Derbyshire County Council: local authority assessment

Through the Joint Strategic Needs Assessment (JSNA) the local authority demonstrated an understanding of diverse health and care needs with data showing a strong correlation between deprivation and health outcomes. It identified 20% of the population were experiencing deprivation. The JSNA also identified learning disabilities, dementia, autism and neurodiversity as areas to address for both children and adults. We saw evidence of action on this data with the roll out of Neurodiversity hubs. There was also a joint dementia strategy, and an integrated all-age autism strategy, which had been initiated following it. There was an impact assessment which recognised the link between housing and health outcomes with a collaborative agenda to tackle this issue with partners.

The JSNA had been used to shape services and staff described plans to do more with the information in terms of understanding the differences in their population. Data had been collected to inform models of care for example, there were gaps identified in the provision of nursing care home and dementia care home provision which was considered in the market position statement process.

A significantly higher proportion of people (78.54%) than the national average (69.81%) felt they had choice over the services they used locally (ASCS). The market position statement made specific reference to identified groups in planning and shaping future services. This included new care and accommodation services, new crisis prevention and support services and clinically led care for those with complex needs. There was a collaborative approach towards a more community-based support offer for people with learning disabilities. A summit on ‘building the right support’ in terms of care and accommodation had been held. There was an all-adults housing accommodation and support strategy that focused on independent living and housing with support. The local authority was successfully working to their own targets of moving people with learning disabilities from more traditional settings such as care homes, into less restrictive settings such as supported housing.

There were significant levels of in-house provision of residential, domiciliary and day services. Leaders described a strategy to shape the market to improve the range of options for people. They explained how their move away from in-house long-term homecare had enabled a more sustainable independent sector market to develop. The local authority was in a period of formal consultation on proposals to re-design and re-size their in-house residential services to focus on short-term reablement services and long-term specialist dementia beds. This strategy was working in its early stages with services being used to support the discharge of people from hospital.

Staff from a variety of teams reiterated the transformation from in-house care provision to an enabling model of community support. We saw examples of commissioning practices enabling people and sectors, such as the homecare framework which increased the number of providers available to the local authority from 55 to 96. There was also flexibility in contracts around volunteer outcomes and service user outcomes. The commissioning team had a direct link to housing teams in districts to get appropriate housing to meet people’s needs.

Partners and providers reported mixed levels of confidence in the local authority’s plans for the future. There was some concern over funding stability, and risk around geography and capacity in the homecare market. There was a sense of detachment and a lack of involvement in market shaping, from some partners. However, an example was provided where the local authority had worked very positively to reshape a provider’s services.

The market position statement highlighted key pressures in the local authority for homecare, extra-care and nursing care provision particularly in the more rural parts of the county. It identified a challenge to develop and sustain care homes in specific areas, at affordable rates. New care homes had focused on areas where there was a strong self-funder market, with fees charged above those paid by the local authority.

The requirement for high staff-ratios had led to some providers informing the local authority that risks were too high to operate. Data showed admissions into residential care had decreased with an average occupancy of 85% and demand for homecare had increased at a rate higher than the pre-pandemic year of 2019. Senior leaders described plans to address this as part of transformation.

Recruitment and retention of skilled workers and a reliance on agency workers, was a challenge. People said homecare staff shortages had an impact on their daily life and their sense of choice and control. People in rural areas found it particularly difficult to access homecare and other facilities such as transport. We heard one example of the local authority supporting providers sponsoring overseas staff, but otherwise there was mixed feedback about support for providers around recruiting staff. Staff described some difficulty in finding care providers due to recruitment issues but said this may be improving. There was significant variation in different parts of the county with less choice for extra-care services for example. The senior leadership team had identified homecare as a priority and there was a new framework to facilitate prepaid rounds and block contracts.

Staff reported resourcefulness and creativity in meeting people's needs. There were good relationships between commissioning staff and staff in localities in arranging support for people in the community and in reporting gaps in provision. ‘Team up’, the locality partnerships where staff from health and care worked together, were described as being helpful in arranging care. The short-term service had daily huddles which helped colleagues to review who would offer support effectively. There was a focus to increase the provision of assistive technology for people to remain independent for longer.

It was challenging to access mental-health impatient beds out of hours, which increased out of area mental health placements. Mental health concerns had increased, including cases of self-neglect. Partners reported gaps in support for people with mental-health difficulties and younger people, especially those with communication needs. Positive feedback was given about supported-housing improvement projects and additional intensive housing support. There were plans to develop four supported living services and one residential care service in the county.

Leaders told us there was a sizeable nursing gap and people told us there were gaps in services for autistic people over the age of 25. We saw that people with complex needs were difficult to place. Leaders described an intention to provide specialist dementia beds and short-break services in-house. Out of area placements had risen over recent years with 334 people currently placed out of area. In the past 12 months there were 84 out of area placements. In 2023 there was an increase of 34%, mainly in older peoples’ nursing and residential care placements.

The better lives residential review team had reviewed care packages for all people of working age in residential care and a new contract had been developed to promote quality and value for money. The specialist placement review team intended to complete assessments and support plans and review all out of area working age adults’ placements, over the next 12 to 18 months.

Data showed the CQC ratings of regulated providers in the local authority area, were generally slightly lower than the national averages. For example, there was 68.63% good-rated nursing care with the national average being 72.11% and 73.65% good-rated residential care with the national average being 75.95%. Good-rated supported living services was 42.42% with the national average being 63.95%. However, homecare was 67.16% good-rated with the national average at 59.21%.

Providers completed quarterly quality assurance returns and the local authority used annual checks, including around financial and information governance requirements, to check there were secure data-systems in place. Intelligence gathering meetings regularly occurred with partners to share information about services and provide assurance about placements and improvements. Feedback was positive around the support offered to providers, for example the local authority was proactive in supporting providers to improve and celebrated success. We heard positive examples of improvement support to providers following CQC inspections. For example, all care home providers had signed up to the local authority’s terms and conditions and received appropriate support and monitoring, however this did not include those without local-authority residents living at the home.

The local authority gathered people's voice around experiences of services using different methods including complaints, compliments and social workers’ concerns and we heard the 65 (years old) service stakeholder engagement team involved Experts by Experience (people with experience of services who provide insight to help service improvement). Specialist services were developed for people, following discharge from long stay hospital placements. The commissioning team used storyboards and person-centred tools to gather individuals’ views on these services and quality questionnaires were used in frontline services to gather feedback.

The local authority provided each homecare agency with an electronic monitoring system at no cost, which had led the local authority to receive 87% of the care it commissioned, and significantly fewer missed calls. Medication administration and management support was written into contracts and followed up through quality monitoring. We heard the Integrated Care Board (ICB) usually led in this work in nursing homes, in partnership with the local authority. Two provider-forum summits were held last year to develop a deeper understanding around the social-care workforce and support joint working. We heard integrated working with the health service around care plans had improved.

Leaders described the transformation plans clearly around maintaining a sustainable market and mitigating challenges around demand for care services. They described workforce as a major challenge and therefore there was a recent proposal with the Integrated Care Board, for a one-workforce approach across health and social care. Derbyshire performed better than average on staff vacancies with 9.14% of all adult social care job vacancies and a national average of 9.74% (Skills for Care). Sick days were slightly higher in Derbyshire (8.38) than the national average (6.24) (Skills for Care). We heard a social work apprenticeship programme was in place to help meet future workforce needs. Frontline staff consistently spoke about how they worked to manage staffing challenges, they reported pay affected retention, however some teams had very high retention rates with many staff working in the authority for many years. The overall staff turnover was 16%.

The people strategy’s priorities involved attracting and retaining the best people, promoting diversity and inclusion, enabling a responsive workforce with a view to develop transformation, well-being and safety. The local authority recognised systemic challenges in its adult workforce strategy, it outlined key workforce priorities including skilled workers to reflect diverse communities and to meet registration regulation requirements.

The specialist accommodation and support strategy, demonstrated the care arrangements for people under 65 years of age living in specialist residential care homes, were under review to support people to live independently. The homecare scheduling team were also expanding to deliver emergency care-worker cover which aimed to replace the use of agency staff. Providers reported good relationships with colleagues in the contract team but there were some issues around accessing social workers. On one occasion when people had to move out of a care home due to a health and safety issue, it was managed well and supported by social workers.

Provider business continuity plans were checked by the local authority as part of their quality audit system. Payment of fees was sometimes not achieved on time, but we heard the local authority was responsive to any escalation of payment issues. Providers told us that in the information around fees there was a section about the living wage, travel time and sick pay. We heard there were assurance frameworks to ensure appropriate working conditions within domiciliary care services and they encouraged an enhanced rate of pay. Providers felt however, that the fees did not take into account the running of a business and the true cost of care. We saw modern slavery risks were built into procurement and monitoring arrangements.

There were 396 active providers in Derbyshire, with 23 non-active providers. In the past 12 months one nursing home and five residential homes had ceased contracts with the local authority and exited the market. Reasons given for these included financial viability, retirement and services feeling unable to meet regulatory requirements. Three supported living services, one specialist extra-care service and one community care provider handed contracts back to the local authority for sustainability reasons, withdrawing from the area and ceasing that type of provision. No homecare provider contracts had been handed back or left the market.