caregiving and to address unpaid carers' needs and help them live their best possible lives.

Local authority hubs were located geographically and allowed for support targeted to the needs of the local area, combined with groups to provide information, training and signposting. For example, northern areas were more urbanised than the rest of Surrey and presented different needs and challenges for unpaid carers.

Data for Surrey shows 71.03% of people who use services feel they have choice over services, which is similar to the England and regional averages. Adult Social Care Survey (ASCS) 2023. The data for unpaid carers accessing support or services allowing them to take a break from caring for more than 24 hours is 18.08%, compared to the England and regional averages of 13.42% and 16.14% respectively. Survey of Adult Carers in England (SACE) 2024.

A positive approach was being taken by the local authority to shape the market using feedback from people to drive this work. The local authority had three strategic commissioning teams for Older People, Learning Disabilities and Mental Health. Overarching these teams was the Market and Commissioning plan and from this teams developed their individual market development strategies.

Partners told us local authority commissioners attended events and listened to people and their views. They said there were good working relationships with the commissioners and they felt the local authority was making good progress in some areas, however there was a balance between what people wanted and what people needed in terms of service provision.

Senior staff explained Surrey was a large county with 27 towns and villages. Over many years places had formed identities so there was variation in different places. Therefore, they had tried to establish a baseline of what variation was important, what responded to local needs and where they needed consistency of the offer they can make, seeing the detail in the data.

Staff in the Brokerage Team had built their own 'outcome sourcing' system so where there was a shortage of services there was a sign up system for new providers. Regular feedback forums were held and written communication with people ensured that their opinions and experiences were incorporated into plans for service development.

The Brokerage team had centralised its commissioning function over the previous year to provide consistency in practice and market management. There was a referral management system which care providers and front-line staff had access to and this supported communication and transparency. Providers could communicate with the local authority directly via the system, which could be viewed by practitioners in local teams to support their conversations with people receiving services and their unpaid carers. Teams felt energised about this new way of working and showed commitment to providing high quality support to practitioners and providers. Feedback had been well-received by the local authority and it had led to positive developments and improvements within commissioning processes.

Co-production and feedback was used to develop the market and services. A lack of respite care for unpaid carers was one theme of consistent feedback from people and partners, with some families unable to identify services to take a break. For another family, respite had been identified eventually, but this had taken some time and was not easy to find.

Staff worked with the unpaid carers network, feedback was actively sought through written communication and forums held quarterly to gather feedback. This feedback was then incorporated into service specifications. The local authority worked with unpaid carers to understand these gaps and to redesign and reintroduce the service. For example, a new ‘Library of Experience’ resource for carers had been created following feedback. Carers partners said the local authority recognised the importance of unpaid carers within the health and social care system, and strategies, engagement exercises and coproduction opportunities reflected this. There had recently been some work done on a carers break service and there was a desire to get this right to meet people's needs.

By engaging in continuous improvement and exploring alternate care models, Surrey demonstrated a commitment to developing high-quality, responsive care services. Market shaping plans for accommodation with care & support were documented which included supported living and extra care housing schemes using data to map projected demand in the future. There were examples of commissioning to support a preventative approach including residential block beds being used to support short-term health needs to prevent hospital admission. There was also a ‘support to recover’ service commissioned which aimed to help people with long-term mental health back into housing. The in-house reablement service was being enhanced with domiciliary care from the private market and these changes had allowed the service to be more effective and support a greater amount of people to independence.

Processes supporting this work include the Co-production Commissioning Guide (October 2023) which demonstrated the local authority had an understanding and commitment to co-production within the adult social care commissioning function.

Although views from partners were positive overall some partners said the local authority commissioning could feel rigid at times and that not everyone in the local authority recognised the voluntary sector had the same goals. Some felt the use of co-production could be inconsistent. However others talked of a close working relationship with commissioners, which felt supportive with regular meetings, which were accessible.

There was sufficient capacity to meet demand in areas such as homecare, however in other areas such as specialist accommodation, support for people with mental health needs and more complex needs, accommodation was harder to source.

The local authority had developed a data management system that drew information from the person’s record and the brokerage systems. This meant that they knew what the market was providing, when and where people were receiving care and they could track a person's journey across different care provisions over time. This data had been used to identify people who were out of county and target the work of the specific teams.

Senior staff told us about risk areas and pressures in meeting rising demand. They felt the mental health system was letting people down and did not function well. They had initially viewed this as a resource issue, but then they took a system view which led to a review of the mental health system in Surrey, the hand off between services, people's experiences, experiences of user groups and providers. This motivated people to work together as a system to identify the issues that lay behind this and a mental health steering group was formed from this.

Feedback reflected a notable gap in services for individuals with a dual diagnosis of learning disabilities and mental health needs. Often, people were referred to community learning disability teams, but when specific autistic traits were present this could make this more challenging if people were considered without understanding these unique needs and could lead to a lack of proper support. Joint meetings with the community team for people with learning disability were held quarterly to address cases, but there was a significant gap in services, as well as for respite care providers, especially for those with Asperger's syndrome. Commissioners were aware of this and this had led to further work with care providers plus a plan to develop a specialist brokerage team.

Partners confirmed placing young people with complex needs could be difficult, however acknowledged everyone was trying to address this jointly. One positive example was the commissioning of a new service for young autistic people. Staff shared examples of working closely with housing teams to support two young people to access a privately rented property working closely with an OT and an advocate. Some good relationships had been formed with registered landlords, with another example of a property being commissioned for 6 young people to address a gap and enabling them to further develop their skills.

Partners gave us examples of when the local authority commissioners had worked well with them jointly to support someone with complex needs creatively. This person had been delayed in hospital and was unable to leave as there was no suitable specialist accommodation for them. Commissioners had worked with the care service to adapt their premises to specifically enable this person to be able to leave hospital.

Development of extra care and supported living sites were underway. The local authority had a 'Right Homes, Right Support' program to increase supported living capacity by at least 500 units to support people’s independence, choice and control with dates for the different accommodation up to April 2026. A proactive approach included offering ex-council properties to developers first to build extra care accommodation which had led to a site in Guildford being developed. The mental health commissioning team had started to see some interest in building supported living flats for people with mental health needs, which would support provision for more complex clients.

Care home and nursing home capacity could be challenging to access a good variety and sufficient capacity to meet demand. High fees were specifically aimed at people who were self-funding which posed challenges for local authority funded options. Challenges to find suitable care homes were also hindered by a market with lots of choice in some areas such as luxury care homes, however with some facilities struggling to accommodate people with complex needs. Residential care home wait times impacted the most people in Surrey, waiting a median time of 18 days over the past three months (before 1 July 2024) for placements and a median time of 13 days for nursing homes for the same period.

Homecare capacity was strong in Surrey, with minimal people waiting for a service to begin and 1 day being the average length of time people had to wait. The local authority recognised an increase in demand for home care, with total home care numbers purchased rising from 3975 in December 2023 to 4065 in March 2024. The local authority however acknowledged a gap in supported living capacity in Surrey, with the median time from referral to closure being 18 days over the past three months (before 1 July 2024) with referral response times varying due to challenges in finding suitable settings.

As of 15 July 2024, 239 people were placed out of county who started placements within the last 12 months. This number has continued to decrease since December 2023, from 983 and the proportion of people placed out of county had significantly reduced over the last four years. The reasons for such placements were due to a lack of specialist support in Surrey, people’s own choice and the timeliness of transfers. Brokerage teams worked with staff to identify any preferred areas for people where they may have local links outside of Surrey, but it was acknowledged that for some provision there may only be one option. Staff told us this was kept under review to support a move if something more suitable arose. Work was progressing to draw people back to the local authority area. Clear guidance relating to transfers of care supported staff in relation to people with funded care moving out of county, or those with pre-existing care packages moving into the local authority area.

There were robust systems in place for quality monitoring of care services enhanced by digital systems. The local authority Quality Assurance Team were located within the Commissioning Team. Care providers had key relationship managers assigned, whose role was to check on quality, maintain relationships and audit the electronic care records. Staff used data from provider key performance indicators and feedback from people and surveys, to help identify and address quality issues promptly, and audit visits to build a picture of quality. Staff visited providers and information was gathered from other sources such as intelligence from the Care Quality Commission (CQC) and Healthwatch. Healthwatch are the independent champion for people who use health and social care services. Healthwatch gathers and represents the views of the public about health and social care services in England. The local Healthwatch network supports people to share their experiences of care or access advice. Other arrangements for collaborative working were in place, for example, joint visits with staff from the Integrated Care Board.

A Service Delivery Quality Assurance Framework Policy and Procedure detailed the processes of the Quality Assurance Team. For example, the team undertake quality assurance audits throughout the year, for care homes these are unannounced visits, for supported living and reablement they provided advanced notice. Audits involved a review and the implementation of recommended improvements and included discussion with people as well as reviewing records.

Staff focused on specific problems where action plans to drive improvement were needed. Through changing the way they engaged with providers and with additional staff resource they had been able to visit providers who had not previously been reached before. The quality checking process started from the point of tender and staff were clear with providers on expectations. For example, some providers were suspended from receiving new referrals through not passing the required quality assurance checks. The local authority encouraged provider feedback following monitoring visits to support this relationship-based approach.

Serious concerns regarding care quality were addressed through a multi-agency process and risk management framework which was overseen by the Provider Quality Improvement Group and Practice Assurance Board. The Provider Support Intervention Protocol set out the roles and responsibilities of the local authority in the event of serious concerns arising about the quality or sustainability of a care service or care provider.

One care provider told us about their positive experience of the Provider Support Intervention Protocol. They told us they found the local authority process to support them was 'phenomenal'. A number of meetings took place and they found the support and partnership working to be amazing. They described the local authority staff as professional, dignified and meetings were well chaired with a multi-disciplinary team approach. Everyone worked with them to support them to meet their action plan. The service had turned around in a short time due to this approach which they felt was collaborative with one person from the quality assurance team being described as fantastic. 

The Quality Assurance Team liaised with the internal Brokerage team and other local authorities to communicate concerns around specific providers. As of July 2024, embargoes had been implemented on 27 occasions in the last 12 months however these were lifted once all necessary improvements were achieved, serving as a temporary measure.

Partners fed back about their experiences working with the local authority in relation to quality monitoring. Comments included communication was good, staff were quick to respond and remained incredibly helpful. Other partner said they felt well supported by quality assurance managers and they felt the local authority had people's experience at the heart of their work. One partner felt there seemed to be more consideration being given to support for people with a learning disability and autistic people than before, and more consideration to the right placements being provided. However, some partners raised concerns about the quality of some of the home care providers commissioned and whether cost was considered over the quality of these services. Feedback was wanted to foster a partnership approach with the local authority to better work together to improve service quality and ensure fair and transparent practices.

Adult social care services in Surrey overall were rated as 4.65% outstanding, 73.55% good, 10.76% requires improvement and 1.89% inadequate, with the remaining services unrated. Areas identified which could be improved further were high numbers of providers on frameworks with quality concerns, such as those who required improvement, and providers who were registered but were not yet rated where the quality of care was more unknown. Feedback from the local authority was that there was a robust evidence-based approach in place which suspended providers with quality concerns. The local authority and providers were also impacted by a delay in CQC re-inspections sometimes where services with previously poor ratings may now have now improved.

The number of contracts handed back by the local authority to care providers in the last 12 month was 1 for home care, 10 for supported living and 12 for residential care homes.

The local authority were involved with a number of initiatives in relation to sustainability of local services, in particularly workforce development plans. For example, the United Surrey Talent Mid-Year Report 2022-23 showed partnership working with the integrated care system and Surrey’s voluntary sector in the development and delivery of a joint health and social care fund supporting a joint talent strategy. The strategy, plan and resource developed the capacity and capability of the health and social care workforce in Surrey to support long term strategic objectives and culture change. Examples included, volunteer recruitment and retention, an integrated recruitment project and a Temporary Staffing Programme.

Work with a care home group and the local authority had taken place to develop a workforce strategy for care home staff based on gaps in skills and competencies and to improve leadership and staff retention in the care home sector. Additionally, an 'Admiral Nurse Care Home Service' was being developed in Surrey to be able to provide advice and support for people living with dementia and their families.

Data from Skills for Care Workforce estimates that in Surrey 53.52% of adult social care workers with the care certificate in progress, partially completed, or completed against the England average of 49.65% and regional average of 50.51%.

Partners commented that the cost of living crisis had affected people on low incomes, and Surrey was an expensive place to reside. More help for people such as support workers was needed, but often they were commissioned and paid at the lowest rate, making it hard to recruit and retain staff, thus having an impact on care services. Commissioning processes could make working with the local authority difficult at times. For example, contract documents, were not always received from the local authority in a timely manner or funding could be delayed and this put more pressure on the organisation trying to plan ahead in relation to the workforce. In terms of recruitment and retention of the workforce some partners felt the local authority provided support with this, others less so.