Hammersmith and Fulham: local authority assessment
Safe pathways, systems and transitions
Score: 3
3 – Evidence shows a good standard
What people expect
When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place. I feel safe and am supported to understand and manage any risks.
I feel safe and am supported to understand and manage any risks.
The local authority commitment
We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.
Key findings for this quality statement
Staff, leaders, and partners told us that safety was a priority for everyone. However, we found inconsistencies in the provision of assessment, services, and the use of data to support oversight of safety and consider where improvements were required. For example, in some operational teams, there were high waits for assessment, and though social care leadership was aware of this these were not included in any risk register. There was also a lack of joint hospital discharge processes which could sometimes cause people to be delayed on discharge or be readmitted to the hospital due to a lack of prevention approaches.
The out-of-hours service was provided under a three-borough arrangement with 2 other London boroughs. Qualified staff supported the service to meet the Mental Health Act assessment needs, however, due to the complexities of the assessment and the high volume, other social care calls were often not addressed in a timely way. In addition, there were no clear procedures for handover to the out-of-hours service which caused inconsistencies. The mental health team sometimes used a different system to record care notes, and these were not accessible by Out of Hours the team.
The local authority had recognised that improvements were required in their pathway for young people transitioning to adulthood following a diagnostic review in May 2023 on the transition service. The transition recovery plan made recommendations to improve co-production with families around daycare opportunities and joint working with housing. As a result, from September 2023 tools and pathways were developed with Children’s Services to support improved transitions to adult social care. A new transition team was recruited and joined Adult Social Care during the summer of 2024. The transition team had social workers, housing officers and occupational therapists to support young people moving to adulthood. The new protocols established a set of principles, guidance, and procedures to support the multi-agency team working; the team had built relationships with schools, children’s services, and carers organisations.
The local authority told us they ceased using the discharge-to-assess model (D2A) with the NHS in December 2023, due to poor outcomes for the people of Hammersmith & Fulham. In Hammersmith & Fulham, the local authority would make Care Act assessments on the hospital ward before discharge except when someone was discharged to a care home, then the Care Act assessment would take place in the care home. The hospital team was a partnership across three local authorities and this team had three different processes for each of the different local authorities, Hammersmith and Fulham had some documented approaches for the discharge process and staff knew what they were doing. The hospital team reported that they felt quite removed from the adult social care team in Hammersmith and Fulham.
There were examples of good joint work to achieve a safe discharge home from the hospital for most people, for example, there were twice daily meetings with health staff, involving the hospital social work team, providing updates to support decision-making that was right for the person and any informal carers, the flow, timeliness and safety of discharges. Support had been commissioned by the local authority from a local charity to support people with non-eligible needs like shopping or greeting the person following hospital discharge.
Since the local authority had left the Discharge to Assess arrangements in December 2023 there was no evidence that the local authority had evaluated the pathway to see if outcomes had improved or gathered feedback from people receiving support about how they experienced the new pathway arrangements. However, the Assistant Director for adult social care attended system meetings to understand the discharge pressures, review the effectiveness of pathways, and problem-solve where people were delayed. Systems meetings included meetings to discuss delaying admission to the hospital, Hammersmith and Fulham felt that their offer of home care without charge supported admission avoidance and were evaluating this with Aston University at the time of this assessment.
The relationship between the hospital, Integrated Care Board, Community Health, and the hospital team was transactional and there was no documented joint process for discharge as a result, when there were delays due to funding or placement issues this caused frustration. For example, there were delays in agreeing on Continuing Health Care (CHC) funding due to a lack of a trusted process, with social care challenging funding decisions while the individual remained in the hospital. The local authority was trying to support this pathway and had used Pathway 3 funds to meet the needs of some people awaiting agreement on CHC funding to support discharge from the hospital.
Where there were delays in social care these were a result of brokerage having challenges in accessing the right provision, for example home care was being provided between 8am and 8pm only which limited some people ability to go home, or people wanted to wait in the hospital for a preferred care home placement. There had been some developments with 5 reablement flats within an extra care site, to be utilised to support as an interim placement for discharges. We heard mixed feedback about the success of these flats and further work was needed to evaluate the outcome of these.
Home care providers felt there was a positive approach when people moved between services or required a more detailed contingency arrangement. They felt the local authority communicated changes promptly with relevant reasons for transition. Joint meetings were held to facilitate safe and easy transfer whenever necessary.
Contingency or future arrangements had not always been discussed with unpaid carers or people receiving care. This meant commissioned services were not always aware of the gaps in need to consider future provision for respite or ongoing needs.
Adult social care had a service continuity plan for service disruption which included the loss of premises, of IT and telecommunications and staff. This plan included an assessment of risk, how this should be communicated and responsibility for recovery of services.