Telford and Wrekin Council: local authority assessment

Telford and Wrekin took a coproductive approach to data collection and community engagement, using multiple sources of data, including census data, Public Health information, data from the JSNA 2024, drop-in sessions, awareness events, complaints and concerns, and frontline teams. Health, voluntary and community sector, and internal local authority partners worked jointly to plan strategies, shape services, and meet current and future service demand.

Population growth, ageing populations, increased need for specialist service, meant demand for several services areas had begun to outstrip capacity. Partners, staff and leaders told us there were enough services to meet domiciliary and residential support needs but there was a need to increase the number of available placements for supporting more complex dementia and nursing needs, as well as more community-based services to meet the needs of people living with learning disabilities, autistic people, and people with mental health needs.

People told us some ethnic communities found it hard to engage with the local authority. For example, people from the Chinese community who did not speak English told us they often felt isolated and disconnected.

Staff and leaders also told us there were smaller, targeted support needs to address. For example, bariatric support and services for people with neurological conditions such as Motor Neurone, Fibromyalgia, and multiple sclerosis. Data for each area of Telford and Wrekin accessed through a ‘Middle Layer Super Output Area’ dashboard allowed data to be analysed at community level.

We saw how the JSNA 2024 broke down the data on people’s needs into 3 key areas: Start Well (Children’s services); Live Well (people of working age); and Age Well (65+). These broad categories were used to ‘track’ peoples’ support needs through their lives and target prevent, reduce, delay services where they would be most effective. For example, Public Health services worked with Children’s services to implement healthy-living initiatives to address concerns around childhood obesity where rates were worse than the England average.

Telford and Wrekin’s market position statement 2021-2025 focused on a ‘home-first’ strengths-based approach, with the person’s skills, family, and community support at the heart of all assessments of need to ensure services met people’s needs, improved outcomes and offered value for money. Care and support services were delivered by a range of organisations and providers including the local authority itself, individual personal assistants, independent and community providers, and unpaid carers.

People had access to a diverse range of local support options, with goals set in the market position statement having already been achieved. For example, an increase in domiciliary care services for rural areas, more flexible approaches to night care and an increased uptake in digital solutions. This allowed people more variety of choice when looking for provider services to meet their needs. National ASCS data for 2023 showed 71.26% of people who used services felt they had choice over which service provided their care and support. This was comparable to the average for England of 69.81%.

The current local authority market sustainability plan (2023-2024), as well as the Supported and Specialist Housing Strategy identified how the local authority and its partners expected to improve current service provision and meet future demand. It estimated 70% of residents in care homes (65+) were funded by the local authority, with 30% self-funding their care and support needs in 2023. In domiciliary care services, supporting people in their own home, this split was 35% council funded, 60% part-funded and 5% self-funded. The local authority’s aim was to increase the number of people accessing council-funded support in their own home. The ‘Homes for All Supplementary Planning Document’ which formed part of the local authority’s Strategic Development Plan embedded the housing needs identified in the Supported & Specialist Housing Strategy into planning requirements.

The local authority ensured commissioning strategies and market shaping activities aligned with the strategic objectives of partner agencies through ICP and TWIPP Boards, with funding streams and joint strategies agreed both with the ICS, ICB and neighbouring Shropshire local authority. However, there was still a need to pull together the existing commissioning documents into an overarching cohesive commissioning strategy.

People told us there was a lack of respite choice for unpaid carers, however national SACE data for 2024 showed the number of carers accessing support or services allowing them to take a break was in line with the average for England. 13.46% of carers felt respite services allowed them to take a break from caring at short notice or in an emergency. This suggested whilst potentially limited in choice, the provision of respite for unpaid carers was in line with the national average of 12.08%. Senior leaders told us the provision of care for short breaks and unplanned situations for unpaid carers was currently being reviewed, with specific groups of people with lived experience being spoken to. Staff leading the consultation on carers services went out to 50 different community events to gain feedback as well as engaging people on the phone and by letter.

Staff and leaders told us the local authority had a variety of commissioned services, including block-contracts for services where ongoing specialist training and support was required (for example reablement services), and spot-purchase contracts for more bespoke, preventative services. There were Section 75 agreements with health partners for integrated community services, including voluntary and community organisations. Section 75 agreements are between local authorities and NHS bodies which can include arrangements for pooling resources and delegating certain NHS and local authority health-related functions to the other partners.

Partners told us the local authority worked closely with housing, Children’s services, health partners and other local authorities to identify future service needs, and commissioning strategies included the provision of suitable, local housing to meet those needs.

Staff and leaders told us the local authority commissioned models of care and support in line with recognised best practice. Telford and Wrekin used a Dynamic Purchasing System (DPS) for care and support services. This DPS aligned to a range of national government policies and initiatives and ensured providers were focussed on a whole family approach. Service provision was commissioned based on outcomes and the range of internal and external providers in the borough and neighbouring local authorities allowed flexibility to deliver services in the way which met people’s preferences and allowed for timely, safe transitions between services. For example, partners told us residential beds had recently been decommissioned and replaced with more nursing provision; the local authority worked with providers to upskill staff and ensure the quality-of-service provision was maintained through these changes.

People and partners told us the local authority supported new and innovative approaches to care provision to improve outcomes for people receiving care and support. For example, following a decrease in demand for day care services for older people, commissioners had supported the recruitment of more personal assistants to provide bespoke, individual support in the community. Staff told us how the ‘planned overnight care’ team had allowed more personalised support at night whilst reducing service costs. The local authority also had its own in-house service provider (‘My Options’) supporting over 300 people in a full range of services, including a shared lives (adult placements) provision, rated outstanding by CQC.

The local authority ensured there was sufficient care and support available to meet demand, and people could access it when, where and how they needed it. However, out of borough placements, particularly with neighbouring local authorities, were sometimes required for specialist needs. Staff told us there was significant demand for mental health placements locally and out of borough placements were required for people needing support with acquired brain injuries.

Updated data provided by the local authority as part of the assessment showed there were 143 people supported in out of borough placements. The majority of these were in the neighbouring local authority of Shropshire, partially due to the joint provider framework with Shropshire for learning disabilities and mental health provision. Other reasons for these placements including personal choice, specialist placements, forensic risks, and emergency placements where services within Telford and Wrekin were full (local authority capacity trackers regularly reflect residential and nursing homes being 90-95% full).

Data provided by the local authority showed the maximum waiting time for discharge from hospital to a new care home placement was 10 days, with the waiting list for discharge home much lower at 24 hours. Further data shared by the local authority in July 2024 showed in April to June 2024, 16 discharges out of 538, were not completed within 48 hours due to a lack of adult social care service capacity in the residential and nursing care market. The majority of the 16 were completed within 72 hours of the transfer of care being received from the hospital teams. Reasons for these delays included the complexity of the needs of the person; the availability of suitable beds at the point of discharge; and negotiations with providers due to people’s complex needs.

At any one time there was an average of 1000 people accessing domiciliary care services, 490 people supported in nursing and residential homes, and a further 150 people in supported living services.

Senior leaders told us one of the main priorities for the local authority was improving supported accommodation in the borough to meet current and future demand for people with learning disabilities, people with mental health needs, and people living with complex needs such as dementia. This included offering opportunities for out-of-borough re-patriation, and improving opportunities for people to remain in the communities they grew up in. Data showed 50 people had moved back into Telford and Wrekin from out of borough placements in the last 3 years.

Partners, staff, and leaders told us the local authority worked closely with Children’s services and housing services (including the local authority’s own ‘wholly owned’ company delivering private rented accommodation, Nuplace). The local authority was using this, and the local authority’s service provider, to deliver accommodation suited to people’s needs.

Strategic plans included an increase in supported accommodation of 446 ‘units’ (self-contained flats) by 2025; this included: 45 units supporting people with a learning disability and autistic people; 32 units supporting people with mental health needs; 275 extra care units for older people (including 14 units supporting people living with dementia and complex health needs, and units supporting bariatric needs); 74 ‘retirement’ units. Of the 446 planned units 106 were already complete and had opened in early 2024. The local authority was further shaping the wider development market directly through their ‘Homes for All’ Supplementary Planning Document.

Staff told us people with lived experience, frontline occupational therapy teams, and housing teams worked closely to support the design and planning of new supported accommodation to ensure compliance with the needs of the people using services. Senior leaders told us a new commissioning strategy was soon to be consulted upon, taking the provision of supported accommodation in the borough forward from 2025.

Partners told us they had good relationships with commissioners and found them very responsive. They told us they had been looking at developing forensic supported accommodation and felt commissioners had been very receptive to their view of a local resource for this being needed. They told us commissioning teams were very proactive and met them regularly, forecasting transitions for young people coming through from Children’s services with specialist needs.

Mental health services had seen joint working initiatives with the voluntary and community sector, with jointly run calm cafes open daily (and into the evenings) cited as “partnership working at its best.” In contrast to older people’s day services, provision for learning disability and autism day services had seen an increase in demand, with requests for services to be open longer, as part of a more wraparound care option to enable parents and unpaid carers to work and access social activities.

People gave us mixed feedback on services supporting unpaid carers, with people stating there was a lack of choice in respite provision and a lack of communication about choice when trying to access replacement care. Other people told us of positive experiences accessing carer support services via the Carers Centre, including culturally competent services for African and Caribbean communities and coproductive opportunities for parent carers of adults with learning disabilities. Carers services also offered training on single-handed moving & handling techniques as well as end of life support.

Data provided by the BCF board (joint health and social care funding arrangements overseen by TWIPP) showed integrated care services were improving outcomes for people around hospital discharge and readmission rates. Data for January 2024 showed improved or sustained rates for avoidable admissions, falls admissions, permanent admissions to care homes and reablement outcomes for 2023-2024. Senior leaders told us an agreement had been reached with the ICB to fund additional Occupational Therapists to improve enablement outcomes and length of stay.

Data also showed a significant increase in domiciliary care use (200% in the last 5 years) with plans to increase the use of Virtual Wards seen as one way to mitigate the impact. Most schemes were performing at, or just below expectation, however, reablement services were commissioned for 27 beds, but were using 100+, with spot purchases needed regularly. Partners told us the local authority worked with providers to ensure staff were trained and competent in providing reablement support, with staff and leaders sharing plans to improve market provision in this area by 2025. Senior leaders told us the local authority had commissioned an additional 13 beds from 1st July 2024 to give additional block capacity, as well as commissioning 2 Extra Care beds as a ‘Test of Change’ to reduce bed utilisation.

Telford and Wrekin had clear arrangements to monitor the quality and impact of the care and support services commissioned for people, and supported improvements where needed. The local authority had designed its own provider quality assurance framework, based on questions drawn from their provider contracts and commissioning processes, as well as acting as an ‘improvement partner’ for services facing staffing or quality issues.

Quality monitoring was based on risk, with safeguarding concerns, complaints and feedback from partners used to measure safety, as well as proactive and reactive on-site visits, ‘desktop’ data and joint visits to assess the safe administration of medicines and infection prevention and control practices. Statistics were used in conjunction with evidence to provide a picture of practice and its impact on individuals. Feedback from practitioners and people with experience of care were also used as indicators of quality.

The local authority allocated a Provider Quality Rating (PQR) to providers on the completion of any quality assurance activities. A poor PQR may be recorded because a provider was in breach of their contract agreement, which could on its own lead to contract actions, suspension, or termination of work. The local authority’s Suspension Policy & Process provided guidance and documentation to support actions taken. Staff told us 1 nursing home had been subject to a suspension in the last 12 months, with action taken to improve safety, and measures implemented to ensure quality service provision before lifting the suspension.

At the time of writing the local authority commissioned 84 Telford and Wrekin based care and support providers: 41 residential and nursing care services, and 43 home care service (including supported living, extra care, and domiciliary care services) registered with the Care Quality Commission (CQC). 57% of nursing homes were rated as good by CQC, with 35% rated requires improvement. 65% of residential homes were rated good, with 30% rated as requires improvement or inadequate. In addition, the local authority had commissioning arrangements with 67 out of borough care homes.

Senior leaders told us they met with providers in January 2024 to look at quality assurance themes and trends and to agree improvement actions, including processes for monitoring and feedback. All services rated requires improvement or below by CQC had been reviewed in the last 12 months and had seen a marked improvement in the safety and quality of care. Staff told us they supported providers to improve by meeting with them regularly to work on identified areas of focus, setting up of action plans, providing training and advice, and monitoring progress through repeated on-site assessments of care and support in addition to monthly safeguarding meetings.

For out of borough providers, staff completed desk top reviews and linked in with quality assurance teams within the borough providing support. Concerns were shared with commissioning and brokerage teams to inform spot purchasing and tendering decisions, and the local authority met regularly with care regulators to update shared information and agree actions. Brokerage teams provided advice and information about adult social care services available in the local authority area. The ‘broker’ found service providers who could meet the person’s needs and choices. They provided information about different types of support available and could arrange service provision to meet people’s needs.

People told us of coproductive approaches to quality monitoring, this was handled on a one-to-one basis, supported by people with lived experience. Voluntary and community organisations felt there was scope for joint working on engagement projects but the local authority currently did not make use of their experience in this area.

Providers told us the local authority undertook regular quality checks and worked collaboratively to enable improved outcomes for people receiving services. For example, feedback given as part of quality monitoring processes was timely, constructive, and highlighted good practice as well as areas for development. Providers also told us the local authority worked with them to ensure appropriate working conditions and asked providers to share how much they paid staff, including travel time pay between care calls for domiciliary care services.

Telford and Wrekin’s Adult Social Care workforce position statement (January 2024) set out the local authority’s responsibilities under the Care Act 2014. As part of the local authority’s contracts, tenders and procurement process, commissioners assessed financial and business plans, sustainability of staff recruitment, provider’s approach to training, and contingency planning arrangements. This applied to all people who had care funded by the local authority and those who paid for their own care (self-funders).

Telford and Wrekin’s market sustainability plan (March 2023) identified current and future market conditions, including risks to support services. For example, the local authority had identified risks to care home provision in the borough relating to the quality of care, undersupply of nursing care, and the fair cost of care, including a projected 30% increase in self-funders requesting support from the local authority.

Staff and leaders told us how the local authority worked with health partners to offer financial assistance for digital technology improvements (with 91% of providers signed up) as well as support with recruitment and health and social care training. Provider business continuity plans were checked by the local authority as part of their quality audit system. Providers told us the local authority paid them fairly and on time.

Although they did not directly ask staff about their working conditions, there were monitoring visits, safeguarding, and complaints processes in place where staff could raise concerns. The local authority had taken a proactive approach to international recruitment concerns and worked closely with providers to reduce risks of modern slavery.

Multiple providers and a mixture of block contracts and spot purchasing meant risks of provider failure impacting the local market were reduced. Use of small, local providers and good working relationships between commissioners and providers allowed for transparent discussions, business support advice and early warnings of potential service disruptions.

People told us of a lack of choice when it came to some types of care provision, with preferred providers often used ahead of people being offered diverse support services. This was especially evident in the support available for unpaid carers and included some rural areas where providers could be difficult to source. The current local authority market sustainability plan (2023-2024) identified this as an area for development and senior leaders told us of plans to address gaps in provision through joint working with other local authorities.

The local authority had a range of long-term and framework arrangements in place which supported strong relationships with providers and supported continuity of care. Contracting arrangements were efficient, provided stability for providers, and allowed them to plan ahead. The local authority was working closely with partners reviewing the commissioning strategy when the current one ended in 2025. At the time of the assessment this was at the design and planning stage, with formal consultation due to begin in September 2024.

Partners told us the local authority offered business audits in addition to quality monitoring support, which helped them work more effectively and reduced the risk of financial concerns. For example, in the previous 12 months 1 domiciliary service, 1 residential home and 2 supported living services had support to change their business model to meet changing local market needs and avoid these providers leaving the local market.

The local authority also collaborated with Partners in Care Shropshire, Telford & Wrekin to offer support, guidance, and training to the local workforce including supporting personal assistants. The local authority’s ‘job box’ team provided key skills training and worked alongside Telford Jobcentre Plus to support providers with recruitment. Data provided by Skills for Care (2022-2023) show 57.87% of Adult Social Care staff in Telford and Wrekin had either completed or partially completed the Care Certificate, compared to the average for England of 49.65%. The Care Certificate is an agreed set of standards which define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards which should form part of a robust induction programme.

According to Skills for Care, in 2022-2023 the total number of care worker posts in Telford & Wrekin was around 6,700. This included a just under 10% vacancy rate. The total number of posts had increased by 325 (5%), the number of filled posts has increased by 200 (3%) and the number of vacancies had increased by 125 (22%) from the previous year. In the social care workforce across the borough (all sectors), turnover and vacancy rates were higher than those seen nationally, with vacancies at 11.4% (national 9.6%) and turnover 29.8% (national 28.1%).