Middlesbrough Council: local authority assessment

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

The South Tees Health & Wellbeing Boards, of which Middlesbrough Council were a member of, have agreed to a ‘mission-led’ approach, structured across the life course. Each mission was a response to a significant local challenge, one where innovation, working together and aligning resources had a big part to play in driving large-scale change. The ‘Missions’ each had a set of ambitious goals that further articulated and explained the mission. The missions were to tackle homelessness, dietary and nutrition and poverty. The JSNA data provided the intelligence behind the missions – it developed their collective understanding of the missions; the issues behind and the broad contributing factors to the current outcomes experienced.

The local authority was working with stakeholders across the Tees Valley to develop a process on that footprint that would facilitate deeper engagement from the Integrated Care System, led by the Integrated Care Board.

The vision and aspirations under the life course framework already existed following previous development sessions of the ‘Live Well’ Board. The life course framework consisted of three strategic aims – start well, live well and age well.

The initiation of the community hubs had already started to help the local authority staff engage with people who were most likely to experience poor care and outcomes. With the further development of a planned neighbourhood model will come a better understanding of the care and support needs of people and communities.

A partner organisation told us, “The local authority community workers play a crucial role in building trust across some of the poorest communities in Middlesborough. They have made significant efforts through initiatives like community hubs. These hubs serve as key points of contact where residents can engage, and where workers stationed there gradually get to know people, building relationships and trust over time. This ‘keeping their ear to the ground’ approach helps the local authority stay informed and responsive to the community's needs.”

People had access to a diverse range of local support options that were safe, effective, affordable, and high-quality to meet their care and support needs.

The local authority had a good provision of Care Quality Commission registered adult social care services. This included home care, residential care, nursing care and supporting living services. Overall, 78.7% of those services are rated good, meaning they were safe, effective, and provided a high-quality standard of care, which met people’s needs.

Data provided by the Adult Social Care Survey dated October 2024, showed 75.3% of people who used services in Middlesbrough felt they have choice over services, which was above the England average of 70.2%.

The local authority worked closely with public health, housing, and the local integrated care system to ensure their commissioning strategies were aligned with the strategic objectives of their partner agencies. There was a joint health and well-being strategy in place with public health which featured the ‘mission-led’ approach to tackle issues such as shortages with suitable local housing with support options for adults with care and support needs, and the historical heavy reliance on residential care.

The local authority’s commissioning strategy 2024 was intrinsically linked to the council’s medium-term financial planning. The 3-year plan summarised the commissioning intentions and the market shaping activities which had supported this, although it was in early development.

One leader told us they were working with the Local Government Association to put together a medium-term plan for addressing housing alternatives. They said historically housing resources had been cut back and they knew they needed to rebuild the housing capacity.

Another leader said the council were working on creating a balance between getting homes adapted and people living in family homes which no longer met their needs. The local plan included influencing developers to consider building more bungalows in key areas, enabling people to remain independent in their own home, preventing and delaying the need to move to a residential care home. In addition, there was a consideration for new homes to be adapted ready to meet the longer-term needs of people.

Staff told us as a result of people with a learning disability often being placed out of area, the local authority had recently opened 2 specialist services to meet the demand. They worked closely with other local authorities in the area due to their small geographical area, to share the resources for people with complex needs.

There was consideration for the provision of services to meet the needs of unpaid carers outlined in the South Tees Carers Strategy 2021 – 2026. This stated through a joint commissioning approach, an equitable and efficient offer would be provided for carers across the South Tees area, ensuring that local authority boundaries do not represent boundaries to services. At the same time a collaborative approach to services aligned with the priorities of the South Tees Health and Wellbeing Board and the strategic vision for joining up health and social care.

At the time of our assessment the local authority had some contracts due to expire within the next 12-18 months, work was underway in accordance with the commissioning cycle to review the process in place, consider evidence of future need and demand and take the opportunity to explore models of care including those in line with recognised best practice.

Middlesbrough Council were part of a North East Association of Directors of Adult Social Services (ADASS) group looking at home care procurement within the next 2 years to gain shared experience in terms of new service models, how they were working, and determine the requirements of the future home care service model in Middlesbrough. The current framework of home care providers was contracted on a task-based spot arrangement. This was not in line with commissioning for positive outcomes whereby providers have flexibility to deliver services in a way that meets people's preferences. Providers told us they had been informed of the intentions for future procurement of home care and they were expecting to be involved in its coproduction.

At the time of our assessment there were 2 extra care housing schemes in Middlesbrough, providing 112 one and two-bedroom apartments for people aged 55+ with care and housing needs. ‘Extra care’ also known as housing with care, provides people with the opportunity to live in their own purpose-built, self-contained household, while accessing care and meals on-site. This can enable people to live more independently for longer. Care is provided by staff who are available 24 hours. It is a newer form of specialist housing for older people.

Commissioning staff supported new and innovative approaches to care provision, where this led to better outcomes for people.

Staff told us they were looking to engage with the community more often for their tendering processes and were looking to modernise some of their service offerings. Frontline staff said they had 9 conversations with people who use services booked in to discuss this and they were looking to work with more people. Staff said they needed more 'on the ground' intelligence to support their market shaping. Leaders told us this had been actioned through the development of a new dedicated post, that had already commenced linking in with grass roots groups, providers and community and voluntary sector organisations to understand the issues and barriers, and how they can work better together.

The local authority commissioned a partner organisation to provide a dementia advisor service, a befriending service, a project which helped older people overcome mental health problems through social rehabilitation, and a new project around older people who hoard. A partner organisation told us they met with commissioning staff quarterly to discuss projects, outcomes, and the funding they provided.

A leader told us there were plans in place to consider co-locating services to enable improved access to multiple services for people. An example provided included setting up in a shopping centre as a health hub which would provide alternative options to people other than that of a hospital setting.

There was not always sufficient care and support available to meet demand and people could not always access it when, where and how they needed it. There were shortfalls identified by people, staff, and leaders in some aspects of adult social care and support. For example, people told us there was a lack of specialist dementia provision including respite and sitting services offered by the local authority. This had impacted on people and their families maintaining their health and wellbeing, relationships, and interests.

Staff told us there were several supported living services that were traditional and did not cater for younger people, they were currently working with a provider to look at alternatives. This was a recent initiative, and more staff had been recruited to support this work.

Staff said there was limited employment support for the young people they supported. The only statutory offer was from Department of Work and Pensions, and nothing bespoke from the local authority. This had identified a gap in supporting people into employment. There were also limited opportunities for people with a learning disability to be supported into employment. Local authority leaders told us these gaps had been identified and were a priority for them going forward.

Staff felt the leaders of the council had listened to staff and the concerns raised. For example, challenges with recruitment and retention had been addressed and a market supplement had been introduced. Another example included bringing community interventions, housing, and alcohol and substance misuse services in-house. This had improved communication and reduced the delays of people accessing timely support.

There were no waiting lists for people in the community who required home care, residential or nursing care and the waiting list for people in hospital who were waiting to be discharged was minimal. The reasons for those delays were mostly out of the local authority’s hands, such as medication and transport not being available.

Data from the local authority showed they currently commissioned in the region of 13,000 hours of home care for approximately 1000 people. There was a capacity of 1724 beds available in residential and nursing homes, of which 1478 were occupied, representing an average occupancy of 86%.

There was some capacity for unpaid carers to have access to replacement care for the person they cared for, in both planned and unplanned situations. However, some unpaid carers we spoke with told us, it was not sufficient to meet their needs. Leaders told us the provision of any replacement care may be provisioned in accordance with the care plan of the person being cared for.

Data from the Survey of Adult Carers in England dated June 2024, showed that Middlesbrough were performing slightly better than the England averages for unpaid carers accessing services which allowed them to take a break. The figures showed 13.9% of carers accessing support or services allowed them to take a break from caring at short notice or in an emergency. 19.5% of carers accessing support or services allowed them to take a break from caring for more than 24hrs. And 22.2% of carers accessing support or services allowed them to take a break from caring for 1-24hrs.

During the care needs assessment process, contingency plans were discussed and put in place for planned and unplanned events. A partner organisation told us Middlesbrough council used to be better at funding breaks but that had reduced, and it was difficult for unpaid carers to get any kind of breaks. The partner organisation said they had been able to bring in some funding to supplement this and some unpaid carers had been able to have a break.

They added, there was a gap in the provision of sitting services for unpaid carers to have a break. The issue was the availability of domiciliary care agencies willing to provide this service which caused delays for people waiting for this type of support.

There was minimal need for people to use services in places outside of Middlesbrough, however most people were supported within the South Tees region. There were plans in place to increase the capacity of specific services so people could move back if they wished to do so in the future, and some provision had recently been increased.

Staff told us they had identified a lack of accommodation for people with complex learning disabilities. This was fed back to the senior leaders and had resulted in the provision of 2 services in Middlesbrough which were specific to people with these specific needs.

Data provided by the local authority showed there were currently 182 people placed outside of Middlesbrough. The highest levels were for residential care, 44% and day care 26%. The 3 main reasons for this were personal/family choice, 44%, specialist services were not available in Middlesbrough, 35% and no vacancies available at the time of placement, 8%.

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. Some services were commissioned jointly with other agencies. In these instances, there were clear roles and accountabilities for monitoring the quality of the services being provided and the outcomes for the people using them.

The local authority’s quality assurance framework aimed to ensure high quality, evidence-based practice, continuous improvement of providers, learning and person-centeredness. Reviews were an integral part of the framework. Follow-up visits were determined by the risks regarding the recommendations given from the contract monitoring visits. Methods of reviews or monitoring included self-assessment, full/themed reviews, and quarterly contract monitoring visits.

Staff told us they currently had 42 separate tools for quality assuring commissioned services, including those jointly commissioned with other agencies. They said they were in the process of amending this and modernising their approach with the support of an analyst. Despite the large number of tools in use, the staff told us their approach to quality assurance worked well. Contract monitoring procedures were in place for out of area placements too.

Providers told us the local authority's approach to quality assurance was positive, with quality assurance tools in use which providers had access to in advance. Providers said they felt the commissioning team was open and honest with them and gave clear feedback and support to improve. They added that compared to other local authorities in the region, Middlesbrough performed the best in this area.

In the last 12 months the local authority placed embargoes on 4 care homes in the area, meaning they were restricted with their admissions. Reasons for the embargoes included, a serious incident, a whistle-blowing investigation, care delivery concerns, concerns linked to medication administration, nutrition and hydration and care planning. These embargoes remained in place until improvements had been made, following ongoing monitoring.

In the last 12 months the local authority had received notifications concerning care homes they were using out of the area, where the local safeguarding authority had implemented suspensions in placing people in these homes. There was a process in place to identify any people they had placed in those care homes and had requested a social care review.

Providers told us the local authority were supportive of their services. An example was given of a care home which had problems and required support from the local authority. This provider told us they had been offered lots of support to improve the quality of their service, and the local authority was easy to contact.

Providers said the local authority offered them opportunities for training and development. An example of this was via the provider forum. They told us at this forum there were often guest speakers such as medications optimisation, infection, prevention and control teams and a dentist. The local authority had linked in with the local university and NHS Trust to offer providers opportunities to learn from and put in to practice recent research.

The local authority collaborated with care providers to ensure the cost of care was transparent and fair. Systems were in place and monitored to ensure a fair market arrangement with providers.

Staff told us they had forecast and demand modelling in place and shared with neighbouring local authorities to support standardisation of fee rises across the local geographical area. They said they had an ‘open book accounts’ relationship with providers so they could be assured of providers financial viability.

In 2022, the local authority moved away from a system which linked price to quality ratings. Annual reviews and regular monitoring were still in place and additional financial support was given to homes graded below 4*, providing greater equity across the entire provider market.

There were a range of contracting arrangements in place, most commissioned through spot contracts, including home care, residential and nursing care, and day opportunities. This type of model is not the most efficient way of contracting and it does not give providers stability to plan ahead. However, these contracts were being reviewed when contracts ended, with imminent plans to implement a new model for home care providers in 2025. However, some providers told us there had been some resistance from the local authority in relation to changing the model of care in residential and nursing care. Leaders told us a full consultation process had been undertaken regarding residential and nursing care.

The local authority worked with providers and stakeholders to understand current trading conditions and how providers were coping with them. 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 people had continuity of care provision in this event.

The local authority had a clear process in place when a provider was at risk of failure. It included guidance for staff in relation to initial work and actions as well as a management checklist. These documents demonstrated a thorough and well thought out process. It showed joint working between adult social care, commissioning, the Integrated Care Board, and other placing authorities.

The local authority followed best practice guidance, such as the North East ADASS Market Information Sharing, Support & Improvement Protocol when a provider was at risk of failure. This included sharing and responding to requests for information and instigating a turnaround team to provide intensive support to reduce concerns and bring about improvements. Staff told us they had previously paid provider staffing costs to avoid provider failure.

A provider told us they had recently been through the process and received this level of support to help them continue to trade. They said, “Middlesbrough council have been offering intensive support from commissioning staff and the medicines optimisation team. They were supportive, positive and gave us space to fix issues. Over the last few months, they have been incredibly supportive, and easy to contact.”

The local authority understood its current and future social care workforce needs. It worked with care providers, and other agencies, to maintain and support capacity and capability.

Skills for Care data showed the local authority had only 5.3% of adult social care job vacancies (all jobs, all sectors). This was better than the England average of 9.7%. The adult social care staff turnover rate was similar to the England average of 0.3%, as was the staff sickness rate of 6.7%. However, only 26.7% of eligible staff had completed or partially completed the Care Certificate. This was significantly worse than the England average of 49.7%.

Leaders told us recruitment and retention was not a major priority at present except in the reablement team. They said the development of the reablement service was a key priority to reduce, prevent and delay people’s needs for longer-term social care, and to promote independence. However, growing this service was impeded by their ability to recruit staff into this team.

Staff told us despite the early adoption of a reablement service, staffing levels due to delays in recruitment had meant that currently they provided a much lower level of reablement than they aspired to. Leaders told us they had commissioned an external provider in January 2023 to support their reablement resource. However, despite this extra support, staffing levels had remained low throughout 2023-2024.

Providers told us when they mobilised new services commissioned by the local authority, staff were supportive of them getting the right staff, not just the numbers. They said they were linked in with other organisations who could help with recruitment, such as Middlesbrough College who offered apprenticeships. Providers said recruitment fairs were held every 3 months, which attracted 2000 people last year, and was supported by Job Centre Plus. They said the local authority do put real effort in, but the challenges across the whole sector still caused issues with recruitment.