Westminster City Council: local authority assessment

During 2022-23 the demand for care services had increased by 11% in comparison to the previous year, where 3535 people accessed long-term support, of which 2180 people were aged 65 and over. Along with an increased demand, health and economic inequalities created complexities. They also used available data to understand the care and support needs of people and communities. For example, through the Joint Strategic Needs Assessment (JSNA) the local authority demonstrated an understanding of the diverse health and care needs with data showing a strong correlation between deprivation and health outcomes.

The JSNA board had collaborated with people and partners towards seeking and identifying the current and future health, wellbeing and social care needs in Westminster. In response to addressing inequalities the local authority had developed a dashboard focusing on mental health wellbeing and had supported the Suicide Safer Community’s Programme. Staff mentioned they had been involved in some deep dive work for the JSNA. The deep dive work entailed community engagement, which highlighted that many people’s priorities related to the wider determinants of health such as housing, employment and cost of living.

We saw evidence of action on data with the local authority’s Joint Health and Wellbeing Strategy 2023-2033 that focused on reducing health inequalities. Feedback from partners was positive as they shared that the local authority was aware and was actively trying to resolve the issues. Providers appreciated the local authority’s relationship and communication between health services and providers, particularly when people were moving between hospitals and care homes.

The local authority had an active co-production group who were involved in the development of specific strategies. The Carers Strategy 2023-2028 evidenced the local authority’s joint approach to strengthen the support to unpaid carers and empower them to live healthier and happier lives. This strategy was co-produced with people, unpaid carers and partners.

People had access to a range of local support options to meet their care and support needs.  Data in Westminster indicated that 66.11% of people who used services felt they have choice over the service they used. This was statistically comparable with the England average of 69.81% (ASCS, 2023). The local authority provided further information which demonstrated some improvement in the uptake.

In October 2022, the local authority restructured their Integrated Commissioning Department to combine strategic commissioning and market management. This integration enhanced the local authority’s use of data and evidence for commissioning. For example, there was a successful case for investment in a new Extra Care Housing Scheme based on people’s preferences. This evidenced the local authority’s understanding of local demand and close engagement with the market.

Frontline staff told us there was a good relationship with providers and communication with them was frequent, with quarterly monitoring meetings and providers were able to ask for support when required. We received positive feedback from providers who shared the local authority had managed their contracts effectively and placed people’s needs at the centre of their decision making. Partners told us that the local authority was responsive and supportive when people’s needs increased. The Brokerage Team was responsive and worked well with frontline staff to accommodate changes to peoples care and support needs.

The local authority’s Market Position Statement 2024 made specific reference to identified groups in planning and shaping future services. This included recruitment and retention of care staff, increase in uptake of direct payments, making information accessible and increase the use of technology to enable people to remain independent at home. There was a collaborative approach with regeneration and property teams to further expand provision for specialist accommodation for autistic people and people with learning disabilities. The local authority had successfully been working in partnership and re-developing four extra-care housing schemes, to increase opportunities for autistic people and people with learning disabilities to live independently. The local authority had been working to enhance further provisions for people with learning disabilities to access general needs housing. The local authority told us they were planning to propose an increase in annual housing nominations in September 2024 to be used by people with learning disabilities.

The Transformation Project had enabled the local authority to review the commissioned day opportunities for older people. Following feedback from people, the local authority had made plans to deliver an integrated service model, where the focus had been on offering a ‘preventative day opportunity offer’ as opposed to a ‘day opportunity with care offer’.  This was an example of the local authority working towards more meaningful and outcomes focused approach for day opportunities.

The local authority’s framework for the provision of homecare used geographical patches to allocate a forecast number of hours to commissioned providers, the number of people aged 65+ receiving homecare were divided between the North and South homecare patches.  All contracts had been in place since 2016 and were due to expire in November 2024. The homecare service was being recommissioned, with plans to have new contracts in place before the existing ones expired. 

The local authority has evidenced strong relationships with the market, despite varying quality and consistency of service. They have been able to maintain occupancy and service delivery through their providers. The local authority had 6 care homes and 7 home care providers, and they also had contractual and quality assurance arrangements with spot providers to ensure it continued to offer responsive services that met people's needs

Commissioning strategies were aligned with the strategic objectives of partner agencies.  For example, the Older People Extra Care Housing Commissioning Strategy 2023 was co-produced with people and partners and was designed to address improvements to ensure older people were provided with high-quality, sustainable, person-centred care and housing options. Providers told us they had been consulted and had opportunities to influence commissioning plans and strategies.

The Learning Disabilities Accommodation Commissioning Strategy demonstrated commissioners had undertaken a review and analysis of the current and future needs for accommodation-based support for learning disabilities. This approach was in partnership with property services to identify opportunities to address a number of high-priority issues with the quality and capacity of the Borough accommodation.

The local authority showed awareness that there was a need to offer a broad range of accommodation for people with a learning disability and recognition of such accommodation being close to family and friends, with a focus to enable integration into the community and increase independence and choice.

The local authority recognised the challenge and cost associated with providing accommodation-based support in a central London borough such as Westminster. Partners told us mental health provision and support was good, but not always appropriate for all levels of needs. Whilst there was support for those with low-level needs and those at crisis, the support available was not always appropriate for those with on-going mental health needs. For example, partners highlighted that there was a gap in the market for specialist nursing home placements, particularly around supporting people who required specialist dementia care.The local authority was aware of the importance of mental health services and was working closely with health partners to improve support for people who required specialist mental health support. For example, additional funding had been provided to support early intervention, accessible resources, and a ‘suicide safer communities’ programme. Senior leaders told us they were working hard to improve access to universal preventative services, including support with housing, employment and education.

As of 31 January 2024, 425 people were supported in out of area placements. The majority of these (321), were within Greater London, of which 153 of these were in neighbouring boroughs. Reasons for this varied, including, but not limited to, cost of accommodation and/or personal choice. The local authority was committed to ensuring people were supported to live locally near their family and support network. The local authority aimed to identify local placements first, if this was the person’s preferred choice.

For example, frontline teams told us that for some people with mental health issues, placing out of Borough supported them to move away from people who had a negative influence on them. Staff told us about a dedicated placement review team who was responsible for people placed outside of the Borough, as they noted the numbers were high and explained they were reviewed once a year or sooner if changes or concerns arose.

Once a placement need was identified for a person, a review was carried out in 6 weeks, and only then it would be determined as to whether this was a long-term option for the person. The focus was on exploring community-based options and enabling people to develop on previous abilities and skills. The local authority had a detailed Standard Operating Procedure, which provided staff guidance for when they supported people in out of area placements. Staff had been encouraged to consider the persons wellbeing and seek consent and capacity when making important decisions.  This included involving the persons preferred supportive network.

Senior leaders told us there were no waiting lists for homecare, detailing that a care package was immediately arranged which ensured the persons experience to care and support was seamless. There were also no waiting lists when providing people with the residential or nursing care placements. Partners shared they were not aware of any waiting lists and felt the local authority had been proactive in supporting people and nobody had to wait to access services. 

The local authority had clear arrangements to monitor the quality and impact of the care and support services being commissioned for people and they supported improvements where needed. In Westminster, 100% of residential care services were rated Good by the Care Quality Commission (CQC) compared to the 75.99% England average. Nursing homes were rated 65.50% as Good, 12.50% were rated as Requiring Improvement, none were rated as Inadequate, and 25.00% had not yet been rated.

The local authority worked closely with partners in managing their services safely and effectively. Service improvement panel meetings were held twice a month. This was an opportunity for all partners to devise appropriate mitigation plans for action where risks and concerns were highlighted at the earliest opportunity as possible. There was close focus on safeguarding and complaints investigations, which included findings from quality assurance monitoring visits and audits.

Commissioning, Safeguarding and Quality Assurance Teams leads met with the CQC inspectors once a month to ensure there was a robust exchange of information on all key partners operating in the area, to prevent escalation of incidences and offer early intervention where concerns were identified. This demonstrated the local authority’s response to actions being taken to support service improvement. There was evidence of good and supportive relationships between the local authority and key partners. For example, there was consistent support to partners following a CQC inspection or when a safeguarding concern had been raised. There were regular focused visits and meetings to check against progress on the action plans to address any concerns.

The local authority had a robust Quality Assurance Framework, which detailed how quality of care was monitored, measured and how the local authority team responded to issues and areas for development. The team worked in partnership with all partners both internally, and externally with CQC and the Northwest London Integrated Care Board, to ensure there was active exchange of information and people were reviewed, particularly for those people placed out of area.

The CQC ratings of home care services were 11.11% rated as Outstanding, 44.44% rated as Good, 5.56% rated as Requires Improvement, none were rated as Inadequate, with approximately 38.89% of home care services not yet rated. The local authority demonstrated its responsibilities to ensure that social care provisions regulated and unregulated were of good quality and standard, to ensure that people’s safety and well-being was being addressed.

The Quality Assurance team engaged with people and their support networks to understand their experience of receiving care. The feedback was used to monitor regulated and non-regulated social care services. The gathered intelligence was through informal site visits, audits, and surveys. For example, the team identified a common theme around punctuality of carers following telephone surveys on three homecare providers. The local authority created an action plan to address the concerns raised and had made plans to follow up, to identify if improvements had been made.

The local authority offered providers proportionate and proactive support, information, guidance, and constructive challenge to continuously improve the quality of services being delivered and consistently deliver good outcomes for people. Learning with partners and collaboration for improvement had been evident. 

The local authority collaborated with care providers to ensure that the cost of care was transparent and fair. Partners told us they have an annual contract review and separate monthly meetings with the local authority.

The local authority monitored working conditions for all social care staff. Frontline teams told us they arranged annual surveys and considered and analysed staff demographics and travelling times. This analysis led to a pay rise of £1.50 per hour for contracted homecare staff. This pay increase was appreciated by partners as this supported them with recruitment and retention of their workforce.

Engagement and monitoring arrangements with partners enabled the local authority to plan ahead in the event of potential service disruption or provider failure. There were contingency plans in place to ensure that people had continuity of care provision in this event. The local authority told us they had no contracts handed back for homecare, supported living, residential care homes or nursing homes within the last 12 months.  This demonstrated the positive relationship with the Quality Assurance teams, Safeguarding team and partners. Partners praised the Quality Assurance team for their support, approachability, and openness.

The local authority understood its current and future social care workforce needs. The teams worked with care providers, including personal assistants and other agencies, to maintain and support capacity and capability. The local authority performed better than the average on staff vacancies with 5.51% of all adult social care job vacancies, which was lower than the national average of 9.74%. The number of sick days recorded for staff by the local authority was reported as 8.12 days, similar to the national average of 6.24 days (Adult Social Care Workforce Data Set – Skills for Care 2023). Further data provided by the local authority (but not yet published) suggested sickness rates had improved for 2024. The local authority acknowledged social care workforce development was an area of focus and they have included this in their Market Sustainability plan.