Metropolitan Borough of Wirral: local authority assessment

The local authority worked with local people and stakeholders and used available data from 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, people with protected characteristics, unpaid carers and people who funded or arranged their own care, now and in the future. The JSNA provided a clear understanding of the key demographics, people’s needs and anticipated changes for the future.

The JSNA identified Wirral had an older population than the rest of England, with 22% of the population being 65 years and older, compared to the England average of 18.4%. There were large disparities in life expectancy, with those in more affluent areas living up to 12.6 years longer than those in the most deprived areas, which makes up 35.8% of the local authority area. Whilst most people in Wirral were white British, there was growing diversity in terms of ethnicity and primary language, including specific Ukrainian, Syrian and Afghanistan communities.

People identifying as being from a Black, Asian and minority ethic background made up 9% of the total population, with the largest minority group being Asian (2.3%). All ethnic groups had grown over the last decade, with an increase of 154% of people who identified as being Black. The data was used to inform the Health and Wellbeing Strategy and the approach to prevent, reduce and delay needs for care, as well to inform the Adult Social Care Commissioning Strategy.

People had access to a range of local support options in Wirral. In an Adult Social Care Survey, 81.32% of people who used services reported they had choice over services, which was higher than the England average of 70.28%. In contrast, people told us that in relation to domiciliary care, they did not always have choice and control of who supported them, with them being allocated an agency and told who would be providing their care. One person told us that they felt domiciliary staff did not always provide person-centred care or a holistic approach to their care. In that case, a meeting was held with the local authority to discuss the agency's actions and clarity was gained with a solution found in finding a different care agency, and the person managing their own care arrangements with a Direct Payment.

Leaders told us there were gaps in provision of day activities for young people with complex needs in the community. They said there needed to be bespoke support rather than the general offer of traditional day centres, for those with Learning Disabilities. The local authority had completed some work in the Learning Disability service and decommissioned Houses In Multiple Occupation (HMO’s), moving to a model of people living in their own properties, however some people reported missing living with peers. Partners told us about plans to reprovision better quality HMO’s in the local authority area.

Partners expressed some frustration at the generic offer of Dementia care and support, reporting there was little available to families other than extra care facilities and domiciliary care. We were told of Dementia-specific nursing support which had previously been available in the community to support people to remain at home longer, however this had been decommissioned by the Integrated Care Board despite partners telling us there was still a public demand for this service. The local authority had invested in building additional extra-care facilities, and leaders spoke to us about plans to consider expanding this model and look to provide support to those with more complex needs in the community, preventing the move to residential care.

Staff told us that due to the Mental Health (MH) bed crisis in the area and having to support more people in the community in crisis, this took them away from prevention work. They said they did engage in prevention work; however, this relied on services being available, which was often a barrier. Staff told us that there was no home treatment team for older people with organic mental health issues, therefore the only option was to seek a residential placement when people had increased needs. It is the responsibility of the Integrated Care Board to include home treatment teams, and no plans were in place to consider this at the time of assessment.

There had been some issues with the quality of the care homes in the local authority area, with two care homes being suspended to new placements due to concerns around quality of care. The Provider Assessment Monitoring Management System team (PAMMS) had actively been working with these care homes to improve standards. The local authority was committed to increasing standards of care, with 70% of all care homes in the borough at the time of assessment being rated as ‘good’ by CQC.

Providers told us there was a huge disparity between the local authority’s relationship with domiciliary care and older people's care home providers, and those who provided residential services to people with learning disabilities and mental health issues. This included unequal access to grants and funding, and access to training. Learning disability providers and mental health providers told us they were not aware of the support other providers in the older persons market had been receiving and reported not being as involved in co-production or collaboration. They were not part of the trusted assessor scheme which they felt would really benefit the people they supported and make their staff feel valued and recognised. Since the assessment, the local authority told us that they are now supporting the dementia care home sector with international recruitment funding, to support recruitment and improve quality within the sector.

Staff told us that residential placements were accessible in the area, including at short notice for respite placements. Data from the Survey of Adult Carers in England (SACE) showed that 17.07% of carers accessed support or services allowing them to take a break from caring at short notice or in an emergency which is higher than the England average of 12.08%. Leaders told us they had sufficiency in all areas, had no waiting lists for domiciliary care and were carrying a 9% vacancy rate in their residential and nursing market. They told us they experienced occasional challenges with specialist dementia nursing services and were working closely with their Integrated Care Board (ICB) colleagues to ensure they had capacity to meet demand for “dementia plus” provision.

Staff told us that young people needed more creative provision for daytime support, rather than the current offer of more traditional day centres run by the local authority. They reported there are no commissioned options for them to do what they want with their day outside of this model, such as educational courses or other meaningful opportunities.

The local authority had a market sustainability plan and a clear sight of future care and support needs, which had informed the investment in additional extra-care facilities being built. Wirral's market position statement and Wirral Plan highlighted priorities for adults’ care services over the next three years: co-producing a new model of care for the Care and Support at Home Service, growing the use of new technology and equipment to support independence, new models of co-operation with providers to deliver trusted assessments, increasing the numbers of people accessing services online, developing outcomes-based commissioning, and working collaboratively with Liverpool City Region Commissioners to use a Flexible Purchasing Framework.

The local authority commissioned models of care and support that were in line with recognised best practice and was keen to decommission outdated models. There had been a proactive approach to increasing housing stock and to reduce the use of houses of multiple occupancy into accommodation where people had their own front door with wrap around support. We were told of HMOs for people with a learning disability and autistic people being decommissioned recently and moving to this new model. There was an overall aim to reduce the use of care homes and provide more independent living options, for example Extra Care Housing (ECH) across all ages. The target was to increase ECH provision by 785 units within 10 years by 2035 which was progressing well. There are plans for 603 units, 484 for those aged 55 plus, and the rest for people aged 18-65, with 80 units in development at the time of assessment.

Frontline social work staff told us that they were encouraged to contact commissioners to discuss gaps in provision, and that contracts staff communicated new placement openings effectively to them. Staff told us there had been improved communication with the senior management team with them more effectively considering their input about what provision was needed.

Staff from the LD team told us that it was difficult to source specialist supported living provision for people with complex needs. They told us due to investment and increased capacity in extra care housing, there was usually availability however, extra care housing did not meet everyone's needs. They said that more options for choice of care provision for people with a learning disability and complex needs was needed, although they said this had improved at the time of assessment, with three supported living bungalows being built recently.

Staff told us about challenges around suitable accommodation and maintaining a living arrangement when a person's health deteriorated. Staff reported trying to enable people to remain in their own home for as long as possible, however this became difficult when a person’s health deteriorated and the buildings in which they lived in could not accommodate a change in their need, such as a stairlift for example. They reported many supported living buildings in the area were old and not appropriate for adaptations, with workers facing these challenges with the people they support as they age. Some client tenancies were private and described as precarious due to threat of no-fault evictions, although there were said to be good relations between the teams and many landlords. The local authority had a decommissioning plan underway to address the future needs of people to replace accommodation with specialist extra care properties.

The local authority had considered provision for unpaid carers. A commissioned service provided support information, advice, guidance and peer support groups. Carers told us that this service was invaluable to them and had supported them with many aspects of their roles. There was the offer of the pre-payment cards for carers of £300, which carers were able to utilise to support their wellbeing in a flexible way. Carers told us that accessing respite had been very positive, with 16.80% of carers accessing support or services allowing them to take a break from caring for 1 to 24hrs (16.14% England average (SACE)).

Leaders told us about future plans and an intention to work more collaboratively with partners in joint commissioning of services where appropriate. There was a focus on planning for the future population trajectory of residents, particularly in relation to the aging population of Wirral. Consideration was being given to dementia care, and how support could be provided for people to remain in the community as their illness progressed, shifting away from a residential care model.

Information provided by the local authority indicated that they had no waiting lists for homecare provision or care homes. Due to the capacity in residential care homes, carers were able to access respite in unplanned circumstances.

We were told that management of allocations for extra care housing properties had been brought into the adult social care commissioning team instead of being held by extra care housing providers. There was now 'live' reporting and monitoring of voids in all of the extra care schemes by the Care Brokerage Team. This enabled an efficient and prompt process which meant that people were being offered a place quickly when a property became vacant, usually with 24 hours.

Staff spoke about challenges in hospital discharge when younger adults required ongoing residential respite which was required following discharge from an intermediate care ‘step down’ bed. In addition, when people were discharged to hotels or hostels due to experiencing homelessness, domiciliary care agencies were not always able to provide care in those settings, depending on possible risk to staff, which created a barrier to discharge at times. We were told by leaders that when people experiencing homelessness were discharged and they required care, hotels where domiciliary care providers could provide care would be sought where possible.

Staff told us about the impact of the lack of Mental Health beds, and Wirral’s procedure to not source beds out of the local authority area when people were being detained under the Mental Health Act (1983). They told us they were not able to carry out preventative work with people due to having to continually focus on crisis work because people remained in the community for treatment when they should have been detained in hospital. Staff told us the number of respite placements available for people with mental health issues were low, and that an increase in capacity could potentially alleviate the need for detention beds and prevent people from needing to go into hospital.

We were told of struggles to provide more specialist types of provision to people with complex needs due to this being a gap in the market. There was a lack of provision able to support people with progressed dementia, learning disabilities, mental health and drug and alcohol issues. Work was to consider provision for people with more complex dementia care needs. The ‘dementia care plus’ model was being considered to respond to a range of different needs such as dementia, EMI, complex needs and additional hours. The service design would be co-produced with the ICB with adult social care leading the project through joint commissioning and joint funding.

There was minimal need for people to use services or support in places outside of their local area. When support was being accessed from outside of the area, this was predominantly due to personal choice or to be close to family. There were 129 people placed out of area in total, with 69 people placed out of area in the past 12 months. Staff reported that this is usually by choice, so that people can live closer to family. People requiring specialist placements which couldn’t be provided in borough may also be placed out of area.

The local authority had clear arrangements in place to monitor the quality and impact of the care and support services being commissioned for people and identifying required improvements. Wirral used the Provider Assessment and Market Management Solution (PAMMS) tool to help assess the quality of care being delivered by providers of adult social care services. Intelligence from PAMMS was used to inform a strategic review of the care home market for future delivery.

All providers had a named contract lead, quality improvement practitioner, and had face to face contract meetings. Each provider was red, amber, green (RAG) rated based on a multifactorial assessment which included intelligence, triggers, and risk tolerances to determine the frequency of monitoring. Frequencies included monthly, quarterly, 6 monthly, or annual monitoring. All providers submitted monthly key performance data and annual assurance reports regardless of their RAG rating. Staff told us that historically there wasn’t a robust quality assurance process for providers, however the quality improvement team (QIT) had been of benefit to the service and providers.

The local authority had a Provider Risk Information Group (PRIG) made up of leaders and partners who met monthly for a coordinated multidisciplinary team (MDT) response to any significant presenting risks identified through the contract monitoring process or intelligence received from stakeholders.

70% of residential homes rated as CQC ‘good’, and 56% of nursing homes rated as ‘good’. 77% of homecare rated ‘good’ or ‘outstanding’. 92% of supported living services were rated ‘good’. 5% nursing homes rated ‘inadequate’ and 2% of residential homes rated ‘inadequate’. Any services rated ‘requires improvement’ by CQC were suspended for all new placements with intervention from the QIT until improvements were verified. Leaders told us that due to the work the QIT carried out, improvements had been made however there was more work that needed to be done. At the point of assessment, there were 7 suspensions of new placements in place in care homes, with reasons cited being concerns about the quality-of-care provision and safeguarding concerns.

Provider Risk Intelligence Group (PRIG) meetings were held with partners and CQC staff to share information and action plans regarding care providers. In addition, development days were held with providers and commissioners to tackle local issues. It was following this that the PAMMS tool was introduced. Providers told us about positive and supportive working relationships with the QIT team, with them being instrumental in driving improvements in their services.

There was a Quality Network Group in place to identify and report any gaps in service delivery to support overarching quality improvement initiatives across the health and social care system. Key objectives were to identify any emerging themes and trends and agree key areas to support and drive quality improvement across the health and social care sector. The membership also identified best practice for dissemination across the Wirral Care Market. Membership included ASC, ICB, and NHS colleagues.

The local authority held monthly forum meetings with the community care market to share information, offer guidance and support, and inform in respect of future commissioning requirements. As a result of recruitment and retention difficulties in the care market in 2021 the local authority introduced two fee rate levels - standard and enhanced – enhanced for providers who pay Real Living Wage. Since 2021 there has been continued growth in the number of providers who take up the enhanced rate.

Staff reported that the market is stable with Wirral having 7% of adult social care job vacancies compared to the England average 9.7%. In the past 12 months, one homecare contract was handed back to the local authority, due to staffing issues and not being able to mobilise care. One nursing home contract was terminated due to them not being CQC compliant, and there were two residential home closures due to the owner deciding to cease trading.

Leaders told us about the support they had offered domiciliary care and care home providers since the COVID pandemic. They told us about providing grants and funding to help with recruitment such as paying for driving lessons or helping to purchase pool cars and personal protection equipment (PPE). In contrast, providers of learning disability and mental health services told us they had not received the same comprehensive support. One partner told us funding for their community outreach support hours was reviewed and uplifted annually, however their service-level agreement contract had not been uplifted for a number of years. This meant there had been a reduction in real terms as delivery costs had continued to increase. Their inability to offer competitive salaries had impacted on recruitment and they were concerned that in the short to midterm this could put some voluntary organisations at risk of closure.

We were not made aware of any monitoring tools to anticipate provider failure and service disruption. Following the assessment, the local authority told us that they had undertaken two exercises to review all provision with every residential and nursing provider to ascertain financial sustainability and identify any risks including assessment of funding streams.