London Borough of Haringey: local authority assessment

The local authority worked with stakeholders to understand local needs for care and support but also recognised the need to work more closely with local people and communities and this was reflected in the Commissioning Strategy for Adult Social Care (2024-2029). Leaders also told us the local authority’s move to a localities model would support a better understanding of people’s needs.

Haringey had launched a commissioning coproduction board as a mechanism for providers and people to support commissioning design and implementation. Due to its infancy, the impact of this approach was unclear, but there was some evidence the board had begun to influence processes such as quality assurance of services.

The adult social care commissioning strategy identified a range of key service needs which included: day opportunities, digital inclusion and technology, more and enhanced respite, developed and expanded support for unpaid carers, support for people with complex needs and behaviours that challenge, more move-on accommodation for people with mental health needs, dementia-friendly services and strengthening of transition services. These areas were in line with feedback we received from people, partners, staff and leaders and showed an understanding of local need.

There were positive outcomes where the local authority had worked with people to respond to local care needs. For example, partners were positive about the provision of the local Autism Hub, which was coproduced and described as an exemplar service.

The local authority worked with local stakeholders to utilise data to understand care and support needs of the community. Data was available on their systems, such as within their Joint Strategic Needs Assessment (JSNA) and market position statement, which helped to inform commissioning practices. A senior leader told us the JSNA and other relevant reports, informed decision making on the best use of resources. There was a focus on the local authority becoming data-led in their decision making and this included commissioning.

People’s access to a diverse range of local support options which were effective, affordable, and high-quality was inconsistent. Care provision within the borough was limited, but the local authority worked closely with other North Central London (NCL) boroughs to provide support for people.

Staff and partners told us about gaps in service provision in the area. This included care homes, dementia-friendly services, specialist accommodation for autistic people, complex placements and mental health provision. These areas were outlined within the local authority’s Market Position Statement (2024) as service needs, except for specialist autism services. There was, however, a separate Haringey All Age Autism Strategy (2021-2031) which did refer to improved autism provision for young people and adults.

The local authority’s Adult Social Care Commissioning Strategy (2024-2029) and Market Position Statement (2024) outlined the need for an outcome-based and person-centred commissioning model. Available provision within the borough made a person-centred model more limited. For example, staff told us there was a lack of available placements for people at a higher risk of falls or needing 1:1 support. They gave an example of a person being ready for discharge from hospital for 10 days as there were no available local placements for them.

The local authority’s commissioned homecare was focused on outcome-based support and was delivered by a small number of domiciliary-care providers which were locality-based. People told us they were supported to access homecare support, which was flexible, person centred and of good quality.

People and partners were not always included in market shaping activity. The Adult Social Care Commissioning Strategy was not recorded to be coproduced, although it was said to be informed by the voices of people and other stakeholders. Some care providers felt they were not given an opportunity to voice their views on local needs and engagement was limited. Despite this, the local authority held monthly care provider forums to understand provider perspectives and gather feedback. A care provider told us the forums were useful and they were also used for external agencies to provide input for local providers.

The local authority’s commissioning approach aligned with internal and external stakeholders. This included the objectives of housing, public health and the ICB. The commissioning strategy, alongside other relevant partner strategies were reviewed by the Health and Wellbeing Board, supporting joined up approaches. Staff, leaders and partners in each of these areas also told us about joined up working at a strategic level. For example, a senior leader and a staff team told us about reduced capacity of accommodation for people with a learning disability, especially for those who required wheelchair accessible housing. Support in this area was reflected in the Housing Strategy (2024-2029) which was committed to supporting accessibility in a set proportion of homes.

Haringey told us there was a range of market shaping activity taking place to improve their carers offer. This included plans to have a carers ‘representative’ at each locality site at least once a week; improved outreach to the hard-to-reach carers; improved identification of carers; strengthened review and assessment arrangements and better contingency care arrangements. The local authority had also introduced a second commissioned provider for carers support. This organisation supported with online information and advice as well as identifying ‘hidden’ carers who did not access support.

Capacity for care and support within the borough was limited and as a result, a large proportion of care and support was commissioned out of the borough.

Data provided by the local authority in June 2024 showed 45.8% of people’s placements were outside of the borough. 45.2% of placements in the last 12 months were also out of the borough. The local authority told us most of these placements were within the NCL sub-region, with which the local authority had a close working relationship. The most recent Market Sustainability Plan outlined a significant proportion of placements outside of the NCL region (approximately 30%). Reasons cited by the local authority for the large proportion of out-of-borough placements included limited suitable accommodation or services; client and family choice and specialist care provision not being available.

The local authority had outlined strategic plans to reduce out-of-borough placements. Staff told us there was a recent project to understand how people could be returned to the borough to reduce out-of-borough placements. This included considerations such as placements in supported living accommodation or other development opportunities such as units to support older people with more complex needs such as dementia.

There was a recognition of the need to ensure sufficient capacity in care provision to meet increasing need within the borough and this was reflected in the Commissioning Strategy for Adult Social Care. For example, it was recognised there was an ageing population, and this would increase demand for services such as homecare, residential care and day services. There was acknowledgement this would require investment in capacity, workforce development, and infrastructure to meet growing demand.

The local authority worked closely with the NCL system to retain oversight of residential and nursing care provision across the system. There was shared consideration of block bed arrangements where there was capacity, which supported consistent capacity for the local authority. This approach helped to mitigate risk to people who required care home placements.

Access to some specialist accommodation was limited, particularly for people with complex needs. While a partner told us a large majority of people’s accommodation needs can be met within the NCL, another frontline team said this was a challenge. Immediate placements for people with complex mental health needs were difficult to source. Another partner told us there was a risk to people residing in institutions, such as long-stay hospitals, facing lengthy waits for placements. Despite these concerns, the local authority had effectively managed waiting times for supported housing. As of June 2024, in the preceding 3 months, 3 people waited for supported housing for over 7 days from the date of their support plan agreement, with an average of a 19 day wait for these people.

Data provided by the local authority in June 2024 showed people could experience delays in accessing care and support where there was reduced care provision capacity. For example, the longest average waits in the 3 months preceding June 2024 were for nursing care provision and supported living services. Waits for these services averaged 27 days from support plan agreement. The local authority cited the likely cause of delays to accessing service provision was a lack of capacity in the market to meet the specific needs of individuals.

The local authority had sufficient capacity in their homecare market to meet demand. A frontline team told us they did not encounter delays with homecare being sourced for people. People were also said to usually have more than one option with language and religious needs considered where applicable.

Lack of local provision had some impact on people accessing personalised services such as day services. A person’s relative told us how a lack of day service provision had meant the service the person attended did not offer access to the type of activities they wanted. National data showed 63.16% of people who use services felt they have choice over services which tended towards a negative variation from the England average of 70.28% (ASCS 2023-2024). This reflected reduced choice over services in the local area.

National data showed unpaid carers accessing breaks from their caring roles was in line with or slightly above national averages. For example, 23.16% of carers reported accessing support or services allowing them to take a break from caring for more than 24hrs which was slightly better than the England average of 16.14%. 16.84% of carers accessed support or services allowing them to take a break from caring for 1-24hrs was in line with the England average of 21.73% (SACE 2023-2024). While this was at least in line with national averages, a large proportion of carers did not feel they were accessing services to allow them to have a break. A staff team told us there were difficulties in sourcing respite for carers. A partner also told us respite was not in place quickly enough and they were aware of carers waiting over 6 months to hear about respite support.

A partner told us a specialist provision which offered high quality services and advice was the Dementia Hub. The Dementia Hub offered information and advice for people as well as day service provision. A senior leader was positive about this provision but felt it was more accessible to people in the West of the borough, where it was located. A staff member also felt dementia services in the East could be more developed. However, the local authority had invested in dementia services in the East, which included, for example, an older person’s day service which was coproduced and met dementia-friendly design standards. Access to support across the borough was also being actioned as part of a NCL dementia working group which were looking at transport and provisions to support people access support in the East. Dementia-friendly services were identified as a key service need by the local authority.

The local authority had clear arrangements to monitor the quality and impact of the care and support services being commissioned for people and it supported improvements where needed. Quality of services data was positive. For example, 87.50% of residential care homes were rated good by CQC rating and the only nursing care home in the borough was also rated good. 66.67% of Homecare services were rated good, and 12.96% rated requires improvement. 42.86% of Supported Living rated good by CQC rating, the remaining services were not yet rated. The local authority had also had no commissioning embargoes related to quality concerns in the last 12 months.

The local authority had a Quality Assurance and Contract Monitoring (QACM) framework which set out the approach they took to ensure local care and support services provide what individual service users needed. The Quality Assurance and Contract Monitoring Board met monthly to oversee and ensure the integrity and effectiveness of service delivery by contracted providers, located within the borough and local NCL system. The local authority worked with partners, such as the ICB, to assess performance data assess compliance with quality standards, and address any issues or concerns.

There were processes to apply suspensions on providers where concerns were raised. The quality assurance team told us they worked closely with other agencies and the provider to analyse any issues and support the provider to create an improvement plan. A staff team told us they worked with the Quality Assurance team and the Safeguarding team to create an action plan and monitor progress where a concern was raised about a provider. There were also processes in place to ensure urgent reviews of people’s care were prioritised when concerns were present about services they used.

There was not a clear process for reviewing the quality of people’s placements outside of the NCL system. While the local authority sourced feedback about placements from people and their representatives during ‘360’ non-statutory reviews, this was a light touch process and did not fully review the quality of the services people received. There were clear processes where concerns could be raised about providers, however, the backlog and delays of people’s statutory Care Act annual reviews highlighted a potential risk of concerns about people’s care services not being known to the local authority which may have been identified during this process.

As part of their contracting arrangements, the local authority did not commission new care with registered services which were rated requires improvement or inadequate. This approach mitigated risk when placing people.

Quality assurance arrangements were in place to support quality of local services. The quality assurance team told us they tried to ensure they visited service providers at least once a year to complete mock inspections and identify potential areas for improvement. They also told us they regularly checked CQC ratings for changes and where ratings had reduced, they requested service improvement plans from providers.

Commissioned partners in the voluntary and community sector were monitored for the quality of their performance. For example, a commissioned partner told us they completed quarterly reports for their commissioner with themes. This supported people to receive better quality services and outcomes.

Care providers told us quality assurance processes supported them to improve their systems and practices. They told us staff were available to speak with them and were part of regular meetings which supported.

The local authority was focused on improving people’s voice in improving quality of services. For example, the Commissioning Coproduction Board had developed a methodology to support people’s voice in contract management and quality reviews of services. This was still being developed but would support people’s voice within this process.

Engagement and monitoring arrangements enabled the local authority to get early warnings of potential service disruption or provider failure; contingency plans were in place to ensure that people had continuity of care provision in this event.

The local authority had developed a shared commitment to paying a sustainable market rate for accommodation with the NCL system, underpinned by sub-regional market analysis of costs and transparent relationships with providers. The system used this evidence base to support market sustainability and where appropriate efficiencies in negotiations with individual providers, including through inflationary uplifts, agreeing common spot rates, agreeing access to each other’s block contract arrangements and agreeing some joint block arrangements.

The local authority had adopted commissioning approaches to support a sustainable market. For example, for homecare, most care was supported by regular contracted homecare providers who had ‘bundled hours’ arrangements (approximately 70%). The remaining proportion of homecare were spot purchases which were sourced through a dynamic purchasing system. This was a system which involved home care providers registering their ability to pick up people’s care without tied contract arrangements. This approach allowed smaller and medium sized providers to stay in the market as they still accessed local authority commissioned care.

Some care providers told us they were concerned about sustainability. A care provider told us they used zero hours contracts and at times where there was a lack people to support, it was more difficult to keep staff and put pressure on their sustainability. The local authority engaged with providers to understand workforce challenges and needs. Provider forums were used as a platform for the local authority to listen to providers.

In the 12 months preceding June 2024, 2 homecare. 3 supported living, 3 residential care homes and a nursing care home handed back contracts early. This impacted the care of 34 people, with 16 of these people in a residential care home. The local authority told us this was due to financial viability of individual packages of care or the business model of the providers. All people’s care was reallocated to ensure continuation of services.

The local authority actively promoted the use of Skills for Care training for care providers. They told us they encouraged and supported them to access these resources during visits, provider forums, and through Proud to Care North London. National data showed 61.45% of adult social care staff with the care certificate in progress or partially completed or completed, in line with the England average of 55.53% (Adult Social Care Workforce Estimates ASC-WE 2023-2024). The local authority told us providers could access training and support to enhance their skills through the NCL Market Programme.

The local authority had identified the need to increase personal care services for people using direct payments and commissioned a partner to promote the role of becoming a personal assistant to support people’s choice in services. Data showed a positive impact of investment in these services, with an increase of 117 people (20%) using direct payments in December 2024 as compared to April 2024. 

Providers gave mixed feedback on the level of support they received for recruitment and retention. They told us some recruitment information was shared with them, but this was not always beneficial. Despite this, national data showed the local authority to be performing better than national averages in this area. For example, 8.44% of adult social care jobs were vacancies which was slightly better than the England average of 9.74%. There was also a statistically significantly better rate of turnover of adult social care employees, 0.12, as compared to the England national average of 0.25. (ASC-WE 2023-2024).

The local authority had a market sustainability plan which assessed the sustainability of local care markets. The plan outlined how the local authority supported the fair cost of care. For example, the agreed cost of care with residential providers was said to not require further subsidy from self-funding users of residential services. The plan recognised the risks posed to local services.

The local authority facilitated fair pay for adult social care staff. As part of contract arrangements, homecare providers were required to pay the London Living wage. There were also arrangements for homecare providers being required to pay for travel and waiting times for staff.