Hammersmith and Fulham: local authority assessment

The local authority was refreshing its Care Act policies, procedures and practice approach. A third-party policy and procedures portal had been commissioned in December 2023, to be a database of documents defining how the local authority would meet its Care Act responsibilities. As part of the project the local authority’s existing policies and procedures from 2018 were being updated in priority order. At the time of the onsite assessment in October 2024, the online portal was being introduced to adult social care staff. Some staff told us they were not confident about practice and process and some people in need of care and support found care pathways confusing. The new portal may help to address this.

Hammersmith & Fulham had a front door team where information and advice was provided on the phone, and people were referred on for assessment as needed. The team told us that in May 2024 they received 1,499 calls of which 1,445 were answered within 2 minutes, but there was no information on how many calls were resolved by the front door team or how they were resolved. The front door had been developed as part of the transformation programme, making the front door team a single point of referral, and Social Workers and Occupational Therapists were relocated to the front door team to triage referrals and complete proportionate Care Act assessments. Proportionate Care Act assessments provided the right level of assessment to suit the needs of a person, for example, someone with straightforward needs could be assessed virtually. As part of ongoing development of the front door the local authority had actions to make better use of performance information and digital technology.

There were specialist teams in adult social care for mental health, hospital discharge and learning disability. Funded by public health, a social worker worked in the 8 local homeless hostels and 3 social workers focused on people with substance misuse. The local authority had not made experts available for the assessment of people who are Deafblind or autistic people. It was found the sensory team who supported the Deafblind did not carry out Care Act assessments, and the learning disability team did not feel they had the depth of training to provide effective assessment and support to autistic people.

The quality of assessment and care planning was mixed. There were some good examples of strength-based assessment, however, other assessments did not reflect people's right to choose, build on their strengths and assets, and reflect what they wanted to achieve and how they wished to live their lives. National data from the Adult Social Care Survey (ASCS, 2023-24) showed that 67.18% of people felt that they had control over their daily lives. This was a negative variation from the England average (77.62%). Strength-based practice and mental capacity assessments were flagged as a development need by the Principal Social Worker, following an audit of 84 cases in March 2024. The Principal Social Worker had developed a new quality audit tool for Care Act assessments which would support feedback to staff on their work and identify wider learning to be shared at the monthly quality assurance board; this was being embedded in the organisation at the time of assessment.

There was evidence that workers were not considering a person’s ability to be as involved as they could or would wish to be during their assessment and support planning activities or identifying when alternative representation should be provided. Staff told us paid carers, unpaid carers or family were being used as a default to support communication needs and decision-making. Guidance and further training were needed around mental capacity, advocacy, representation, and communication needs to support staff to better capture and represent the views and wishes of the person in need of care and support.

The local authority recognised timeliness of assessments was an area for improvement and was taking steps to manage and reduce the length of time people waited. The customer journey was being reviewed to reduce transfers between teams, increase focus on prevention, and build on the link worker schemes in the Primary Care Networks.

A monthly service-wide performance meeting had been established for oversight and the service was moving staff capacity between teams to support assessment completion. The local authority was unsure that the waiting lists were reflective of current needs, for example in the Mental Health team they did not know if people waiting were health or social care responsibility due to recording across 2 databases. A screening process by staff was being undertaken, starting in May 2024, actively calling people on the waiting list to clarify referral details and identify risk and priority.

Data shared by the local authority showed between August 2023 and September 2024, the median waiting time for Care Act assessments was 60 days and the maximum waiting time was 677 days. In May 2024, 444 people were awaiting a Care Act assessment, with the biggest waits being post-reablement (201 people) and in the mental health team (128 people). Between August 2023 to September 2024, the median wait from completed assessment to care planning was 14 days and the maximum wait was 647 days. In May 2024 there were 1399 people awaiting review and between August 2023 to September 2024 the median wait for review was 417 days and the maximum wait was 1819 days. National data from the Short- and Long-Term Support Survey (SALT, 2023-24) mirrored this showing that 34.90% of long-term support clients were reviewed. This tended towards a negative variation from the England average (58.77%).

The local authority had hired agency social work staff for a review project team to complete the backlog of annual reviews. This team had found over and under provision of support, as well as people who had not been spending their direct payments as anticipated. These reviews were proving helpful to ensure people had the care and professional support they needed. However, there was no specific team, guidance, or figures for reviewing out-of-borough placements. Feedback from partners and people needing care was mixed. Some people told us they received prompt service and other people said they could not get a timely assessment or review despite multiple calls to the local authority. This showed that whilst assessments and reviews were happening, waits for services varied.

The needs of unpaid carers were recognised as distinct from the person with care needs; assessments, support plans and reviews for unpaid carers were undertaken separately. Social work staff made unpaid carers aware of the right to a carer assessment. A carer’s organisation was commissioned by the local authority to provide statutory carers assessments, and the local authority completed some themselves. There was no guidance on carers assessment and who should take the lead on carers assessment. Following assessment carers could receive a direct payment up to £500, in addition to respite services for the cared for and signposting to local support groups.

Carers had poorer outcomes when compared to partners nationally and regionally. Data from the Survey of Adult Carers in England (SACE, 2023-24) showed that carers in Hammersmith and Fulham were experiencing financial difficulties (65.82%) and were not in paid employment (45.76%) because of their caring role and only 18.99% had as much social contact as desired. These were all significant negative variations from the England average (46.55%, 26.70% and 30.02% respectively). The local authority was committed to supporting carers and a co-production process was started in 2022 to create a carer’s strategy, progress on this had slowed and the local authority hoped to have this finalised by November 2024. As part of strategy development, the local authority produced an analysis of unpaid carers this showed 60% (2,014/3,402) lived in the 40% (decile 1-4) most deprived areas of the borough and that Black and Black British people were disproportionally formal or informal carers.

Most unpaid carers experienced a delay in assessment but once assessed they found the experience positive, feeling heard and valued. In May 2024, 378 people were waiting for a carers assessment with the carers organisation and 65 people were waiting for a carers assessment with the adult social care teams. The median wait was 1 day, and the maximum wait was 179 days across both organisations.

Adult social care staff said a reason they completed carers assessments themselves rather than refer to the carer's organisation was that people referred experienced delays. The carer organisation was meeting its contracted target, from January to March 2024 the carers organisation completed 108 of its targeted 110 assessments. This indicated that there were not enough resources commissioned for the carers’ organisation to meet the demand for assessment requests that they were receiving. The carers’ organisation had raised concerns with the local authority about their lack of capacity to meet the demand.

The quality of carers assessments produced by the carers’ organisation was not included in social care practice audits or considered during contract monitoring, so the local authority was not providing assurance that these delegated functions were carried out appropriately. There was no evidence that carers’ assessments were being shared back to the local authority so it could help inform the assessment for the cared for as part of a whole family approach.

The mental health team had a carers peer support group once a month. The group included different multi-disciplinary professionals from mental health services who talked about their roles, listened and offered advice. Staff told us the impact of this had been noted in improvements in how the mental health trust and the local authority supported and involved unpaid carers when supporting recovery for residents.

People were given help, advice and information about how to access services, facilities and other agencies for help with non-eligible care and support needs. Staff also signposted people to voluntary agencies. For example, the local authority had recognised there were people with non-eligible needs who were hoarding and had worked with housing to ensure support was available, so properties remained safe and suitable. Staff had a good understanding of additional services in the borough and there was an online directory and leaflets available to help with signposting.

National data from the Adult Social Care Survey (ASCS, 2023-24) showed that 35.91% of people felt that they had as much social contact as they wanted. This was a negative variation from the England average (45.56%). However, Hammersmith & Fulham’s leadership team was passionate and committed to making their borough a place where people in need of care and support were an integral part of the community. This was reflected in their co-production activities which included: a dementia strategy, celebrating the contribution of older people from the Windrush generation, the provision of additional community safety officers to make people feel safe, and many other initiatives that were about building capacity, understanding and trust in communities.

The Care Act 2014 and the Care and Support (Eligibility Criteria) Regulations 2015 provided the framework in which eligibility decisions were made. In addition, the local authority was refreshing guidance as part of the work on the policy portal, training was given about eligibility, and the social care case file audit tool was launched in April 2024 checked eligibility was appropriately applied.

The local authority offered home care and daycare services without charge for all residents who had eligible care needs. This meant that where people would have a financial means test to see what they needed to pay towards their care, this was not required in Hammersmith and Fulham. Means testing only applied when people moved into a residential placement in a care or nursing home. There was political support for this charging practice as politicians felt this would improve the health and wellbeing of the people of Hammersmith and Fulham. The local authority had commissioned Aston University to evidence the outcomes of providing care without charge.

There was an Independent Living Practice Assurance Meeting (ILPAM) which was a gatekeeping system for purchases, quality of practice and to support compliance with financial assessment processes. All care and support plans of £1000 and above a week and all placements/change of residency/respite went to this meeting. When talking about the ILPAM staff focused on the financial limits of care rather than meeting the assessed need. Some staff told us this slowed down the provision of care and support, as support packages may have to go to the meeting multiple times. There was no separate appeals procedure for Care Act eligibility, but there was a complaints procedure supported by a resident experience team.

National data from the Adult Social Care Survey (ASCS, 2023-24) showed that 69.11% of people did not buy any additional care or support privately or pay more to ‘top up’ their care and support. This was tending towards a positive variation from the England average (64.39%). There was guidance on top-ups for people in need of care and support and this was available online.

There was information and advice for people who may need to pay for a residential placement. In May 2024, the local authority said people did not have to wait for financial assessment and there was no process for home care or daycare, as this was provided without charge. Staff had to complete a financial form before someone could be placed in a care home, which was monitored by the Independent Living Practice Assurance Meeting.

There was no separate appeals procedure for financial assessment, but there was a complaints procedure supported by a resident experience team.

The local authority had a provider for statutory advocacy which supported people who needed an Independent Mental Capacity Advocate, Care Act Advocacy, Independent Mental Health Advocacy and people going through the Deprivation of Liberty (DoL’s) process. Another organisation provided non-statutory advocacy to disabled people and parent carers to support them in voicing views and wishes and understanding their rights regarding lifestyle, health and independence issues. The local authority spot-purchased out-of-area advocacy provisions as required. Providers reported that they had enough provisions to meet referral numbers. The local authority was considering changing its advocacy offer by bringing it together under one contract and were engaging with providers and the community about this.

We received feedback that requests for advocacy support were not always made in a timely way with referrals made with 24-hour notice, which did not give enough time for the advocate to get to know the individual, their views, and wishes. The local authority workforce development plan highlighted it wanted to ensure that staff had the skills to identify when advocacy was needed and provide it in a timely way. There was a lack of analysis of who was receiving advocacy and checks on whether this was being used for people placed out of area.