Medway Council: local authority assessment

The local authority worked with local people and stakeholders, and used available data, for example the Joint Strategic Needs Analysis (JSNA), to understand the care and support needs of people and communities. This included people who were most likely to experience poor care and outcomes, unpaid carers and people who fund or arrange their own care, now and in the future.

The JSNA chapter titled ‘Adult Care and Support’ recognised Medway’s population was ageing and was predicted to continue to age, with the number of people over 80 needing help and support with at least one self-care task and/or one domestic task was projected to increase by 43% in women and 53% in men by 2040. It identified a larger number of older people implied increasing age-related conditions such as dementia, multimorbidity (where someone has multiple health conditions), frailty and falls, as well as more older adults with disabilities. Service data indicated a rising prevalence of dementia in care home users, and the number of people with dementia in Medway was predicted to rise by 46% between 2019 and 2030.

The local authority was proud of their multi-disadvantaged network and multi-disciplinary drug and alcohol service team. These were developed following identifying gaps in the market and worked to support people in the community. The multi-disadvantaged network was a joint multi-disciplinary group consisting of the Integrated Care Board (ICB), outreach nurses, housing, mental health, nighttime support, and others. It brought together separate initiatives to bridge the gap to people who found it difficult to access services.

A senior leader told us they were keen to work more collaboratively with public health in relation to prevention of services in the community. There were plans in Autumn 2024 for commissioning to be restructured to sit within adult social care to ensure oversight of the market and gaps in services to ensure people’s care and support needs were being met.

The locality teams we spoke to told us about close working relationship with the brokerage team. They told us communication pathways were good and were able to raise concerns to each other.

We received mixed feedback from provider partners in relation to whether the local authority consulted with their services to help them to understand the care and support needs of local people. Whilst some providers said they actively worked with the local authority, other providers stated this only happened occasionally. Some providers spoke positively regarding the supportive local authority forums and the themed discussions and spoke positively about the team who supported them. The local authority gave examples of working with providers to complete audits, identify staff champions and supporting providers with medication issues.

In the main, people had access to a range of local support options to meet their care and support needs, however there were gaps in service provision. National data showed 66.21% of people felt they had choice over the services they used. This was in line with the England average of 70.28% - Adult Social Care Survey, October 2023 (ASCS).

The Market Position Statement (MPS) was published in May 2024. Within this, was adult social care’s commissioning intentions (Commissioning strategy), quality assurance, market shaping, and the Adults Needs Assessment was completed in the form of the JSNA.

A senior leader told us the local authority plans to improve the market were ambitious, with a clear vision to improve services for people in Medway. One plan was to build a multi-purpose, multi-disciplinary care home with rehabilitation, nursing, and step-down beds under one roof. This was specifically to support the commissioning of dementia services and increase accessibility. The local authority had identified a shortfall in the number of step-down beds and had recently commissioned more beds to bridge the gap. The local authority had also identified the need for more extra care facilities and were looking at repurposing buildings to achieve this. The local authority had worked with developers and providers who had submitted a planning application to encourage them to provide the capacity Medway required. Currently the local authority was looking to improve the nursing and dementia offer. 

Medway had introduced a new dynamic purchasing system (DPS) for the purchasing of supported living providers which had improved the number of services available from 20 to 120. We received negative feedback about how the local authority worked with provider partners in market shaping. Provider partners told us the local authority did not engage with them in determining how and what they commissioned. We were told some providers partners had been asking to work on a strategy with the local authority for a number of years, to input into the number and type of people providers could support, with long term plans for increasing capacity, but this has never happened.

There was some consideration for the provision of services to meet the needs of unpaid carers. Medway’s Better Care Fund Plan recognised the importance of unpaid carers through the Medway Joint Carers Strategy (2019-2025) which had been co-produced with unpaid carers and key partners such as health organisations. The commissioned provider who supported unpaid carers in Medway, delivered all adult and young carers support services. The local authority was exploring the potential for this service to undertake statutory carer assessments under a trusted assessor model.

There were no delays providing home care, however an area for improvement was to increase capacity across residential and nursing provision and for young people with complex needs. Whilst staff recognised there were new services developing, there remained a shortfall. There was also a shortfall of services supporting clients with mild learning disabilities or autistic people, who required 30 hours a week support. A priority for the local authority was to increase capacity across residential and nursing provision.

In recognition of the financial challenges facing Medway, the local authority had requested the Local Government Association (LGA), through the Partners in Care and Health (PCH) programme, undertake an independent finance review, and to review the local authority’s use of resources in Adult Social Care. The review highlighted issues with the social care market and the lack of vacant placements across all service types.

Information provided by the local authority showed they were facing unprecedented challenges to support and sustain the 65+ care home market. At the time of the assessment there were 43 care homes registered to provide care to older people in Medway. Of these, 14 were registered to provide nursing care. In total these care homes were registered to provide 1,390 care homes beds. The population of people aged 65+ in Medway was almost 47,000 and local authority data stated around 13,200 people aged 65+ needed help with at least 1 self-care activity, for example, having a bath or shower. With approximately the same amount needing help with Activities of Daily Living (ADLs), for example housework and laundry.

People were offered increased home care packages whilst they were awaiting placements in residential nursing provisions. However, staff told us they were concerned this was not the best solution as there were issues around arranging night support whilst people remained in their own homes. The information provided by the local authority stated there were challenges to support and sustain the 18+ domiciliary care market as a result of reducing budgets, reduced staffing levels, and the increasing cost of care. This meant the local authority would struggle to ensure continued support and sustainability. Community partners told us people were finding it increasingly challenging to access support within their own homes when needed. However, this contrasted with data provided by the local authority confirmed the average waiting time for a package of homecare was 1 day due to good capacity within providers. The average waiting times for mental health and learning disability supported living placements were 33.5 days and 39.5 days respectively. In relation to residential care home placements, the average waiting time was 36.25 days, and 31.3 days for nursing home placements.

The local authority had 9 providers on a framework, and 23 spot purchase providers who provided homecare, as well as 5 extra care schemes. A senior leader told us the local authority were currently reviewing their assets to determine whether any buildings could be resourced and used to support adult social care, for example to create more extra housing and supported living placements. Whilst staff felt there was a gap in the care market for support provisions which were a less restrictive option than residential care, the local authority had introduced a new dynamic purchasing system (DPS) for the purchasing of supported living providers which had improved the number of services available from 20 to 120.

The local authority confirmed there were hospital discharge delays due to lack of service availability and capacity. The local authority provided us with current data which showed the shortest delay was 4 days and the longest 119 days. Staff told us some people were in hospital when they were medically fit for discharge because of lack of residential and nursing beds. To address this, the local authority was looking at block purchasing, as they were placing people out of area more. Staff also told us respite beds where being blocked by people needing residential nursing services.

Due to lack of capacity in residential services, some people were supported outside of their local area. There were 369 people placed out of area for several reasons and not solely because of lack of capacity. Due to the geographical location of Medway, many people had family or friends who lived ‘out of area’ where often the placement was closer to the family member, and this would be by request of the person and family. Or people may have been placed out of area if they required specialist support/placements or moved to another home within the same provider group.

The local authority planned to fund the purchase of a total of 20 additional care home beds to meet the expected pressures during Winter 2024/25. The beds were to be used primarily for 'hard-to-place people’. In addition, the Health and Care Partnership proposed to utilise this funding to ensure a ‘wrap around’ service comprising of a dedicated social worker, social care officer, occupational therapist / physiotherapist, falls prevention staff and a dementia support specialist. The aim was for people to either return home with homecare or move into residential care on a long-term basis (following this intervention) which would be easier to source within the local market. This proposal demonstrated an understanding of the local market and an aim to address gaps in service provision.

The majority of provider partners stated they did not receive any support from the local authority to address the recruitment issues they had been facing. Partners told us housing was an issue within the region, and the local authority had responded by increasing the provision for rough sleepers, including a counselling service to be more proactive.

The local authority had arrangements to monitor the quality and impact of the care and support services it commissioned, and supported improvements where needed. The Provider Development and Quality Assurance team had created a 'super' training matrix which pulled in training needs from a number of providers and could therefore identify where the skills gaps were across Medway. However, only 1 provider we spoke with was aware of the 'super' training matrix and told us it was created a long time ago. They had not received any feedback after they had submitted their information.

At the time of our assessment 1.92% of residential homes were rated outstanding by CQC, 69.23% were rated good, 23.08% were rated requires improvement, and 5.77% had not yet been rated. Of the homecare services in Medway, 35.23% of home care services were rated good, 21.59% were rated requires improvement, 2.27% were rated inadequate, and 40.91% had not yet been rated. 58.82% of nursing homes were rated good and 41.18% were rated requires improvement, 33.33% of supported living services were rated good, 23.81% were rated requires improvement, and 42.86% had not yet been rated

Data provided by the local authority said there were 6 active commissioning suspensions, 4 restrictions, and 1 termination of contract. Reasons for these included concerns from the Home Office regarding immigration and sponsorship licenses, providers with poor CQC ratings and where the local authority had concerns about the quality of services.

The provider development and quality assurance team had oversight of the quality of provider, however this was a small team who, at the time of our assessment, covered all the providers in Medway and was unable to meet the demands of the service. This meant they were not able to visit all providers annually. Providers confirmed this, with some saying they had not had any visits in years, and others saying they had received no support at all. Providers were rated red, amber, or green according to risk. A risk could be triggered by a provider having a CQC rating of requires improvement or inadequate, a concern being raised, no registered manager within the service, or if a home office license was revoked. Any of these issues would trigger a quality assurance visit. A senior leader told us about the staff growth plan ‘right sizing’ to recruit more staff to the team which would enable them to cover complaints, professional concerns, and safeguarding enquiries more effectively.

Care providers gave us negative feedback on how the local authority collaborated with care providers to ensure the cost of care was transparent and fair, and on the local authority’s contracting arrangements. They told us the local authority did not work with them to ensure appropriate working conditions for the workforce, including living wage, sick pay or travel time. They told us there was a website for training, and although providers had requested face to face options for moving and handling and basic life support training, this had not been forthcoming. One provider told us there used to be links to Medway College of Social Care, but the providers we spoke with were not sure if it still existed. They also identified some training was quite costly. Providers in the network worked together to fill courses to reduce costs. The local authority told us they regularly advertised free training for care workers in their newsletter and on their provider portal. Workforce, recruitment and retention were a significant challenge to the stability of Medway’s provider market.

National data for Medway showed adult social care staff who had the Care Certificate in progress, partially completed, or completed was 51.49%. This was in line with the England average of 55.53% - Adult Social Care Workforce Estimates.

Data provided by the local authority showed 4 nursing homes had handed back packages of care in the last 12 months due to people’s increased support needs. This further reinforced the need for more complex nursing provision as identified in the Market Position Statement. For residential placements there were 7 packages of care handed back. There were 5 packages handed back from supported living settings. Three homecare packages handed back and 12 locations had left the market in the last 12 months.

The local authority understood its current and future social care workforce needs. They told us they worked with care providers, including personal assistants and other agencies, to maintain and support capacity and capability. This was not the experience of the majority of the providers we spoke with. Residential services in Medway had experienced a reduction of staff especially in residential and nursing care homes. In response to this challenging situation, the local authority had created a number of strategies including a ’Self directed Support Workforce Strategy 2023-2025 and a draft Adult Social Care Workforce plan draft, which the local authority continued to monitor.