Wiltshire Council: local authority assessment

Commissioning was shaped by community engagement which enabled the local authority to understand local needs and facilitate effective services in the area. People, carers and partners told us the local authority listened and used co-production. This approach took longer to complete projects, but the local authority was seeing positive impact and outcomes through implementation plans aligned to corporate planning. Overall feedback around involvement was positive. However, we found there was more to be done to include the voices of people who were less likely to be heard. The local authority was aware of this and were committed to improve. For example, the ‘Voice it hear it’ contract was used to gather performance indicators, development, and evaluation of the approach. Staff told us that involving people, especially those harder to reach, was challenging, but by working with very small groups the outcomes were likely to be better.

The local authority used and shared some data with partners to understand the care and support needs of people and communities. There was a published Joint Strategic Needs Assessment (JSNA) and a commissioned video called ‘Christine's story’ to bring the work of the JSNA to life and show how health inequalities can impact someone over their life course. The JSNA shaped and aligned the local authority’s funding decisions and recommendations with the joint health and wellbeing strategy, and through the population health board particularly around preventative approaches. Data from the JSNA and other local-level data was used to inform partnership working and address shared priorities. For example, data had shown a correlation between hypertension and depression and a focused preventative piece of work was taking place between the local authority and health partners to tackle this.

Commissioning teams used the JSNA and other national and local data to develop services which would improve people’s outcomes and meet current and future demand. For example, the local authority’s independent living strategy drew on national demographic forecasting to understand how many adults with learning disabilities, autism spectrum conditions and mental health conditions lived in Wiltshire, and how this would change over the next 20 years.

We also heard the local authority commissioned external consultancies to carry out wide ranging needs analyses. For example, analysis of accommodation-based care and support to inform commissioning intentions up until 2025. This identified a likely 25% increase in commissioning spend, the need to reduce out of county placements and improve the use of Shared Lives provision. The local authority used data and co-production in understanding and supporting their biggest challenges in commissioning. These challenges were identified as being their ability to meet the needs of people with multiple or advanced health and social care needs, noting an ageing population, those living with dementia and in rural areas.

There was enough care and support available to meet the demand for care at home, and no delays for homecare provision. For unpaid carers we heard there was a good offer of short break options which carers could use direct payments to support or to replace care for the person they cared for, in both planned and unplanned situations. According to the Survey of Adult Carers in England 2023-2024, national data was low overall in relation to carers reporting they had access to support and services allowing them to take a break from caring at short notice or in an emergency. However, in Wiltshire there was a positive statistical difference (22.12%) compared to the England average (12.08%).

The local authority was carrying out monitoring and analysis around the availability of supported living and care home services. There was a need for people to use services or support in places outside of their local area. The local authority told us they had a total of 328 out of county placements and 62 people had been placed out of county in the last 12 months (April 2023- April 2024). There were two main reasons for people moving to accommodation outside of Wiltshire. Firstly, from choice, for example people moving to be closer to relatives. Secondly due to a lack of suitable provision within Wiltshire. Data provided by the local authority between January to March 2024 showed had people waited an average wait of 41 days for supported living and an average wait of 26 days for nursing and residential care.

There were plans and processes to address the gaps in provision. The local authority worked with people, staff and partners including Care Quality Commission (CQC), Integrated Care Board (ICB) commissioners, health and neighbouring local authorities to ensure people were considered for in county options first and had processes to reduce risks to people while they were in another county including people who funded their own care. There were plans to provide more care and accommodation for people living with dementia, autistic people and people with mental health needs, so people could move back to Wiltshire if they wished to do so. This included but was not limited to remodelling their mental health provision and purchasing new properties to increase supported living provision in Wiltshire.

Local authority staff spoke passionately about how they ensured people received high-quality care and accommodation, the support they provided to settle people into their new homes and the positive impact this was having on people and their carers. However, we also heard about people who had no access to mental health and drug and alcohol support, leading to a revolving door effect where people without suitable support went in and out of hospital. The local authority was addressing this concern. Social care staff worked with commissioning teams to identify gaps in the market, and gave examples where complex care services had been created locally to bring people back into the county and avoid residential care placements. The local authority was outcome focused and was working with local landlords and wider council estate teams particularly to meet the supported living needs of people with mental health conditions. We were told that social care staff had worked with a local organisation and commissioning staff to listen to autistic people, and as a result had set up an autism hub to address the gap in services for autistic people who needed specialist support.

There were multiple community services available for people with a learning disability and autistic people in Wiltshire. These included: short break services; a learning disability and autism Outreach and Enablement Service; Mental Health Intensive Enablement Service (IES); and Shared Lives (incorporating Shared Days). Wiltshire had in-house registered services providing short breaks for people with learning disabilities and physical disabilities. These benefited local people as there was a focus on supporting people to build and maintain friendships, try new experiences, learn new skills, and engage in community-based activities. The services featured accessible kitchens, sensory rooms, and resource rooms. Staff told us how one service had supported people to take part in money management, food hygiene and customer service courses, helping them gain the skills and confidence they could use when volunteering in the local authority’s 'Waverley Café'. The volunteering opportunities in the café also helped people connect with their community and improve their confidence, skills and abilities.

The local authority acknowledged there was always room for improvement in their care provision and said they were pro-active in seeking feedback and constructive challenge around ways to meet current and future social care needs. A senior leader told us about a 'think tank' to challenge any set views the local authority may have. One senior leader told us the local authority were thinking 20 to 30 years ahead to meet gaps and future gaps in provision or lack of capacity. The local authority planned on Technology Enabled Care (TEC) influencing and impacting the way they support people in their homes. We found the local authority were confident in making changes in the market by overturning existing models of care to prepare and improve the market, for example utilising old care home models for supported living initiatives and reviewing provider fees to ensure more equity in the system.

When considering the quality of services, local authorities must facilitate markets that offer a diverse range of high-quality and appropriate services and have regard to ensuring the continuous improvement of those services. There were 301 active adult social care provider locations registered with CQC in Wiltshire (CQC data, September 2024). CQC assess registered adult social care services in the Wiltshire market, services had an overall rating on the quality of care using 4 descriptions: outstanding, good, requires improvement, or inadequate.

Homecare in Wiltshire was statistically positive with 68.91% of services rated good compared to England average of 59.45% (CQC data, September 2024). Wiltshire local authority had five in-house homecare services including shared lives and reablement services, 4 were rated good overall and 1 was yet to be inspected as of September 2024. Feedback from leaders indicated the local authorities’ internal provider services had been a success, and this success had shaped future commissioning and re-commissioning planning to provide additional internal services to ensure quality was high. We received consistent feedback from people that use services and their carers, that the quality of care in Wiltshire was good and was having a positive effect on the wellbeing of people and their carers receiving care and support.

In Wiltshire, 2% of residential homes were rated outstanding and 76% rated good, 1.67% of nursing homes were rated outstanding and 73.33% rated good (CQC data set). Partners mainly spoke positively about the local authority’s quality assurance and the scheduled audits conducted, describing an approachable team and supportive processes which included engagement with people using services and staff at all levels as well as carrying out checks on relevant documentation.

The schedule for quality assessments could be adjusted flexibly if needed, and the local authority was proactive in managing provider risk. The local authority provided data to show they had carried out 66 commissioning suspensions because of quality or safeguarding concerns including concerns raised by partners between April 2023 and April 2024. In September 2024 Wiltshire had no residential or nursing care homes rated inadequate, this was statistically a positive difference than the national average of 1.25% for residential homes and 1.54% for nursing homes. The local authority communicated well with health and regulation partners around services including those with people from Wiltshire living out of area. Early conversations, regular meetings, multidisciplinary working and action plans supported people to be safe and access quality services. However, staff and partners told us the local authority could be risk adverse when responding to quality concerns. For example, people could not be returned to a care home if they were admitted to hospital and the home had a local authority suspension in place despite this being where they lived. This also happened when safeguarding concerns were raised regardless of the nature of the concern or persons desired outcomes. The local authority had a low threshold when suspending services and we were told this did not routinely include people using services or their representatives to weigh up risks and make informed choices. There were written processes to demonstrate it was best practice where possible or practical to place peoples wishes at the heart of plans, and processes to inform people at the end of strategic decision making. However, more could be done to ensure risks were communicated earlier with people using services, to allow them to make choices in care providers and for some people where they wanted to live. This would ensure people using services voice remained a priority and was central to any actions about how and where their individual care and support needs would be met.

There was a market sustainability plan linked to strategy identifying strategic risks which included workforce, inflation and current payment rates to providers. It identified actions the local authority planned to take to support market sustainability, including working towards a fair cost of care, support for recruitment and retention, and improved working with providers. However, there was mixed feedback from partners about how effectively the local authority collaborated with providers to support provider sustainability.

We heard about tensions across local authority and provider relationships caused by the competition of the self-funding market and differences in fees and fee uplifts (In April 2024 there was a difference in uplifts of 8.23% to homecare and 5.87% to residential care). The local authority was transparent about their current ‘all age framework’ needing to be improved. For example, care provided for people of working age was paid at a lesser rate to those aged 65 and over, this was said to not be sustainable for providers. The local authority was actively increasing focus groups, had well attended forums for engagement, and co-production approaches to hear from different providers and voices. However, we found providers did not always have a good understanding of the local authorities’ strategies, risks, and plans in transformation work. There was more to be done to develop and encourage trusting relationships with providers to better meet the needs of people in the area and understand the impact on people’s experiences of any actions taken.

The local authority was not the most significant purchaser of care and support for care providers in the area because of Wiltshire’s large self-funding market. Therefore, there was a need to consider the impact on the local market beyond those services which the local authority contracted. The local authority had block, spot and framework contracts, the impact of this had mixed feedback from staff and partners. Block contracts is where the local authority commissioned the purchase of a large volume of services from a particular provider. Spot contracts are where the local authority purchases care for immediate delivery either due to specialism or non-availability within the block contract. A framework contract is how the local authority decides which care providers can deliver care to people in Wiltshire from a list of pre-approved providers with agreed terms and conditions. Spot contracts for nursing or residential care went to providers in the Wiltshire Care Home Alliance (WCHA) first and then providers who were not in the alliance. To join the alliance there was a quality assurance process, and according to local authority’s data 95% of placements were with providers on the alliance. The contracts were working as there was enough supply of providers, however the number of differing contracts per provider was a source of frustration for staff and partners, and wider transformation plans were addressing this.

There was mixed feedback from providers about the fee levels paid by the local authority’ and how the fair cost of exercise was carried out. Some providers viewed their involvement as tick box exercise and told us it did not impact the outcome. Some providers told us that fee levels were not sustainable for some providers in the long-term and that some contracts had been handed back due to them being no longer financially viable. In contrast, there was positive feedback supporting the change and modernisation of how the local authority commissioned care and how rates paid above the national average allowed providers to plan. For example, one national provider told us the fees permitted them to create a workforce that was paid better than any other county in England (outside of London), this allowed high-quality services to individuals to support their wellbeing. National data showed that the average weekly rate for nursing care was over double the England average making Wiltshire was the highest payer of nursing care in England. Residential care and homecare were also paid higher than England averages (NHS Digital: Adult Social Care Finance Return (ASC-FR) 2022-2023).

According to CQC data, September 2024 there were 11 providers who became de-active or left the market in the last 12 months. At the time of our assessment there was sufficiency of provision to meet current demand for services.

The local authority demonstrated it was monitoring and checking the effectiveness of the adult social care workforce, including care provider workforce which had experienced an increase in workforce vacancy rates since 2021. In the Wiltshire area the total adult social care workforce vacancy rate was 10.76% tending towards a negative statistical difference from the England average of 9.74%, and staff turnover rate 0.37% tending towards a negative statistical difference from the England average of 0.29%. (Adult Social Care Workforce Estimates 2022-2023). However, we were told by the local authority, 59.3% of new workers had been recruited from within the existing adult social care workforce as opposed to leaving the sector or the council area meaning some skills, knowledge and experience were transferring across local employers. One senior leader told us this allowed adult social care staff to explore career opportunities which was important for workforce retention.

The local authority had a Market Sustainability Improvement fund (2023- 2024) to support with internal and external workforce capacity and retention. They distributed their funding across several areas including extra occupational therapist roles, one-off incentives for providers to join their framework, an internal staff market supplement, extra commissioning capacity to support with adult social care transformation and the undertaking of a peer review.

The Wiltshire Care Partnership (WCP) a provider forum, was funded by the local authority, and had worked with key national organisations in developing the wider workforce. However, there was mixed feedback from partners about the effectiveness of this, some told us they didn’t always know what support the local authority was providing around workforce. In contrast some shared positive feedback about workforce support including an annual recruitment fair that co-ordinated recruitment across Wiltshire, the Market Sustainability Grant, and training offers. Therefore, communication between partners and the local authority specifically about workforce support could be improved to maximise the potential benefits.

The local authority told us they were continually looking for ways to improve and had several schemes planned for 2024- 2025 to continue to support workforce strategy to ensure they have enough capacity and capabilities in the workforce. These included extra resource for an internal staff recruitment and retention incentives, and promotion of co-production and design work.