London Borough of Hillingdon: local authority assessment

The local authority, the Hillingdon Health and Care Partnership and the North West London Integrated Care Board (NWLICB) are jointly responsible for the Hillingdon Health and Wellbeing Strategy. This key document incorporates early intervention and prevention as a fundamental principle. The local authority did not have its own formalised strategy specifically focused on preventing, reducing, or delaying the need for care and support, but told us they were committed to delivering a range of initiatives aimed at achieving these outcomes. All staff and partners we spoke with had a clear understanding that early intervention was a significant part of the local authority’s approach to delivering its duties under the Care Act.

The local authority said their focus was on addressing the root causes of care needs and promoting independence and well-being among residents, particularly older adults. They based their actions on proactive intervention and collaborative working across health and social care partners, people and the local community. Stakeholders offered a range of services, facilities, resources and other measures to promote independence, and to prevent, delay or reduce the need for care and support.

Voluntary sector organisations were commissioned by the local authority to deliver provisions such as job clubs, social activities and an early intervention service to adults 18+ promoting mental health and preventing worsening of mental health issues. Whilst the local authority told us they had provided a 12-month lead in time to the change, and support to develop business models, we heard the change from core grant funding to commissioned services, had had a disproportionate impact on smaller voluntary groups.

Health and social care agencies had a joined-up approach to people who relied heavily on services, including interventions and care packages to identify the most appropriate resources to intervene early and reduce crises. Hoarding was a particular issue in NW London. Partners in the Health and Wellbeing partnership were testing an approach, working together to address this, but had not yet captured any outcome data.

Assistive technology was being used to support people to remain independent. The local authority was piloting use of an aid which allowed them to understand a person’s movements and subsequently provide proportionate, appropriate support which reduced risk but was not restrictive.

Partner organisations felt the local authority understood the challenges people in the community experienced, such as, housing and the double impact of cost of living and getting into debt. It was noted Hillingdon had some specific low-income areas. The local authority was aware of the lack of affordable housing and was explicitly seeking both to build and to buy additional housing stock, to address this.

We heard in recent years in Hillingdon, there had been a significant increase in the numbers of people, who had died by suicide. Partners in Hillingdon including the local authority, voluntary sector groups and transport providers were working together to seek to prevent this and to identify hotspots.

According to the Survey of Adult Carers in England, (June 2024) 80 % of carers found information and advice helpful which was slightly less than the England average of 85.22%. Only 12.5% of carers surveyed in Hillingdon reported being able to spend time doing things they value or enjoy. Whilst this is consistent with the England average, it is only 1 in 8 carers. However, carers spoke highly of the organisation commissioned by the local authority to support them, through whom they received help to complete difficult forms, provided benefits advice, information about local groups suitable to the carer’s requirements, and direct support.

Data from the ASCS (October 2023) about adults with care and support needs, were mostly consistent with average results across England. For example, 62.41% people in Hillingdon who were surveyed, said help and support helped them to think and feel better about themselves, compared to the England average of 62.32%). 69.15% reported they spend their time doing things they value or enjoy which was comparable to the England average of 68.17%.

Public Health worked with organisations to support them in offering relevant opportunities to people to meet their individual needs and interests. Staff gave an example of how they met a person with early onset dementia who had worked for many years in a role they really enjoyed and was becoming depressed due to having to give this work up. The local authority worked with partners, provided training and advocated for them to become a volunteer in a similar role within the borough, which was still accessible to them. The person was able to volunteer for around 18 months and gave feedback during this time they felt valued and proud they could contribute to their local community.

The local authority had a significant extra care offer, where sheltered housing was provided with housing and personal care related support available on site. We heard there were only a few vacancies, but significant demand. There was a proactive approach by the local authority to reduce and delay demand for residential and nursing care home placements. Staff told us in the last 18 months there had been many success stories with people known to mental health teams, where they had supported discharges from Mental Health wards, and those struggling in the community moving on, into supported housing and extra care.

They were now introducing daytime support for people who did not live in extra care schemes within established services, so people could see what the schemes were like and consider them as a more independent alternative care option.

The local authority had taken steps to identify people with needs for care and support which were not being met. They had a Communities’ Programme team who worked closely with the voluntary sector. A partner said they were very good at investing in facilities and green spaces, creating resources for communities, dementia cafes, language groups, and reaching into the heart of communities to find people. Leaders acknowledged they needed to do more but were using community places such as the sports centre, and running engagement events across the borough, to listen to people and provide information and advice. Where appropriate, people would be signposted to make a referral via Hillingdon Social Care Direct.  Accelerated reform funding was being used for work to identify unpaid carers.

The local authority considered whether reablement approaches were appropriate before any long-term services were put in place. By screening at the front door for reablement, this reduced the number who went on to need longer term care. Reablement was provided as a partnership between a commissioned domiciliary care provider, and occupational therapists who provided the care plans. Local authority staff told us reablement programmes were based on an individual’s personal goals but getting the therapy calls at the right time, and for long enough duration to work in an enabling way rather than doing for the person, was challenging. Reablement was also available to anyone on discharge from hospital who had the potential to be supported to improve their independence.

According to the ASCS (Oct 2023) 80.28% of people in Hillingdon who received short term support no longer required support as compared to an England average of 77.55% Impact of reablement was measured by whether the aim was achieved – but what this meant in practice could vary from one person to another and did not necessarily mean they did not continue to need care.

The local authority also worked with partners to offer intermediate care. They had 15 nursing care beds where there was in-reach from physiotherapists and other allied health professionals to help people to rehabilitate after hospitalisation.

The Adult Social Care Outcomes Framework – Short- and Long-Term Support (ASCOF)/SALT: (Dec 2023) found 1.86 % of people 65+ received reablement/rehabilitation services after discharge from hospital which was slightly lower than the England average of 2.91%. A senior NHS leader noted the local authority guaranteed all patients on the P1 pathway whose needs could be met by provision of support in their own home, would leave the hospital on the same day. This meant they could plan discharges for the day. They consequently had the lowest number of patients who did not meet the criteria to stay in hospital in NW London.  The Bridging Care service was part of the P1 offer to people leaving hospital and gave 5 days support to facilitate same day discharge.  This mitigated the immediate pressure on the wider domiciliary care market.  Rehabilitation and reablement in Hillingdon was effective. ASCOF (SALT) data also showed 92.31% of people over 65 were still at home 91 days after discharge from hospital into reablement/rehabilitation which was significantly more than the England average of 82.18%.

People who needed assessment for and provision of aids, equipment and adaptations to their home, could access it. If a person was in hospital this would be dealt with by NHS staff who had access the same services as the local authority. if a person was not allocated to a social worker, Hillingdon Social Care Direct, were able to request a range of minor aids and equipment such as a raised toilet seat, and only make a referral for a full OT assessment if necessary. There was a difference of understanding between staff and the local authority about what happened if a person was already known to a social worker. Staff told us that in these cases, HSCD would pass the referral directly on to the social worker who would make a referral for an OT assessment for even minor aids, because they were not trained as Trusted Assessors for these. The local authority told us that all people could access minor aids and adaptations via HSCD.

Referrals were triaged by a senior OT who worked for the local authority and passed within 24 hours to external OT providers for progression. Part of the triage was to determine urgency. The most urgent cases were to be assessed within 2 days, high priority within 5 days and normal priority within 14 days. We heard the local authority and external providers worked together to expedite individual cases when necessary. The local authority also had access to the NHS rapid response (NHS team) for critically urgent assessments or interventions. More than 90% of assessments were booked within 2 weeks. The external provider had had a backlog with some referrals going beyond 14 days in February/March 2024 and took a pause for 1 week due to capacity, but reported they were performing normally now. Two service coordinators at the provider were trained as Trusted Assessors, which meant they could also order minor aids, to reduce waiting times for all.

Oversight of the end-to-end occupational therapy process, which involved different teams in different circumstances and an arm’s length relationship with the outsourced providers, did not sufficiently ensure that people would receive an efficient and effective service. The process for accessing equipment varied according to whether a person was already known to social care and added a delay for some people.  The local authority was unable to report median and maximum waiting times over the last 12 months but had noted this was an area for development.  The local authority told us that assessments were quality checked and signed off by a senior OT employed by the local authority, and that cases were kept open until the equipment had been delivered, was meeting the persons needs and had been reviewed.

Referrals for Disabled Facility Grant applications for major home adaptations, were dealt with by a different local authority directorate.

Equipment was supplied by a provider commissioned at a regional level. Staff told us there were sometimes issues when an item was out stock, and the equipment provider did not keep either the local authority or the individual informed about this. They said there was an expectation that either the person themselves or a member of staff from the local authority would follow this up. The local authority told us in contrast that the equipment contract manager was kept informed of outstanding orders and would follow these up with the provider.

The individual would be without the necessary equipment, and it was unclear as to whose responsibility it was to ensure that they had safe and sufficient care in the interim.

We heard OT staff who worked for the local authority found it more difficult than previously to access training, for example about mental capacity, and the OT’s used by the independent provider were responsible for their own continuing professional development. The local authority’s contract with the provider placed responsibility on them to ensure personnel employed in connection with the contract were sufficiently qualified, competent, skilled, honest and experienced, and sufficiently instructed and supervised.”   The local authority told us the contract is monitored quarterly regarding agreed key performance indicators.

The local authority told us it provided information and advice and signposted people to the most appropriate resource at each touch point with services, from the front door to adult social care to the point a social worker is allocated. This included unpaid carers and people who fund or arrange their own care and support.

One way for people to access information and advice on their rights under the Care Act, and to meet their care and support needs was via the Local authority’s Care and Support Directory. People, voluntary sector organisations and partners all noted the online nature of this resource was a barrier for some people. ASCS data (Oct 23) 65.68% of people who use services found it easy to find information about support which was consistent with the England average. Carers reported having more difficulty, and SACE (Jun 2024) showed 48.78% of carers in Hillingdon found it easy to access information and advice which was lower than the England average of 59.06%.

The local authority was aware of these concerns and was arranging an audit of the website to ensure it was as accessible as possible. They had committed to resolve all accessibility issues identified by the audit which were within their control. Nevertheless there was presently some inequitable access for people who were not able to use online sources of information.

Direct payments are money a local authority pays to people regularly (or someone acting on their behalf) so they can arrange their own support, instead of receiving social care services arranged by the local authority. The local authority had a lower uptake of direct payments than the England average of 26.22%. Data showed only 633 people, representing 13.65 % of total service users received direct payments. These were 19.83% of service users aged 18 - 64 compared to the England average of 38.06%, and 7.75% of service users aged 65 or over compared to the 14.80% average in England. ASCOF/SALT data (Dec 2023) shows 100% of carers who received a service, did so via a direct payment. Staff told us however they had had a 22% increase in direct payments in the last year. People reported it was hard to recruit personal assistants, so the local authority now gave them a list of providers of payroll services and recruitment support for Personal assistants which had helped.

Data from the local authority showed more people from ethnic minority groups used direct payments (360 out of 633), than white British people (270), with 3 people not disclosing their ethnicity. Just less than a third (190) of payments were ongoing personal budgets for carers, used to support them in their caring role.  About one third each were used to employ personal assistants or to pay for agency care. The remainder was used for daycare.

There was a direct payment support service and people had ongoing access to information, advice and support.  The local authority said ordinarily, a person would be able to use their direct payment to begin care within 4 days and most could within 2 weeks, although it could sometimes take longer.

People were signposted to use the Council’s care and support directory but could purchase care from any provider. The local authority said they advised people who required personal care that they should use a CQC registered provider and consider their rating and most recent inspection report. We were also told the local authority had increased the direct payment rate for those who wanted to recruit personal assistants, rather than use a regulated domiciliary care company.

In the 12 months to March 2024, 60 people stopped using direct payments. All stopped because they were no longer eligible or suitable to the person. No-one was reported as moving from direct payments because they were unable to meet their needs through them.