Royal Borough of Windsor & Maidenhead: local authority assessment

The local authority used a variety of methods to understand the needs of the local community to commission the right services. In some areas there was tangible evidence of commissioning practices having a positive impact but in other areas strategies were either under development or had not yet been fully embedded. Staff and leaders told us about work going on to improve the use of data to inform commissioning practice, and we heard about initiatives starting to have a positive impact. The previous year the local authority and health partners used the Better Care Fund to run 'world café' events in every area of the Borough. The local authority employed staff who took the lead on understanding the local community, from the perspective of strategic planning and commissioning, as well as staff whose role was to reach and speak up for seldom heard groups.

There was evidence of commissioning being used to address gaps, but leaders acknowledged a need to do more with data. We heard about how public health data was being used to understand health risks to inform what the local authority would need to commission in the future. Staff and leaders told us there were new IT systems being commissioned to support changes in assessment approaches and to provide more effective methods of data collection and analysis.

There was a Joint Strategic Needs Assessment (JSNA) for Berkshire East which was published online and used data across a patch of 6 local authorities known as ‘Berkshire East’. The local authority had also carried out a People and Place JSNA, with a focus on the Borough. These JSNAs showed data was being shared with partners and was used to set priorities for care and support, including how to strengthen transparency and accountability.

The People and Place JSNA highlighted loneliness and isolation was an area to develop a response to mitigate risks; this was also an area of focus arising from the World Café events. This had led to the development of a working group to work on tackling loneliness in the Borough. Staff and leaders were aware of this priority and described effective work in the community to provide information and advice, as well as visibility of the local authority’s offer. The local authority also commissioned small projects to respond to this need, such as a cookery group developed with local authority funds which started as a group to encourage healthy eating but evolved into a social group that became highly valued by the local community who used it. Whilst the examples provided showed the local authority was meeting identified needs, the overarching strategic approach was still in an early stage. Many of the working groups had only recently been set up, and further time would be required for this to develop and become embedded in practice.

In other areas, the local authority recognised a need to improve but had not yet achieved their ambitions. The local authority’s adult social care strategy identified a need for a focused strategy for commissioning services for people with a learning disability and autistic people; work had started but the strategy was not expected to be published until the end of 2024. The local authority had also commenced plans to increase provision of supported living to meet an identified need for secure housing for people with a learning disability, who staff told us were either placed out of borough or in unsuitable housing. This project was underway, with plans to create new provision later in 2024. This showed the area was identified as a strategic priority but at the point of this assessment it had not yet been fully realised. Staff and leaders described recent difficulties finding the right provision for working-age adults with complex care needs, including dementia. The local authority had also identified this as a gap but had not yet implemented a strategy to address it.

Demographic data showed a growing aging population, with an expected increase in people aged between 65 and 80. Staff and leaders told us about plans to address this, we heard about development of new extra care provision which was underway as well as work with the provider market through a market management planning process. Staff told us there was sufficient capacity in the older people’s care market in the borough, but staff were working with providers to ensure the right care was available for this anticipated increase in need.

The local authority’s market shaping plans had recently been reviewed. The Market Positioning Statement (2024-27) identified further work to shape the local provider market, but the full impacts of this work had not yet been realised in areas such as direct payments and complex care for working age adults. There was a market shaping plan which identified several actions in response to areas identified to improve outcomes for people. The plans were underway at the time of this assessment, but many were at an earlier stage and not yet fully implemented. They included a plan to develop a commissioning strategy for people with a learning disability, develop an adult social care workforce strategy, and to improve uptake of direct payments. We heard from staff and leaders these projects were progressing but had not yet had time to impact on the local market and meet local people’s needs.

Staff and leaders told us the local authority had a number of initiatives in place to shape the wider market. The local authority collected data through partnership working and engaged with the local community through events and via staff employed to engage communities to inform strategic commissioning. For example, staff identified the need for live-in care was increasing in the Borough and new care provision was being considered for the local aging population. However, staff also said they felt there was less planning in areas such as prevention services and complex needs provision.

The local authority showed awareness of housing inequalities and understood the barriers for housing provision for adults with care and support needs in their local communities. For example, they had identified there was an insufficient supply of social rented housing for all of those who need it. The local authority commissioned a housing needs assessment for people with learning disabilities. The assessment concluded there was a need for 16 units by 2025 and further requirement of 33 by 2030 and there were projects underway to meet this need.

The local authority was also aware of a need to develop more community provision, alongside health and voluntary partners, to address risks associated with loneliness and isolation identified as a priority through the world café programme. Whilst extensive work had been undertaken to understand this risk and the current provision in the Borough, there had been limited time for actions taken to have the impact the local authority intended by the time of this assessment.

The local authority told us they had an excess of provision for older people with less complex needs. The local authority commissioned 22% of this type of provision to meet demand within the Borough. Staff and leaders told us the number of care home beds available was higher than the demand for these beds. Therefore, there was a higher than expected number of placements into the Borough from neighbouring local authorities as well as a high number of people moving into the Borough to receive care privately.

There were challenges presented by a strong provider market, where people had moved into the Borough who funded their care privately. This resulted in challenges for the local authority in relation to inappropriate placements. There was a strong private care market in the Borough because higher numbers of people who funded their own care lived there relative to other Boroughs in England. Staff and leaders told us how this presented challenges as people could often be privately placed inappropriately in care homes and when their capital fell below the financial threshold for local authority funding these placements often costed more than the local authority’s budget for the type of provision, or people’s assessed needs did not demonstrate they required residential care.

The local authority had identified that instances of this had quadrupled in the previous 12 months and were actively working with providers to address this as part of their contract arrangements. Staff and leaders told us about work to engage the provider market to identify at an earlier stage when people’s capital made them eligible for local authority funded provision, so teams could carry out an assessment and plan care in a timely way whilst reducing the risk of transfers of service provision.

Feedback about unpaid carers provision was mixed, we heard there was provision available but opportunities for unpaid carers to influence commissioning were limited. National data provided by SACE showed 60.61% of carers felt involved or consulted as much as they wanted to be in discussions. This was below the national average of 66.56%. SACE data also showed only 38.89% of carers felt it was easy to access information and advice, which was significantly below the national average of 59.06%. Senior leaders told us they were working with other local authorities across the ICS to review the support available for unpaid carers. We heard from partners how a strong voluntary sector meant there was an offer for unpaid carers but the local authority’s role in shaping that had previously been limited.

Staff and leaders told us about local support options for unpaid carers, including residential respite, personalised carers breaks and access to leisure activities. Social prescribers and dementia care advisors also supported unpaid carers to access learning and gathered feedback on people's outcomes and the impact of service provisions. However, we heard feedback from unpaid carers who felt opportunities to influence service development was limited despite local voluntary organisations being particularly good at signposting them to the right services. 

The local authority told us service capacity in the area was mostly good, with data showing there was sufficient provision and choice for older people with less complex needs. In a survey of Adult Care in England 65% of people who use services felt they had choice over services, this was slightly lower than the average in England of 69.81%. The local authority was aware of gaps in provision for people of working age with a learning disability or long-term conditions, including more complex health needs, and there were projects underway to address these areas through work to develop new supported living accommodation and plans to increase shared lives provision.

People were sometimes placed outside of the Borough, but these placements were often within the county of Berkshire. The local authority monitored data on placements which showed in the last 12 months, 5 people had been placed outside of the Borough to receive specialist care for physical and/or learning disabilities and long-term conditions. Data showed all other out of Borough placements had been due to individual choice and the data showed for residential and nursing care for older people there had been no out of county placements that were not due to individual choice in the last 12 months.

The local authority had worked with health partners to understand local needs around hospital discharge and reducing hospital admissions. The ‘Home First’ hospital discharge model was developed with health partners and there was joint commissioning of reablement and homecare services designed to meet rising demands. Adult Social Care Outcomes Framework data (ASCOF) showed 94.12% of people aged 65+ avoided readmission to hospital within 91 days for people discharged from hospital with reablement, which was significantly higher than the England average of 82.18%. Health data also showed improvements to discharge waiting times. 

The local authority had systems and processes in place to monitor and ensure the quality of the providers they worked with. The were systems to identify and respond to concerns, such as safeguarding issues, concerns with compliance or service quality. The local provider market showed good quality, with 84% of care home providers rated as good or outstanding following assessments by the Care Quality Commission (CQC). The local authority had a clear policy about not placing people in services that had not achieved at least a good CQC rating, including that providers could not join their commissioning framework without being rated good. We heard from staff how they were able to routinely achieve this due to sufficient choice of commissioned and non-commissioned care in the Borough.

There were robust checks in place for homecare providers both before they were commissioned by the local authority and on an ongoing basis. We heard how rates were designed to ensure travel time was paid for between care calls and agreed as part of contacts with providers. Before contracting with a provider, commissioners carried out intelligence gathering to check quality or follow up on any intelligence of concern the local authority might receive. Staff also told us about effective communication between teams if there were concerns or intelligence to share before agreeing placements. We heard examples where concerns shared with the local authority had led to a swift visit from the quality assurance team and saw how they worked with providers to produce action plans in response to quality concerns. There were systems to share information with partners about quality of provision for people placed out of area and staff told us they would conduct reviews in person for anyone in an out of area placement.

Feedback from providers told us the local authority undertook regular quality checks, and we heard there was a supportive approach from the local authority, allowing providers to feel comfortable raising queries. We also heard positive feedback from health partners about sharing of information, prompt sharing of concerns, and local authority responsiveness to issues raised about care quality; this was a shared strategic priority, and we heard how there was effective sharing of information between partners to monitor quality and respond promptly to any concerns.

The local authority had a plan to overcome challenges and ensure the provider market was sustainable. Commissioners assessed all new providers and their assessment included the sustainability of staff recruitment, including training, pay, conditions and providers approaches to recruiting staff from overseas.

The local authority had put a sustainability plan in place which included an assessment of the current financial sustainability of local care markets and how the local authority currently commissioned them. The plan identified current and expected challenges in areas such as workforce and contracts. The plan detailed how the local authority would use fair cost of care funding to ensure social care jobs were attractive and could be recruited to. The plan described how providers already mostly offered above living wage rates to their staff because of the challenges of recruiting in the local area, and the local authority recognised a need to increase provider fees to sustain this. Providers spoke positively about working with the local authority around contracts and rates and staff told us how this was a key component of their commissioning and tendering processes.

Staff and leaders told us the local authority had a proactive strategy for monitoring the risks of provider failure in the Borough. This included a support framework, monitoring of financial stability, joint working on overseas recruitment, and contractual agreements on staff terms and conditions. Provider forums offered further support through peer review, training and the sharing of good practice. There were processes in place to understand provider’s plans in the event of fires and floods to ensure continuity of care, which were monitored by commissioning and care quality teams as they worked with providers.