London Borough of Camden: local authority assessment

The local authority demonstrated a good understanding of its community’s support needs. The Joint Strategic Needs Assessment (JSNA) was refreshed in 2020 and the local authority had since developed more focused documents such as a health needs analysis and ‘deep dives’ into specific topics such as social isolation, drugs and alcohol needs, inclusion health groups, long covid and employment. The health and well-being strategy 2022 to 2030 and the North Central London (NCL) population health and integrated care strategy alongside the public health directors report 2023, detailed the needs of the population.

This analysis was live and ongoing with partners. An inclusion health needs assessment published in March 2023 showed the NHS Integrated Care Board (ICB) commissioned the local authority’s public health department to conduct a needs assessment around 6 distinct groups. They were: people living with multiple disadvantage; homeless people; individuals with a history of imprisonment; people who sell sex; vulnerable migrants and Gypsy, Roma and Traveller communities. The health and well-being strategy reflected their principles around prioritising prevention, tackling inequalities, empowering communities and integration and communication. Priorities and ambitions were clear with lead organisations and timelines attached.

The drug and alcohol needs assessment in January 2024 incorporated a ‘think family’ approach. These partnership considerations led to preventative work and a pathway design from the criminal justice system to substance misuse services. It demonstrated a strong use of data approach, making recommendations to rectify gaps in data and promoted better use of co-production. The local authority had invested in data analysis to good effect and the changes from public health moving from a bi-borough approach to a local authority approach had allowed specialist academic and data lead resources to be deployed more effectively in the service of groups in the local area. This involved a better understanding of people at risk of deteriorating health and care outcomes as result of cold weather and other vulnerable groups. Data was used innovatively to evaluate the demand of reablement services and performance of providers in the local authority. The reablement service had been recommissioned from two providers to three as a result of support provided from this analysis which helped to tailor the service to the population and had been used in continuous monitoring with commissioners.

It was clear the local authority had used its housing resources effectively to respond to the local challenge in sourcing care resources. They had considered the full range of people and care needs and had provided innovative solutions. For example, the extra-care model was used effectively to provide flexible and person-centred care to a variety of groups of people including younger adults with disabilities. We heard this had supported people's independence, wider life goals and ambitions. They also had further extra-care schemes in development and had remodelled some sheltered housing into extra care services. Support through shared lives was also used creatively by expanding to meet the needs of people with mental health challenges and people leaving asylum provision. These changes had been co-produced and consulted upon with the new potential people. Staff said the local authority had invested heavily in shared lives and support for shared-lives carers had been enhanced recently with financial incentives for people sharing their home.

The local authority had other clear ambitions to support people at home and clear plans to alter commissioning strategies when current provider arrangements expired. These included the further integration of health and social care, the roll-out of integrated neighbourhood teams, further workforce development and in-house community-based services with testing underway until 2026. Commissioners worked throughout the whole commissioning cycle and had both design and lead roles. We found commissioners engaged with the community, providers and people in Camden.

The local authority used commissioning and effective market shaping to meet local needs. There was a long-term care, support and reablement commissioning strategy which showed plans to commission one provider per neighbourhood of the long-term care and support of people at home market and two providers of reablement support on a localised footprint. There were examples of the provider sector being convened by the local authority to support a good market culture and provide the most appropriate placement. In general, people had access to a diverse range of local support options that were safe, effective, affordable and high-quality to meet their care and support needs. There was a NCL partnership market management update which described joint work to sustain and shape the market. The market position statement described current provision for residential, nursing, home care, supported living, extra care, community-based care and reablement. It also highlighted the role of unpaid carers with some suggested future improvements.

The local authority had set out their intention to meet demand for nursing and residential care more locally. The market sustainability plan detailed plans to change the home care arrangements from 32 separate providers which had taken place and was effective. There were now stable home care organisations providing locality-based home care in neighbourhoods. The market position statement said the local authority were looking to develop a greater number of care home placements for people with dementia, mental health needs and those with distressed behaviours through working in partnership with providers and colleagues in NCL. Community day services had been reorganised so people could stay in services and not move around based on level of need. Partners were generally extremely positive in their feedback about the local authority’s market management relationship with them. Providers were supported to participate in consultation and were consistently treated as equal partners in discussions around residents’ placements and contract management issues. The local authority’s relational and power sharing approach to market management was strongly appreciated by partners. Their commissioning practices encouraged a collaborative culture between organisations, rather than a competitive one.

However, ASCS (2023/2024) data showed fewer (59.90%) people who used services felt they had choice over services, compared to the England average (70.28%).

The integrated health and local authority strategic commissioning teams were separated in 2024, reverting the shared team and budget to separate local authority and ICB teams. Despite this change, mental health and learning disability funded services were commissioned in an aligned way with services unaffected by the change. We heard many examples from staff, leaders and partners of joined up effective relationships and services. The local authority had worked with the autism hub to redesign the tender for advocacy and autistic people had designed elements of the tender by giving examples of the challenges they faced and then reviewing and scoring the tender responses to these scenarios. We heard about creative commissioning such as an example with social prescribing, areas of joint commissioning with the ICB and a data led approach.

Leaders described work undertaken over recent years to understand and improve access to carers services and had identified this as an area for improvement. This included learning from other local authorities and bringing proven governance methodologies to the local system. There was a clear strategic and service level delivery plan to implement and monitor improvements. We heard praise from carers for the commissioned carers organisation. There was one example where a person had attended a day centre for young carers which they had found useful, and another reported they had been supported with a housing issue. We heard another example where a person had received money for a short break, although another said they didn't think the council would help them and they would rely on family instead. We also heard examples of effective support for a carer who was going into hospital. However the nationally published data (SACE 2023-24) showed fewer carers (5.71%) accessed support or services allowing them to take a break from caring at short notice or in an emergency, than the England average (12.08%)(negative variation); fewer carers (11.43%) accessed support or services allowing them to take a break from caring for more than 24 hours, than the England average (16.14%)(tending towards negative variation), and around the same proportion of carers (16.67%) accessed support or services allowing them to take a break from caring for between 1-24 hours, than England average (21.73%)(no statistical variation).

The local offer for young people with transitional needs was excellent, with meaningful day opportunities, skills support and employment support offered consistently to young people. The integrated 0-25 team was able to support young people in their education setting and the ‘living a good life panel’ was a person centred and empowering way for young people to speak directly to service providers and understand what support and community activities were available to them, depending on their interests. It was also an innovative approach to market management.

The local authority provided data showing there were no waits in finding a place for people in home care, residential or nursing care services. Staff said there were no capacity issues with home care, and they used ‘spot’ providers when needed. This was supported by no waits in hospital discharge. Staff had regular meetings with providers and commissioners to plan for capacity in known pressure points such as during the winter period. Partners reported an excellent working relationship around placements and meeting demand.

There were high levels of people placed out of area due to a lack of residential nursing services directly provided in the local authority. 55% of these placements were within North Central London and a further 22% within the Greater London area. We heard from staff about how out of area placements were managed, reviewed and supported with some choosing to live nearer family and there was clear evidence of people out of area being supported well. Partners also said the residents placed out of borough were well supported. However, we heard about one example where a person waited a long time for a placement because they needed specialist accommodation, which wasn’t easily available in the area.

Capacity in supported housing and services for people with learning disabilities was considered and planned for as a result of the local authority’s ambition to move people away from residential care. The learning disability accommodation strategic framework refresh (2024) showed 26 supported housing schemes for people with learning disabilities had been inspected annually and red, amber, green (RAG) rated. Recently, 11.4% of the schemes had been rated Red, which had improved from nearly one third in 2019. Plans showed the local authority had 17 new letting units in development, intended to be delivered by 2027/2028 and further shared life schemes and schemes offering people more support in their home.

There were now five home-care providers contracted with one in each neighbourhood team area. Staff said this meant providers act as partners to one another rather than in direct competition. There were examples of creative working with providers and building networks between them to support trauma informed work, cultural competency and working in a relational way. There was a trial underway with a small group at the time of our assessment to improve and support care practices.

Staff working with emergency placements and mental health placements told us the local authority was supportive in helping them find a placement as close as possible to the person’s preference, and there was positive working with social workers and families. Staff said the local authority was flexible in its funding decisions for placements. The local authority’s supporting people connecting communities accommodation plan, ‘a place to call home’, set out 5 ambitions to meet accommodation needs in the next 10 years. It detailed a commitment to co-production and hearing people's voices whose views were seldom heard. There was significant joint work with housing to review accommodation needs capacity and extra care and other housing schemes. There was also evidence of a ‘Home-First’ model in use and we heard examples of supporting people to live with family again, by enabling the move of a person to an extra care scheme from a care home. Staff consistently told us there was sufficient supply for all types of accommodation for people in the local authority and there were no barriers to sourcing care or housing for people and partners confirmed this. Although national data showed carers breaks were not as available as they could be and carers gave mixed feedback about availability of respite and short breaks.

There were no delays to hospital discharge and the reablement service was person centred and effective. The demand for care placements exceeded the capacity in the borough year on year and so the spot placement market across and beyond North Central London was key to the local authority. Commissioners worked at the 5 borough level to find joint solutions through a joint market management strategy which included workforce development initiatives. There was effective collaboration with VCSE services providing emergency support to vulnerable residents. The central London local authority location meant they experienced increased numbers of homelessness presentations, and they had people with no recourse to public funds awaiting a decision from the Home Office. Despite these levels of demand, we heard consistently about the availability of homelessness services and a very strong collaborative and supportive working relationships between housing and adult social care.

The local authority expected young people to be in education until age 19, to facilitate this there were a number of colleges well equipped for those with complex needs and those with more profound learning disabilities.

There were effective arrangements to monitor the quality and impact of care and support services commissioned for people. The local authority was proactive in identifying concerns with local providers and supporting improvements, including in out-of-area placements. There was a provider oversight board, and commissioners held quarterly meetings with providers. There were no commissioning embargoes currently in place at the time of our assessment. There were clear action plans in place when quality concerns had arisen. In one example where a provider had received a ‘Requires Improvement’ (RI) rating from the Care Quality Commission (CQC), the local authority worked with them to create a plan to improve. The local authority was proactive in establishing concerns around quality rather than reactive to CQC ratings and findings. Providers described an equal partnership and a supportive relationship about learning from issues or problems and finding improvements together. There was a provider oversight and quality assurance arrangement procedure, which showed regular contract monitoring and management quality assurance visits to providers, involved residents and carers feedback and monitoring of CQC ratings and intelligence. There were regular meetings of the quality assurance teams in order to produce up-to-date information as well as monthly provider oversight board meetings which were used to share significant safeguarding actions or concerns about providers. They were attended by commissioners and senior adult social care staff. Staff and partners equally said any issues or concerns were raised at the monthly meetings. Arrangements were effective in creating a culture of quality assurance oversight and joint working. In addition, integrated neighbourhood teams met quarterly with local providers to consider the quality of services and met with community coordinators to enable them to gain knowledge about the local community and support available within each integrated neighbourhood team. Providers said they were encouraged by the local authority to work collaboratively and plan together. One provider gave negative feedback about their experiences of going through a provider concerns process.

There was a small market of care providers based in the local authority area and from those, 50% of nursing care homes were rated good, 33% Requires Improvement (RI) and 16.67% were not rated. 60% of residential care homes were rated good and 40% were rated RI, 6.67% of Home Care Services were rated outstanding, 57.78% good, and 15.56% RI, with 20% unrated. 100% of supported living services were rated good by CQC. Two locations had been de-registered within the previous 12 months.

The local authority took steps to ensure there were appropriate working conditions and pay in practice reflecting requirements in commissioned contracts. Staff, during annual provider visits with a safeguarding colleague, looked through staff files including payslips and ensured they were paid the London living wage and travel. Individual staff members were also contacted individually on pay and whether they felt supported at work. Monitoring provider meetings also happened quarterly. Home care had been recommissioned onto a neighbourhood model, where a single provider had responsibility for the service in each neighbourhood area. This meant home care staff worked in a local area which reduced travel and effectively supported service sustainability. The local authority was a signatory to the Ethical Care Charter and staff said they wanted to offer specific hours to workers, however following feedback found many staff like the flexibility offered by flexible contracts. Staff and partners said the home care recommissioning had been a success in terms of staff and service sustainability. A forum for care workers had been facilitated by an arts organisation on behalf of the local authority to support team development and bringing people together. They also provided some cooking sessions to improve cultural competency in the home care workforce.

A workforce strategy was launched in 2024 (alongside a Health and Social Care Academy) which had a focus on workforce sustainability and a commitment to good governance and long-term planning. The NCL partnership had given guidance to providers on international recruitment. We found the local authority knew about levels of pay, the percentage of staff on zero hours contracts and vacancy rates among commissioned providers and had future workforce projections. Skills for Care workforce estimates data (2023/24) showed there was a staff vacancy rate of 16.78% compared to an England average of 8.06% in the local authority (significant negative variation), but a 0.10 adult social care staff turnover rate, which was a significantly positive variation to the England average of 0.25. The local authority also had an average sickness rate of 5.30 days, consistent with the England average of 5.33 days.

The NCL social care workforce programme stated it had made progress towards recruitment and development of an adult social care workforce. We heard training in the ‘What Matters’ approach was delivered to providers and there was a bespoke ‘What Matters’ induction for new staff within providers. There was training for providers around safeguarding, occupational therapy, manual handling and on trauma informed care. Partners said the local authority worked well with them to develop a training package for staff in managing distressed behaviours in the workplace. ‘Proud to Care’ was a website dedicated to the recruitment training and development of staff within the NCL area and it contained an employer's hub to be used by providers seeking to employ social care staff, which was user friendly.