London Borough of Brent: local authority assessment

Demand for care services had increased with 4292 people receiving adult social care in Brent in March 2023, from 3819 in April 2020. Along with an increase in demand and there was an increase in complexity of care needs of people. The highest area of support was for homecare, followed by direct payments support, then residential care.

The local authority worked with local people and stakeholders using available data sources to understand the care and support needs of people and communities. Data was available on their systems, such as census data. However, the local authority described how they wanted future data to enable them to enhance their planning for the future of adult social care, including the demand for housing.

The local authority worked in collaboration with 6 neighbouring boroughs in North West London to share information on quality across the care provider sector. This was facilitated by engagement in the North West London Commissioning Alliance forums which focussed on care homes and the supported living provision.

Staff worked with people to understand their care and support needs. For example, carers were offered respite, which varied depending on the complexity of needs. There was flexibility with the respite hours offered and that they were usually able to offer consistency in staff used to minimise disruption for people. The local authority recognised improvements were needed in this area and staff had been encouraged to think more creatively about care for people. For example, referring carers to dementia cafes for support, rather than use more traditional options such as sitting services which could be more restrictive. Brent Carers Centre offered some free therapeutic support sessions for carers.

A new initiative of a night support care offer had reduced care home placements by providing floating support for people at night. This could be 2 or 3 calls in the night and care staff were provided with a car. This service enabled people to be more independent and stay at home when they may have previously had to go into 24 hour care.

Other challenges included the gradual process of getting people with learning disabilities and autism back to face-to-face support after the COVID-19 pandemic. Specialist teams involved were experienced and reported good joint working with families, people and health staff.

People had access to some local support options to meet their care and support needs. One carer told us about a service in the community which was particularly good in relation to supporting people with mental health needs and their family member enjoyed attending this. Data in Brent shows 65.1% of people who use services feel they have choice over these, which is slightly lower than the England average of 66% but above the London average of 62.3% (ASCS, 2023).

Staff worked with care providers at a provider forum, which facilitated good working relationships, provided support and helped further understanding when allocating packages of care. Staff had a strong relationship with the brokerage teams which sourced care which ensured a link between allocation of packages and available resources.

Co production was being used to help understand local needs in relation to days services and commissioners were engaging with providers to better understand the gaps and shape the market. Staff explained they were moving away from more traditional models of day support as a result.

Commissioning strategies included the provision of suitable local housing with support options for adults with care and support needs. There were challenges in commissioning services within the care home market that could meet the complexity of people's needs, while balancing the capacity of services with price and quality. Growth areas in Brent had been within mental health services, especially around housing.

The grant programme which provided funds to the voluntary sector was managed centrally and there was no clear connection with the commissioning function. Therefore, this lacked a focus on how the local authority were shaping the market for prevention and for reducing people’s needs for care and support. Feedback from local authority leaders was that there was some work with commissioning and the voluntary sector taking place which included work in relation to carers and day services.

The Accelerating Reform Fund for 2023/24, was set up to provide innovation and scaling up in adult social care and kick-start a change in services to support unpaid carers. Brent had been given some funds for this and this was being used to ensure funding for the voluntary sector aligned more fully with the requirements of the Care Act. Senior leaders felt more was needed to be done around prevention of people’s needs and use of technology.

The local authority Market Sustainability Plan (2023-2025) stated demand for services had increased since 2020, however, to date there were new challenges to manage in terms of recruitment and retention of staff to ensure service quality. The care home market consisted of 17 care homes, 11 nursing and 6 residential. The market was generally small with the main providers being national care home providers. Brent commissioned some residential and nursing homes in the wider West London market too and commissioning was in place with two of the other local London boroughs.

Commissioning strategies were aligned with the strategic objectives of partner agencies. Health partners explained there was a focus on care provision in all areas and how they were working to commission with the local authority with pooled budgets to enable financial efficiencies and better coordinated services. There was a recognition of the social challenges in the area and with the demand for housing and employment.

Some community partners felt there was a gap in provision for people living in hostels who were not in drug and alcohol related treatment and didn’t meet the threshold for intensive support. There was an outreach team in the local authority, but more was needed. They told us other local authorities placed people in the area and Brent were not informed of this which placed people at risk. Other partners told us there had been positive recent attempts to improve commissioning, for example, accommodation for people with both mental and physical health needs.

There was sufficient care and support available to meet demand. There was a strong provision of day services, respite services and supported living services in the borough for people with a learning disability. However, there was less availability of learning disability specific residential services for people. Feedback from local authority staff was there was a lack of understanding of autism spectrum disorder within the local authority and that there was also a gap in services to support people with this diagnosis. This had been fed back to leaders.

National data in relation to carers showed 10.17% of carers accessing support or services allowing them to take a break from caring at short notice or in an emergency which is similar to the England average of 10.76%. However, 25.86% of carers accessing support or services allowing them to take a break from caring for 1-24hrs was higher than the England average of 20.08% (SACE, 2022). Carers gave mixed feedback about services. One carer told us Brent Day Centre was good. However, another felt they had watched community resources being withdrawn or closed down which had impacted on them.

Commissioning staff had positively set up the NAIL project (New Accommodation for Independent Living) which was an initiative to reduce the reliance on residential homes, and a 61 bedded extra care scheme was part of this project. There was a driver within teams to further develop extra care, with the focus to keep people local. There were 8 extra care sites, with others being developed or repurchased by the local authority to enable them to be developed.

Shared lives staff teams felt well supported by the local authority to expand and develop the service. Shared Lives matches people who need care and support with an approved carer. The carer shares their family and community life and gives care and support to the person with care needs. This team told us they were focussed on being a viable alternative to other provisions such as residential care, supported living and homecare.

Some staff told us about gaps in services. For example, there were some challenges around specialist housing for example, there needed to be a more joined up approach with other agencies for people with drug and alcohol issues. They told us there was a lack of provision for young people for age-appropriate services. For example, some of the day services in the borough had an older demographic so on occasions staff commissioned a continuation of the children’s services instead. It was also identified services specific to those with mild to moderate needs to support training and life skills development for young people was not well developed. The team told us this had been raised with the commissioning team as more transition-appropriate service provision was required and we were aware of work to redevelop day services to move away from the more traditional service model, which linked to this.

Feedback from partners was the low use of sheltered housing and pressure for people to stay at home had put pressure on the adaptation budget and exacerbated waiting lists. There was a middle group of people who were not in need of care support enough for specialist accommodation, but too ill for general housing and this was being reviewed through commissioning.

Brent Council Market Sustainability Plan documented the increase in placements within supported living and extra care housing with a focus on people living independently. In terms of market and commissioning there was sufficient residential and nursing provision to meet the needs and demand for people in Brent. Brent's commissioning intentions were to reduce the need to make care home placements and move towards services in extra care, 24 hour homecare and peripatetic night support to support independence.

The local authority had 16 providers on a framework with packages being advertised on their system. Other care providers were used on a ‘spot’ contract basis. Three reablement providers supported the prevention aspect of the market. There were limited waiting times for care services starting as there was enough capacity in the market to accommodate demand, with no waiting list for homecare unless there was a need for a specialist package. Beds could be found for residential and nursing care within 24 to 48 hours and interim one to one support could be provided to enable people to be promptly supported in care homes (such as dementia care). Supported living could take longer to plan in terms of tenancy agreements but staff told us there was not a pressure to make these placements.

There was some need for people to use services or support outside of their local area. However, support was provided for people to move back if they wished to do so. For example, progress had been made around learning disability placements in reducing the out of borough placements from 200 to 77. Many of the remaining 77 people did not want to return to closer settings due to longevity of the placement or family reasons. There had been 273 out of borough placements made in the past 12 month against 646 in borough, which was mainly based on people’s choice, family preference and affordability. These placements were reviewed annually. Other local authorities, NHS and people who funded their own care utilised the remaining beds in Brent.

The local authority had clear arrangements to monitor the quality and impact of care and support services commissioned for people and it supported improvements where needed. Actions were taken to support quality improvement.

In Brent 100% of nursing homes, 83.72% residential care and 68.97% of homecare were rated as good overall by the Care Quality Commission (CQC). The proportion of care home beds (across all sectors) rated Good or Outstanding was 80% and compares well with other areas of London. The majority of placements made by Brent Council were in homes rated Good or Outstanding and again compares well to London.

Weekly quality assurance meetings were held by commissioning staff to gather intelligence, feedback issues and the providers were RAG rated based on risk. Any appropriate concerns were shared with partners such as other boroughs. Announced and unannounced visits were carried out to review the risks and quality. This meant the team were able to monitor services in a structured way. Three care providers had been subject to the provider concerns process in the last year and this was in relation to management, staffing and safeguarding concerns.

Packages of care were consistently reviewed by local authority provider relationship officers along with providers receiving regular checks and monitoring. Providers told us the local authority was responsive, communicating and engaging well with them. For example, small changes to care packages could be done through a computer portal, allowing for some flexibility when needed.

There was a system in place to manage any quality concerns with action plans and support. Where embargos had been implemented the providers were supported to address the issues and all current embargos had been removed. Providers gave us positive feedback about these quality assurance measures and told us quality monitoring was thorough and supportive.

The team had been developing an approach to obtain peoples feedback for services which were to be re-tendered. The feedback obtained would support the development of the services, for example the support contract for people with learning disabilities.

Quality of care services was assured with supported training and development for care providers. The provider process included yearly visits and completion of a quality assurance checklist. Contract management meetings were held with providers connected to contracts. Commissioners and staff met with CQC to share information on risk and quality. Sector specific provider forums took place each year run by a Brent care home registered manager, plus monthly care home forums and peer support programmes. A supported living accreditation scheme supported quality assurance processes and for the region to deliver shared objectives.

A North West London Quality Group was chaired by a Brent senior commissioning manager which meant they took a key role in quality in their local region cross-borough. The local authority worked well with neighbouring boroughs in West London to share information on quality across the sector. This was led by the engagement with the North West London Commissioning Alliance with forums focused on care homes and supported living.

An ‘Enhanced Health in Care Homes Programme’ was in place where the local authority worked with health partners to provide training, support, coaching and a peer network for providers to improve.

The local authority worked with providers and stakeholders to understand current trading conditions and how providers were coping with them. Local authority staff were able to assure themselves about staff renumerations and working conditions. The London living wage was assigned to all the provider contracts and they monitored care staff contracts to ensure these were not ‘zero hours’, and staff had enough time to support people safely. Each provider was encouraged to look at geography allocation to reduce staff travel between calls.

National data for Brent showed adult social care staff who had the Care Certificate in progress, partially completed, or completed was 45.23%, slightly below the England average of 49.65%. Adult Social Care job vacancies were much higher at 25.10 % in Brent however compared to the England average of 9.74% (Adult Social Care Workforce Estimates, Skills for Care, 2023) which added to the challenge of care provision.

The local authority worked with care providers to maintain and support capacity and capability. Support was offered to care providers by the local authority, for example manual handling training was being offered for personal assistants which people employed. Grants were offered to care agencies and they had an academy for overseas recruitment.

Care providers told us the local authority supported them in recruiting and retaining the social care workforce and spoke positively about the provider forums and quality assurance visits undertaken.

Placements for care provision were made through a contract with annual cost of care reviews. The local authority commissioning strategy continued to review alternatives to care placements with the main areas of risk being the gap between people who funded their own care, the rates the local authority could pay and the workforce supply. Annual fee reviews helped to ensure the sustainability of the market along with the internal quality assurance teams who had all round oversight of providers. In terms of domiciliary care, 44 providers contracted with Brent, however there were 63 providers working with Brent in total, the difference being ‘spot’ contracts. A lead providers homecare model was in operation, with 7 lead homecare providers for older adults and physical disabilities and 4 lead providers for mental health and learning disabilities.

The local authority Market Sustainability Plan documented planned investment in other services including 4 new extra care services and 3 new learning disability services over the next 4 years. Further actions to improve market sustainability included the uplift of ‘spot’ rates for care services not on the local authority main framework.