London Borough of Ealing: local authority assessment

The local authority worked with local people and stakeholders and used available data to understand the care and support needs of people and communities. Priority information within the Joint Strategic Needs Assessment (JSNA) was updated to support organisations to work together to understand local needs for care and support. While updates that were completed gave a good understanding of care and support needs in the community, more specific concerns and changing demographics could have been used to better support an understanding of local needs. For example, several groups of staff and partner organisations recognised gaps in dementia service provision, and the dementia JSNA chapter was last updated in 2015. Updated analysis, based on the changed health and social care landscape following the COVID-19 pandemic could support continued improvements where more recent data was available.

The local authority made their JSNA data available on Ealing Data. This was an online tool that provided reports and graphs which anyone could review to understand the health and wellbeing needs of the borough. Information was not always displayed in an easy-to- understand way, such as infographics, which may have contributed to a communication gap between communities and services. This had been recognised by the local authority and improvements were being made in how information was presented to local communities. For example, providing strategic information about Mental Health in a poster and easy read format and through increased opportunities for engagement and consultation.

The local authority felt the integration of public health within the adult social care structure was positive. This supported the strategic understanding of local care and support needs, including work with the voluntary and community sector, and in direct pieces of work such as suicide prevention with the co-production group. Additionally, the local authority had recently been successful in securing National Institute of Health Research funding which included work with the Somali community as peer researchers. This work was expected to support the way local people were able to inform and influence services.

The local authority described examples in which they had reviewed information about who accessed services but went on to stop using those services, such as talking therapies for mental health. They used this information and worked with the voluntary and community sector to develop services to better meet people's needs. There was mixed feedback about how people and community organisations felt the local authority used people’s experiences to understand local needs for care and support. Many carers had been part of consultation to develop the local authority’s carers’ strategy, but some organisations did not feel carers had been well consulted about other services, such as respite. Some people told us the local authority was open to hearing directly from people who used services. The local authority was refreshing its co-production boards at the time of our assessment and people who were involved felt positive about the opportunities they had to be involved in service design and challenge.

The local authority and partners recognised specific area challenges in the borough, including the impact of having several acute and community-based hospitals in the area on care services. Senior leaders recognised that NHS funding played an important role in the delivery and sustainability of care services and the quality of people’s experiences, such as timely hospital discharge, in the local authority and across Northwest London. The local authority was working in partnership with the Integrated Care System to maximise available funding and to support continued integration and delivery of services to better meet the needs of the population.

These considerations informed the local authority’s market sustainability planning. The local authority demonstrated a good understanding of the factors that influenced their market, including rising complexity of people’s care and support needs. The local authority’s approach included bringing strands of their vision together to deliver broader objectives. For example, the local authority wanted to support more people to use direct payments: developing the local economy to support community investment and micro businesses would help to deliver this. This would, in turn, fund local businesses and continuing to strengthen the diversity of their market.

The local authority maintained strong working relationships with commissioning teams across Northwest London to share intelligence about local care providers and sought to take a consistent approach to market management. This included attendance at cross-borough quality assurance meetings. This supported a cohesive, quality market of care across the sub-region to improve services for people.

People in the area did not always have a choice in their daily lives. National data showed that 57.05% of people who used services felt they had choice over their daily lives, which was significantly lower than the England average of 69.81% (Adult Social Care Survey, October 2023). The local authority provided choice to people in many areas of service provision and market shaping was underway to improve capacity and quality in specific areas that lacked sufficiency, for example, complex care home beds.

The local authority was also aiming to improve choice through their dynamic purchasing system, which provided prompt information for people about the providers that could meet needs identified in care plans. The local authority told us that people had the most choice of home care provider, followed by supported living provision. People who required extra care, long-term residential or long-term nursing care had more limited choice of provision. When commissioning a service on a person’s behalf, some staff felt there was a commitment to offering choice, rather than using the cheapest provider. Some staff described hospital discharge delays due to family choice regarding placement, rather than a lack of care service capacity to meet their needs.

Commissioning strategies were linked to the refreshed JSNA chapters and combined with information gathered through engagement, consultation, and coproduction. This included, for example, the development of the new carer’s strategy, the learning disability commissioning strategy, and the autism strategic action plan. The learning disability strategy, for example, included significant co-production with Ealing Power Group, which was a group of people with learning disabilities who advocated for their community, in conjunction with other community and voluntary sector providers.

The local authority’s market sustainability plan was produced in March 2023. The last published market position statement was in 2019-2020. The local authority had refreshed the Market Position statement for 2024/2025 and this was in draft form at the time of our assessment.

There was reflection from staff and some partners that complex needs, such as dementia, and people who were communicating a need or an emotional reaction were not well supported by the market, this was also identified in the local authority’s published market sustainability plan. Providers told us the requirement in their contracts to accept referrals sometimes created pressures for them to provide levels of support that they felt were not always appropriate for their services. They told us it could sometimes be difficult to get agreement to provide one-to-one care for people when they felt it was needed, pending a formal review of their care needs. However, in care homes and supported living settings, the local authority had recognised the increasing prevalence of funding one to one support, citing c£3m additional spend on this in care homes, and £4m in external supported living services. This was a priority area for the councils commissioning and market management team to address. Additionally, some staff felt that while there was a good supply of supported living provision across Northwest London, there were gaps in specialist housing provision for people with mental health needs and autistic people who didn’t also have a learning disability. The local authority’s market sustainability plan recognised some gaps and outlined joint working with NHS partners alongside training, increased nursing provision, and wraparound support and guidance to meet these identified issues. The local authority was working with the Integrated Care Board to develop specialist services to support people following hospital discharge and to meet gaps in dementia specific care.

Some partners told us there were capacity challenges in respite provision and that they felt this the provision had decreased in the borough over the past few years. Staff felt there was a gap in respite provision that met the needs of younger adults, aged 18-25 years old. Some partners were concerned about sharing information about their respite offers as they did not feel they had the capacity to meet demand. The local authority had recognised the need for increasing respite options. They had recently commissioned new services for younger people and were focused on increasing respite at home options.

The Survey of Adult Carers in England stated 20.69% of carers in the borough accessed support or services allowing them to take a break from caring for more than 24 hours. This was slightly lower that the England average of 15.99%. 21.23% of carers in the borough accessed support or services that allowed them to take a break from caring from 1 to 24 hours, this was slightly above the England average of 20.08%. 12.5% of carers were able to access support or services that allowed them to take a break from caring at short notice or in an emergency which statistically in line with the England average of 12.08% (Survey of Adult Carers in England, June 2024).

Some people and organisations we spoke to said that there seemed to be less services available for carers outside of respite, such as carers support groups. Specifically, the needs of carers who supported people with high needs and complexity, and those with dementia, were not met. Some services were available in the community that were not arranged or funded by the local authority. Some staff described looking to improve their links with the voluntary and community sector to help fill gaps in commissioned services.

The local authority was ambitious regarding its reablement offer, aiming to ensure it was an approach available to all. The bridging and reablement service provided directly by the local authority was well regarded and seen to be having a positive impact on hospital discharge. National data indicated that 89.13% of people who received short term support no longer needed support, which was better than the England average of 77.55% (Adult Social Care Survey, October 2023). However, this was a limited resource. When the in-house service reached capacity, reablement support was commissioned externally. Staff told us the service struggled to find care providers that were skilled at reablement, and some staff told us this meant support did not fully promote independence and was difficult to reduce after the reablement period ended. Leaders identified further work was needed to improve capacity and the quality of reablement provided by external providers and plans were in place to improve this.

At the time of our assessment, the local authority did not have the analysis systems in place to outline the number of times people had to wait for their service to begin due to lack of capacity, or the average length of time people had to wait. People who required long term residential nursing care occasionally had to wait for support. There was over-supply of homecare in the borough, and people who required a supported living service generally had sufficient choice about their service or provider. The local authority tracked bed availability in care homes and available hours in home care services to monitor capacity and target referral requests more efficiently.

The local authority described their care market as buoyant, especially in relation to home care. 90 providers of home care were actively engaged in local authority placements, all of whom the local authority told us were rated good or outstanding at the time of our assessment. Brokerage and placement services were able to use spot purchasing to secure additional home care capacity if needed. The local authority used block purchased beds across the borough to support speedy hospital discharge where needed, recognising this was a complex partnership environment.

The local authority was clear their priority was to find care placements for people within the borough and, following this, within Northwest London so they could remain as close to home as possible. The local authority told us that 82% of their total residential placements for people with a learning disability in January 2024 were out of borough. A third of these out of borough placements were within surrounding boroughs, which meant 45% of people were placed in the area or in the surrounding boroughs. The same information told us that 38% of the total residential placements for people aged 65 and over were out of borough. Approximately half of those were in surrounding boroughs, which meant 82% of people were placed in the area or in the surrounding borough. Partner agencies told us that there was not a lot of dementia friendly or specialist provision in the borough. The local authority was taking action to address these gaps. Some staff told us that people with complex needs sometimes had to be placed out of borough, but usually not too far away. They felt this policy supported people’s quality of life and ensured minimal distance from family.

Some staff in frontline services and within commissioning felt there had been a shortage of supported living services. Staff told us about recent recruitment in supported living sites to help improve the position. The local authority assessed their supply of supported living had capacity and most people had choice about their service or provider.

Many of the partner organisations we spoke to felt that the local authority understood their commissioned services well. They reported that regular information was requested about provider’s performance and capacity.

Local authority commissioners worked with the commissioned advocacy provider to understand referrals, capacity and support the provision’s development to best meet need.

Most of the people we spoke to were positive about the quality of services in the borough. People described how the local authority responded well to their concerns and set up new arrangements for existing care. Where specific requirements could not be met, the local authority worked to provide alternative appropriate solutions in line with the individuals wishes and concerns, such as where male only carers were requested but could not be guaranteed. Some people we spoke to described having choice about agencies to use to provide their care. There were occasional issues regarding inconsistency of care workers. Recent local authority monitoring found that 92% of people surveyed were satisfied with their care provision in 2023 to 2024 (over 200 people surveyed). This was higher for people in care homes.

Based on Care Quality Commission information in August 2024, 53.85% of homecare provision, 57.89% of nursing homes, 64% of residential provision and 50% of supported living provision was good or outstanding. The local authority used only good or outstanding home care provision for local authority arranged care. They monitored CQC quality ratings monthly and had recently noted an improved rating profile. They worked with the Commissioning Alliance to establish an accreditation scheme for supported living providers in Northwest London as part of a drive to assure quality.

Ealing hosted the largest number of care home beds in Northwest London of over 1500 in February 2024. Local authorities are responsible for managing the quality of the care provision in their area. Where there are out of area placements, both placing and hosting local authorities are responsible for ensuring the quality of provision to meet the needs of the individual using it. Significant numbers of the care home beds in the borough were used by people who were not originally Ealing residents and were funded by other local authorities. The local authority’s complex context regarding who used services within the borough created additional challenges regarding the management of quality commissioned services. Ealing was in the process of testing an out of area quality check for any placements they made outside of the borough to assure themselves of the quality of out of borough provision. They worked closely with other local authority commissioning and quality teams and partners to support their work to manage the quality of provision in borough. As part of the sub regional collaboration through the Commissioning Alliance, a sub-regional adults' quality workstream group had been established to share quality intelligence across the 8-boroughs.

The local authority had some success in supporting some providers to improve their CQC ratings from ‘requires improvement’ to ‘good’ in conjunction with the local Healthwatch. This work improved the service for over 30% of the care home beds procured by the local authority. Partners and providers felt that there was a clear focus and drive for quality in care. Providers described the way the local authority worked with them to make continual improvements, such in working together to implement improved processes regarding bed bugs in care homes. Others described the recent local care home summit that improved the training offer for providers and shared issues identified, such as dementia, dental hygiene, capacity and engagement with families. Staff in the local authority described monitoring complaints, safeguarding concerns, and operational concerns, and implementing effective actions, including linking with partners to tackle specific risks and providing training, to improve quality. Appropriate teams worked with providers to develop support plans.

There were some examples provided of creative provision, for example in a day opportunities theatre group for people with a learning disability was a good example of support that met people’s needs and helped achieve their outcomes. However, gaps were still identified regarding supported employment opportunities and other imaginative day service offers. Other day services were described by some carers as having a kind but old-fashioned culture. The local authority told us there was inconsistent contractual quality monitoring of day centre provision at the time of our assessment. This had been addressed through their new commissioning framework, and improved monitoring was being introduced in April 2025.

There was a recognised issue with dementia care in the borough. We heard there wasn’t much specialised dementia provision in the area, and there was a particular challenge about the quality of dementia care, with quality not as high as other care provider groups. Work to improve the provision of dementia care in the borough was ongoing with the opening of new residential dementia provision, the introduction of the CHILLs service and bespoke care home and dementia specific training, supported through the Social Care Academy. The local authority and partners planned to continue work in this area.

The local authority described strong provider quality controls. A dashboard of ratings information, both current and historic, alongside concerns and suspensions of contracts, was shared with key partners including CQC, Healthwatch and health partners to support joint working and a borough-wide understanding of quality. Processes for responding to quality concerns included clear escalation to the area’s risk review panel, which agreed actions regarding improvement and decided when to stop working with a provider if they did not improve. The Director of Adult Social Services (DASS) told us had happened twice in the last 12-18 months. There were 15 open provider concerns the local authority was monitoring in March 2024 around the time of our assessment. The local authority told us there had been 7 service suspensions in the 12 months prior to our assessment. Reasons for suspensions included staffing levels and training, safeguarding concerns, and medication and care management errors.

The local authority’s market sustainability plan covered the current sustainability of care homes focussed on people aged over 65 and the home care market for anyone over 18, the impact of future market changes, and plans for addressing sustainability issues. The local authority outlined how they worked in partnership with providers, sub regional commissioning agencies, other Northwest London boroughs and health partners on matters of market sustainability, quality, and best value pricing.

Providers felt they were able to develop good relationships with commissioners and the local authority’s commissioning approach supported their sustainability. The local authority worked with providers to develop contingency plans and future processes to reduce service disruption, for example in sharing early details of potential closure to support continuity planning. According to CQC information, 6 providers left the market in the area between July 2023 and August 2024. Where reasons were known, this was due to declining quality of the service, and a reduction in CQC rating.

Some providers felt that some companies received a disproportionate amount of the care packages in the borough. The local authority’s dynamic purchasing system and subsequent processes aimed to counter this, ensuring that social workers provided people with information about all successful bids from providers to enable them to choose which one they wanted to use. Staff generally felt this worked well in supporting choice in the community but was time-consuming in a hospital discharge environment. The local authority had reflected they needed to make changes to ensure people received a timely and supportive service and choice, as well as delivering fairness for providers. They had adjusted their process in response.

The local authority had worked with providers around fair costing and subsequently implemented a real living wage for care workers delivering local authority arranged care in the borough, which supported appropriate working conditions for staff. Providers told us this had had a positive impact on their ability to recruit and retain staff. 9.86% of all adult social care roles in the sector in the borough were vacant, statistically in line with the England average of 9.74% (Adult Social Care Workforce Estimates, October 2023). The turnover rate for adult social care employees in all roles within the borough was significantly better at 0.13 compared to the England average of 0.29 (Adult Social Care Workforce Estimates, October 2023). This linked with the overall focus for the local authority in supporting economic regeneration through good jobs. Leaders were aware of the challenges posed in hosting the largest number of care home beds in Northwest London. This limited the effect of their locally funded initiatives, such as the real living wage, as this was not common in all arrangements funded by other local authorities in the area.

Ealing made their free training offer available to colleagues in the private, voluntary, and independent sectors through the social care academy via joint funding with the Integrated Care Partnership. Attendance at courses had increased significantly and was recognised as improving outcomes for people supported by the sector. The local authority also aimed to support more staff in the sector to complete the care certificate. 51.57% of adult social care staff in the area had either started, partially completed or fully completed the care certificate, which was statistically in line with the England average a 49.67% (Adult Social Care Workforce Estimates, October 2023). The social care workforce strategy focussed on the local authority’s internal workforce but did include training and support activity identified for the wider sector as part of a continued commitment to improve the quality and sustainability of provision in the borough.

The local authority’s adult services workforce strategy had a clear focus on mitigating risks and challenges related to recruitment and retention of social workers and social care assistants. There was limited clear activity within the strategy focused on the skills of the commissioning workforce, however, leaders told us the local authority had delivered bespoke training for commissioning staff in the last 2 years. The local authority also linked care providers into the NHS overseas recruitment offer.