London Borough of Hounslow: local authority assessment

People with care and support needs could easily access the local authority’s Care and Support services. There were multiple channels to request an assessment, including online and self-assessment options. The complexity of need, and whether the individual was recently known to a social worker influenced who picked up the request, but in all cases, referrals were triaged, and risk assessed.

The approach to assessment and care planning was person-centred and reflected people's right to choose. It built on their strengths and assets, reflected what they wanted to achieve and how they wished to live their lives. Staff took a ‘strengths-based’ approach to social work practice where they focused on what people could do and their abilities, knowledge, and strengths. Assessments and care and support plans included information about medication support in line with best practice, but we found variable amounts of detail or clarity around what those support needs were. There was a strong focus from staff on keeping people safe, preventing the deterioration of needs, maintaining independence, and building resilience.

Hounslow staff told us they have adopted the Lundy Model to engage with people during the assessment process and in their ongoing engagement with people. The Lundy Model focuses on creating an environment where officers can listen to the person. The four principles in the Lundy Model ensure officers provide people with:

• Space - creating inclusive environments for diverse participation and collaboration.
• Voice - ensuring everyone’s perspectives and opinions are heard and valued.
• Audience - identifying the intended recipients or stakeholders of the messages or decisions.
• Influence - empowering individuals to impact decisions, policies, or actions through their contributions and involvement.

Some people we spoke with were happy with the assessments they had received, and the care put in place. Others raised concerns about assessments and care planning, for example about the transparency of decision making, and a lack of support provided as a result the assessments.

National data supported our findings with 76.65% of people in Hounslow who used services felt they had control over their daily life, 63.64% being satisfied with their care and support, and 42.23% respondents reported they had as much social contact as they wanted with people they like, which was not statistically different to national or regional data (Adult Social Care Survey, published 20 October 2022).

Some people told us their experiences of care and support ensured their human rights were respected and protected, they were involved throughout in decisions, and their protected characteristics under the Equality Act 2010 were understood and incorporated into care planning. By contrast, other people told us very clearly this was not their experience.

There were clear pathways and processes to ensure people’s support was planned and co-ordinated across different agencies and services, particularly in relation to timely, safe, and effective hospital discharge.

The local authority had specialist teams for adults with a learning disability or autistic adults, adults with mental health needs, and a team for young people in transition from Children’s to Adults’ services. Other adults with care and support needs were assessed by Locality teams or the First Contact team. All assessment teams were competent to carry out assessments, including specialist assessments. Teams understood risks for people who were most likely to experience inequality in experience or outcomes, and for people with protected characteristics.

The local authority told us they ‘practice within the underlying principle...that service users should receive an assessment and services without unnecessary delay’. Their approach was to triage to identify if there were urgent presenting needs or risk factors which must be addressed, and which cases needed to be prioritised for a full Care Act assessment. Where it was apparent that the person required urgent support, interim care arrangements would be provided immediately, even before a full Care Act assessment had been completed. This is in line with the most recent guidance on the Care Act 2014 issued by DHSC in October 2023. Hounslow told us they were reviewing the way the data is captured as they felt the current system did not accurately reflect their approach.

The people with care and support needs who we spoke with, had no concerns about the timeliness of assessments or care planning. However, some people waited longer for completion of a full assessment. Social work teams reviewed unallocated referrals weekly, and there was a risk framework against which these were prioritised. Hounslow recorded data about waiting lists from initial request for services, which included details of people waiting more than 28 days for assessments following contact/requesting services. In March 2023, 291 people had waited over 28 days for an assessment, including 99 people waiting for a Care Act Assessment, and 105 people waiting for an OT (Occupational Therapy) Assessment.

Hounslow acknowledged performance in relation to reviews of peoples’ long-term or short-term care were lower than the national and regional average and this was confirmed in the Adult Social Care Finance Report (ASCFR) on Short and Long-Term Support (SALT). According to this data, 42.63% of people receiving long-term support were reviewed (planned or unplanned) which is significantly lower than regional average of 58.6% and national average of 55.2%. Hounslow told us they closely monitored performance of annual reviews and acted when it fell below 60%. Actions included the prioritisation of reviews of cohorts of people and directing additional resources to reduce backlogs of reviews.

The local authority had robust processes to assess and manage risk, and to ensure people were safe, pending full completion of Care Act assessments or reviews. People awaiting assessments were contacted regularly to check whether their needs had changed. They might also be provided with short term provision to mitigate risk for the individual until a full assessment could be completed.

There were no notable delays in assessments for people awaiting discharge from hospital. Feedback from staff indicated the Out of Hours (Emergency) team, had sufficient capacity to assess and meet need. They told us they recognised the need to be flexible at times to accommodate extra demand.

Data provided by the local authority showed longer delays for assessments to be completed in some specialist teams, for example Mental Health team and the Adults with a Learning Disability or Autistic People Team, and in some Locality teams. Challenges around increased demand, complexity and capacity in the teams all contributed to these delays. Each team had a process for triaging, prioritising and keeping referrals under review. Contact was made and referrals were prioritised according to risk, and where necessary protection plans put in place pending full assessments. Where there was a significant capacity issue which was affecting the start of assessments, this was escalated and a range of measures including diverting staff resources was available.

Where a person’s needs changed or risks to them increased, these were triaged and prioritised as necessary. Hounslow were clear, the safety of individuals and the prevention of deterioration was of prime importance, and this meant prioritising assessments of new presenting needs and risks, over reviewing people already in receipt of packages of care.

The needs of unpaid carers were understood to be distinct from the person with care needs. When they occurred, carers assessments, support plans and reviews for unpaid carers were undertaken separately. However, the local authority recognised they do not serve unpaid carers as well as they should, and they have developed an Improvement Plan to address this. The number of carers assessments undertaken in the last year is relatively small and not always timely with waiting times averaging 24 days. Dependent on which team was dealing with the request, the waiting time for assessment could be as long as 93 days. Staff told us there was a low uptake of carer’s assessments; telling us “People say no”. They attributed this to a relatively weak offer for carers. They noted there was a carer short break service, but it was not very well utilised. Most of the provision was for people with care and support needs as opposed to carers.

The national Survey for Adult Carers (SACE) data for Hounslow suggested poorer experiences and outcomes for carers. Only 31.34% of carers were satisfied with social services, which was reflected in what we heard. One carer told us they did not receive any support from social services, and they did not know where to go to get help. They said they felt "very lost, and alone" and felt social services should make it more public what help and support is out there for people. They told us that before their family member was admitted to a care home, they had been "crying out for help”. This reflects the SACE data for Hounslow that only 22.34% of carers accessed a support group or had someone to talk to in confidence, and only 26.80% of carers felt they had encouragement and support.

Some carers we spoke with were satisfied with their experiences, telling us that staff were responsive and supportive, their assessments met their needs and were timely. In contrast one person described the assessment process as “long winded and said there was little offered after the assessment had been completed. The only plus was the Emergency Card.” Others noted they did not get an assessment when they had asked for one, or they did not know they were able to ask for a review when their needs changed.

Whilst no carers spoke of it, the SACE data suggests that more than half (51.55%) Hounslow carers experienced financial difficulties because of caring. This was likely to be linked the fact that 43.66% of carers reported that they were not in paid employment because of caring responsibilities. This was significantly worse than the England average of 28.14%.

People were given help, advice, and information about how to access services, facilities, and other agencies for non-eligible care and support needs. These could be obtained by online directories, contact with Hounslow by telephone or in person, and through a roaming roadshow called the “Gazebo”. Hounslow worked in partnership with Community Solutions and other organisations to host events where people can obtain useful information, advice, and support – for example “cost of living” cafés which were delivered in council offices and other community places.

We received mixed feedback about whether the local authority’s framework for eligibility for care and support was transparent, clear, and consistently applied. We heard from people who felt eligibility decisions were fair and clear, and received feedback from some people who felt assessment decisions about eligibility were unfair and did not take account of their needs. Some of these also reported that complaints or efforts to appeal decisions were not responded to. No data about appeals against Care Act decisions was provided by Hounslow. Hounslow told us there were 26 complaints received between January – December 2023 (Data provided in relation to adult services) of which 22 related to ‘significant or repeated failure to provide a service’ which might reflect dissatisfaction with the way the eligibility criteria was applied, but this is unclear. 14 (53%) complaints were not upheld, 5 (20%) complaints were partially upheld and 7 (27%) were upheld. This was a very small proportion of the number of assessments and reviews undertaken in 2023 and 183 compliments were received in the same period. There was no evidence to suggest that particular groups or individuals were likely to be treated unfairly in relation to the use of eligibility criteria in Hounslow.

Hounslow had outsourced financial assessments. People waited a long time for decisions regarding their financial assessment, particularly when moving into residential care. There was no evidence that this delayed people from moving into placements but could have caused financial worry to them or their families and meant that people were unable to make a fully informed decision prior to moving without delaying a necessary move. Some people reported a lack of clarity and poor communication of the Charging Policy. Hounslow had recently redesigned these processes, and in January 2024 launched an online calculator to work out personal contributions. The local authority told us there were two complaints about the cost of services. We also received direct feedback from an individual who told us they had complained about their financial assessment amongst other issues, but no data was provided about complaints specifically about the financial assessment process by Hounslow.

Most advocacy was commissioned from a single provider to meet the council’s statutory advocacy requirements. An advocate can help a person express their needs and wishes and weigh up and make decisions about the options available to them. They could help them find services, make sure correct procedures are followed and challenge decisions made by local authorities or other organisations. In the last 12 months, this single provider hadn’t always been able to meet demand in a timely manner or meet specialist needs. When this had happened, the local authority commissioned other organisations on a case-by-case basis. This has minimised the delays, so most people receive timely, independent advocacy support to help people participate fully in care assessments and care planning processes.