This relates to assessing needs, planning, and reviewing care, arrangements for direct payments and charging, supporting people to live healthier lives, prevention, wellbeing, information, and advice, understanding, and removing inequalities in care and support, and people’s experiences and outcomes from care.

Strengths

Strategically there is good engagement across the Adult Social Care and Public Health space particularly with relation to the Ageing Well Programme, Joint Strategic Needs Assessment (JSNA) and Health and Wellbeing Board arrangements. These could be enhanced further through earlier engagement with Public Health on Adult Social Care strategies and plans, and more opportunities to be involved with OneBexley’s vision.

Capacity for all areas of assessments has been maximised through a range of outsourcing agreements which is supporting a timely approach.

Considerations

The Council needs to consider the balance of risk, particularly for people with the most complex needs, and how to support staff who are managing the most complexity to feel appropriately supported.

Quality Statement One: Assessing needs

Practice Considerations

There is a significant practice and quality assurance input in multiple forums, including social workers embedded in OneBexley and strengths-based forums within the complex care service with a focus on advice and problem solving. However, across the board there was difficulty articulating what good looks like in terms of outcomes for the residents of Bexley. This suggests that despite best endeavors the quality assurance process is not having the desired impact.

The principal social worker and principal occupational therapy roles are both embedded within wider service roles, but the evidence that they were able to bridge the narrative between front line practice and strategic direction was difficult to see. The Council may want to review this capacity to ensure a focus on practice.

The peer team heard that whilst there was a reference to strengths-based practice the policies and framework are not in place yet, the Council may want to consider accelerating this work to provide clarity on the approach.

Assessment, reviews, and carers assessments

The Council has a commitment to undertaking timely assessments and outsources a significant amount of Care Act statutory assessment and review work through partnership agreements. This is likely to be having a positive impact on people waiting for care. The average wait for assessment is 43 days and review performance is 75%. Most carer assessments are completed within four weeks.

However, this approach is not without risk. The case files audits suggested that some outsourced assessments focused on single issue assessment rather than a holistic consideration of needs and teams reported that people who were waiting had complex needs. The Council provided details of how this risk was managed. This included an initial risk assessment to set priority level with any urgent needs being immediately met, weekly management led reviews of people waiting, minimum of monthly phone calls to the person to follow up and allocation and oversight of people with the longest wait. Adult Social Care regularly reports to Scrutiny specifically on demand and capacity issues.

There is clearly a balance for all Councils in managing increasing complexity of need and demand with reducing resources. The team heard reports that there is a focus on resources to support throughput. The impact is a significant level of risk and under capacity within complex care support. Additionally, the team heard that occupational therapy was significantly stretched. The Council may wish to consider a review of team capacity and the workforce strategy in this area.

There are clearly benefits to assessments being undertaken by people who are linked into local communities however there are risks in this approach. The Council does have a range of contracting management tools and frameworks with partners, which includes links to ASCOF performance measures on carers and self-directed support and this is overseen by a quality assurance board. The key is how the Council quality assures and risk manages the approach in line with the care and support statutory guidance and articulates what good looks like for risk managements in Bexley.

Information from the national 21/22 Carers survey, reported on the Council data hub suggested that 39% of respondents were very or extremely happy with the support that they received, this is higher than the London average and Bexley benchmarks well in the ASCOF survey responses. A carers audit was undertaken in 2022 and an action plan put in place in January 2023  The Council has advised this work is continuing however in advance of CQC the Council may wish to ensure action plans are updated with this progress.

Financial Assessment

Financial assessments and debt recovery are undertaken on behalf of the Council through a partnership arrangement with Capita. Information is collated using paper-based systems and processed in a timely manner with notifications being made within five days. The Council have noticed a trend in complaints regarding invoicing and are aware there is some work to do around these processes.

Quality Statement Two: Supporting people to live healthier lives

There are reports that an integrated approach to both initial contacts, with a combined triage function, and an assessment process across health and social care is resulting in a more joined up approach for people with care and support needs. However, within the review the peer team could not identify the outcomes for people with care and support needs and carers as part of the work. The Council may want to strengthen the focus on the “so what” question to articulate more clearly how this model is benefiting the population.

The proportionality of occupational therapy resource to social work appears to be low and this was highlighted within the review. Social Care Assistants and the disabled living foundation are offered internal training in assessments for equipment to support independence enabling both equipment and non complex adaptations to be recommended by the non qualified staff.

There is evidence of joint working to improve resident’s lives through the joint Heath and Wellbeing strategy with clear outcomes for adult social care and public health. There are opportunities for adult social care to involve public health at an earlier point when developing plans and strategies. As separate teams, public health and adult social care are both actively partners within the integrated care system but there are opportunities for adult social care and public health to align more closely around Care Act specific duties and preparation for CQC assessment. There are also opportunities identified for closer working, shared training, etc, across the two services.

There was a mixed picture on whether there was sufficient wellbeing and prevention support and community capacity available within the OneBexley model, with some front-line staff reporting a perception that the assessment model has reduced capacity for delivering preventative services. This was tested out with OneBexley and Council leaders during the review who did not share this view, however it is a perception on the front line and something that the Council may wish to assure themselves of.

The team heard reports that 90% of reablement capacity is allocated to support hospital discharge. There is an opportunity to expand and accelerate this offer further at the front door and as part of reviews to prevent, reduce, and delay the needs for care and support. The Council may wish to assure themselves that the providers consistently adopt a reablement approach.

Housing is a huge challenge for Bexley and the peer team recognise that this is wider than adult social care. This impacts on the ability to provide Extra Care as an alternative to residential care and ability to prevent, reduce and delay the needs for care and support.

Quality Statement Three: Equity in Experiences and Outcomes

The Council has recognised that there is a significant shift in the demographics of the Borough it may want to articulate more clearly plans to meet this changing need. Workforce analysis shows that 72% of adult social care staff identify as white. There are opportunities for adult social care to work more closely with Public Health to ensure plans are reflecting population demographics and demand and capacity can be modelled effectively. There have been positive outcomes from public health led delivery of inequality projects using Integrated Care Board (ICB) funding to improve health outcomes in vulnerable groups.

These opportunities could also be explored further in relation to co-production which is at the early stage of co-design. There are several partnership boards in place and over the last few years there has been a shift so that there are more people with lived experience than officers on the board, however whilst officers are present at the partnership board there is not member involvement in these forums. The week of the review the Council had just launched an App to support people to engage with services.

Voluntary sector advocacy and support services, such as Mencap talked positively about the joined-up approach with the Council and the positive impact of linking people with local community assets through the model of partner supported assessment.

The inclusion of a fully integrated mental health hub at the front door is supporting to reduce inequities in relation to eligibility for secondary mental health services, although staff in the complex care team report that they do struggle to support people with mental health needs that do not meet secondary eligibility criteria and this is one area in which partnership working across social care delivery may benefit from being strengthened.

There is a solid shared lives offer and good links with pathways to adulthood and promotion of equality, diversity and inclusion.

Co-Production

Co-production in Bexley seems relatively underdeveloped, compared to best practice. The exception being the partnership boards which are increasingly developing their membership of residents with lived experience. There are opportunities to build on this, for example expanding the community champions into paid lived expertise advisor roles that could help drive co-production and co-design approaches.

There is a draft co-production framework drafted by the ICB in internal circulation. This has not been subject to co-design. Given this is a draft there is an opportunity to develop this in partnership with residents. The system governance groups have limited representation of residents with lived experience or their representatives.

There are four partnership boards: learning difficulty; carers; autism and mental health. There are no boards for older people or disabled people with a physical or sensory impairment. There are some good bespoke examples of positive working such as the election practice and the community champion roles. People with lived experience reported the Council are more receptive to positive news than challenge.

The peer team heard some specific examples that clearly demonstrated a commitment to co-production and outcomes for residents, these were repeated at multiple points throughout the review. The examples were strong, and the Council may want to consider expanding this repertoire further to demonstrate the impact the Council are having on resident outcomes.