Hammersmith and Fulham: local authority assessment

Hammersmith & Fulham understood the local needs for future care and support but did not show how they had developed their market position statement and sustainability plan with local stakeholders, including people who were most likely to experience poor care. But there was a clear commitment to involve residents in co-production and decision-making in future commissioning activities.

The local authority had a Market Position Statement for 2024 published on its website. This set out its core values around co-production, supporting the workforce, building trust within the community, and adding social value. It gave an overview of data from the Joint Strategic Needs Assessment (JSNA) to define broad areas of need in the future. It set out when commissioning would take place, requesting providers with a focus on independence, being person-centred, and greater use of technology.

A Market Sustainability Plan (MSP) was produced in 2022 as part of a government return which identified more services were needed in the borough for people with mental health conditions and learning disabilities to support independent living and access to paid employment. Also, it highlighted further development of care providers in the community was needed to support people with dementia. Inflation was indicated as a key issue and paying the London Living Wage was seen to value the workforce and support retention of provider staff.

The local authority was involved in regional and national discussions with other local authorities on benchmarking, joint commissioning, and data sharing.

There were no specific commissioning strategies to deliver on areas of need highlighted in the market position statement but there were several overarching adult social care strategies completed or in development that referred to commissioning requirements. Also, staff and senior leaders told us they had plans in place, which included exploring the use of excess extra care provision to meet the needs of people with learning disabilities and mental health conditions. The local authority also was exploring transforming its day services to offer more flexibility and encourage independence with a blended approach of community and building-based opportunities after a drop in referrals.

The dementia strategy 2021-24 had recommendations for commissioning to review specialist dementia support and consider extra provisions but there was no evidence that this was completed. New strategies were being developed with residents like the Autism Strategy and the Carers Strategy which may support with commissioning strategic plans for these communities. In addition, the local authority had invested in a new post, strategic commissioner for transitions and had been appointed to lead on provision in this area and work closely with the parents' co-production group.

Some people had access to a diverse range of local support options that were safe, effective, affordable and high-quality to meet their care and support needs. The Adult Social Care Survey (ASCS, 2023-24) showed that 62.63% of people who used services said that they have a choice over services. This was tending toward a negative variation with the England average (70.28%). In Hammersmith & Fulham, home care was provided without charge as part of the council’s commitment to support residents to live independently. This provision could be in place on the same day, depending on the nature of the person’s needs.

The local authority had been attempting to recommission the home care contract to provide greater choice and sustainability in the market. At the time of the onsite assessment in October 2024, there was no home care contract in place, as the previous home care contract had ended in June 2024.

The local authority was proud that they did not charge unpaid carers for replacement home care to have a break. Figures from the survey of Adult Carers in England (SACE, 2023-24) did not show a significant variation from the England average when carers were asked if they could take a break for 1-24h (24.68%) or more than 24 hours (18.18%) but did show a variation that tended towards the positive for allowing carers to take a break at short notice (15.79%).

The carers’ support contract was receiving one-year extensions, which created sustainability issues for the provider in meeting the demand for carers’ assessment as they were unable to renew staff contracts. The local authority was reviewing how they were providing carers services, with some assessments being conducted in-house, which allowed ongoing skills, expertise, and awareness to be fostered internally. Provision of respite for people with learning disabilities in the borough was low with only 4 beds available, meaning that sometimes people were placed out of areas which disrupted access to their communities, employment, and education.

A Brokerage Team sourced a range of suitable support options for residents and used a mixture of contracted and spot contract arrangements to meet needs. A contracted arrangement is with a provider that the local authority can draw down on and this is normally set at a fixed rate over many years, providing security for the council and provider. A spot contract is made at a one-time transactional price, and these arrangements are normally more volatile and harder to quality assure. In some complex cases, social work teams brokered individual arrangements directly and then sent them to the brokerage team to arrange the contract, as operational teams felt they had a better knowledge of a providers’ ability to meet needs.

Hammersmith & Fulham had 4 care homes in their area providing a mixture of Nursing and Residential care. Data provided by the local authority showed that from June 2023 to May 2024 there were 494 people in care home placements and 73% of residential and 45% of nursing placements were out of area. Data provided by the local authority showed between March to May 2024 the wait for nursing care was a median of 9 days and a maximum of 20 days. The wait for residential care was a median of 19 days and a maximum of 24 days. People were more likely to be placed out of area if they had complex needs or dementia, and though some people chose to be closer to family, capacity in the borough did not always meet demand. At times this caused delays in time-sensitive placements like hospital discharge as people wanted to wait for care home beds in their chosen area, or the needs of the person could not be met locally.

Extra care placements were all met in the borough and there was excess capacity. There was good capacity for home care, and data provided by the local authority showed that between March to May 2024, the median wait for home care was 2 days and the maximum wait was 22 days. Where there were specific needs that could not be met by the contracted home care provider, for example, a specific language or a cultural need, these were sought, and if possible, provided through spot purchase.

Data provided by the local authority showed from June 2023 to May 2024 there were 134 people in supported living placements made by the borough of which 62% were out of area. The main reason given for this was the complexity of needs, but there was also a lack of supportive housing in the borough to meet demand. Hammersmith and Fulham had acknowledged that more developments were needed for people with complex needs to live in the borough. The local authority did not further define what it meant by complex needs in relation to supported living placements, but it was used as a general term when talking about meeting needs. Feedback from several groups told us that people placed out of area experienced barriers, especially with health service handover, access to families and communities, and support for regular review.

There were gaps in the provision for activities to promote independence and employment for young people, people with learning disabilities and mental health needs. The local authority knew this was an area that needed development. The transitions team had been developing some activities by reaching out to football teams within Hammersmith & Fulham, as well as a disability-led charity who were now providing a drama and a horticultural club.

The local authority provided day services with specialist provision for dementia and people from the older African Caribbean and Asian communities. Referrals for day services were reducing, and the local authority was considering reshaping this provision. A voluntary sector partner worked collaboratively with the community issuing grants on behalf of the local authority to improve mental health for people from ethnic backgrounds, and health and social care outcomes in communities. There was monitoring of the mental health grants, but no evidence was given of how the 22 community grants had improved social care outcomes for adults.

Hammersmith and Fulham had arrangements through their Care and Governance Quality Framework to monitor the quality and impact of the care and support services being commissioned for people and it supported improvements where needed. The local authority's in-house reablement service and short breaks service had both been rated Outstanding by CQC since 2018. As of June 2024, most of the home care provided by agencies was rated Good; of the 4 care homes in the area, 3 of these were rated Good, with 1 Requires Improvement, which the local authority was actively supporting. The local authority had a policy to only place people in care services rated Good or above.

Hammersmith and Fulham undertook quality audits of its care services by speaking to residents, checking records, policies and procedures. This was both proactive and reactive, and staff could record concerns on the care system to be reviewed by the quality team. Where improvement was required, action plans were put in place and support was given; working closely with the commissioning team so contractual measures could be taken if needed. For people who lived out of area, staff linked up with other local authority staff responsible for managing safeguarding and quality assurance through regional sector-led improvement initiatives, so any major quality issues were flagged. There had been no embargoes or restrictions on providers in the borough within the previous 12 months, and the brokerage team held a risk register for providers out of the area that held suspensions.

There was a mixed picture of contract monitoring at the local authority for non-care contracts. Some providers spoke of strong relationships with the local authority and regular meetings. Other providers reported that the commissioners often changed, and it took time to establish a relationship and understanding of service provision. In these cases, there was a reduction in the scrutiny and engagement on the performance of their contracts.

Hammersmith and Fulham were not strategically commissioning in line with their vision. There was a co-production commissioning cycle in place which aimed to allow time and support for co-production activities within the commissioning schedule. However, the contract forward plan provided by the local authority in June 2024 showed that as contracts came to full term, one-year funding was being given to current providers. The Council had plans in place to start open competitive processes in line with their new Market Position Statement.

The one-year funding arrangements limited the local authority in achieving its ambition to include residents, politicians, and providers in the commissioning cycle and open opportunities to the wider market. The contract forward plan showed that direct awards were signed off by the cabinet member for adult social care, in line with standing orders. Key services affected by this included carers, advocacy services, and local Healthwatch, with these yearly awards making it difficult for them to plan long-term.

The commissioning team had regular quarterly provider meetings and knew procurement needed to be improved. For example, the local authority had been trying to increase its provision of supported living accommodation over several years but had not been able to deliver this. To support improvement the leadership team brought in a new Director of Commissioning, Transformation and Partnerships, to deliver future supported living procurements.

The local authority had a costed proposal for providing uplifts to the market for 2024/25 and was involved with work as part of the northwest commissioning alliance to manage the care home market. The local authority had moved away from the use of a Dynamic Purchasing System where care homes entered the cost they needed to provide care. Instead, the local authority was using a third-party platform that estimated the cost of care based on care needs to support brokers with price negotiations.

The local authority had completed the fair cost of care exercise with a small number of providers, but the prices they were offering in the uplift were lower than the prices from the cost of care exercise. The local authority did reference in their uplift document they were working towards providing fair cost-of-care prices. The local authority completed payroll checks to ensure all care workers were receiving the London Living Wage and as part of the contractual agreements travel costs were paid by the providers. Hammersmith and Fulham had a framework for managing provider failure and handbacks, there were no reported handbacks or suspensions in the 12 months leading to the assessment.

National data from the Skills for Care Workforce Estimates (ACE-WE, 2023-24) showed that 36.06% of adult social care (ASC) staff (all jobs, all sectors) had a care certificate in progress or partially complete or completed. This was a significant negative variation from the England average (55.53%). Staff vacancy rates and sickness absence rates from the same survey had no variation from the England averages. The staff turnover of ASC staff (all jobs, all sectors) was 0.20, this was tending towards a positive variation from the England average (0.25). In its market sustainability plan Hammersmith and Fulham said that there was a shortage of care workers and were supporting care providers with recruitment and offering training to new care workers, but there was no strategy or training programme in place.