North Somerset Council: local authority assessment

Senior leaders told us prevention was central to the local authority’s corporate vision. The Integrated Care Systems (ICS) Health and Wellbeing strategy was the local authority’s guiding strategy around this vision. Adult social care worked closely with Public Health colleagues and the Integrated Care System with the focus on improving health outcomes. The Public Health directorate led on a range of universal preventative work streams which had a focus on a whole population approach, not just those with care and support needs. Examples included physical activity initiatives, including health walks and exercise classes for older adults, aimed to enhance overall well-being and reduce risks of frailty and falls.

In North Somerset 61.50% of people said the help and support they received helped them think and feel better about themselves which was similar to the England average of 62.48% (ASCS, 2023-2024). The local authority had a new prevention offer to further embed and develop early intervention and prevention services with public health. Adult Social care had a broad range of preventative services for example, there was also a long-standing in-house service which delivered meals to people with minimal care and support needs who had any challenges preparing food. However, there was some mixed feedback from staff about their knowledge of community resources and if this was up to date. For example, staff found there were concerns about the quality of information being shared.

There was consideration for preventative interventions aimed at minimising the effect of disability or deterioration for people with established or complex health conditions, including progressive conditions, such as dementia.

Staff told us voluntary, and third sector providers ran support groups for carers, these included creative activity events and peer support which provided essential opportunities for carers to enjoy a break and share coping tips with others to avoid decline in their independence and wellbeing. Although national data relating to the experiences of unpaid carers in North Somerset indicated that 12.28% of carers were able to spend time doing things they enjoy, which was somewhat worse than the England average of 15.97% (SACE 2023-2024).

In North Somerset 0.61% of people aged 65 and over received reablement or rehabilitation services after discharge from hospital, this was significantly worse than the England average of 2.91% (Adult Social Care Outcomes Framework, 2023-2024). National data showed 70.07% of people who had received short term support no longer require support, which was somewhat worse to the England average of 79.39% (Adult Social Care Outcomes Framework, 2023-2024. Local authority data showed, in the 12 months prior to December 2024, demand for domiciliary care priority (1) pathways, showed that 14% of delays in pathway (1) discharges were caused by challenges in sourcing care. This included both bedded and non-bedded care, funded by the local authority or privately by people.

The local authority had a clear commitment to developing the TEC and Reablement offer to maximise independence showing outcomes through better use of data. There was a specialist technology offer to support hospital discharge which positively impacted people’s length of stay in hospital and independence on discharge. For example, one partner described the local authority as ‘pioneers’ as TEC initiatives had resulted in a 5% reduction in home-based care diverting more people home without formal care support particularly those with a risk of falls but otherwise managing independently.

The hospital NHS trusts had a Transfer of Care Hub to process discharge and to assess pathway referrals, this included being discharged home with reablement support or being transferred to a short-term care home placement. Staff told us they were based at the hospital between 1 and 4 days a week to provide social care advice and support alongside clinical leads which helped with any challenges around complexities or delays.

We heard that frontline staff were actively embracing the expansion of the ‘Reablement First’ approach, aligned with the vision of maximising people’s independence and well-being. Although this was still in the early stages of implementation staff told us of the increase in demand for services had resulted in more referrals which was impacting on the discharging planning arrangements and causing delays in hospital discharges. This had an impact on people receiving early support to promote their independence, aid recovery and avoid any further deterioration related to being in a hospital environment. Frontline staff informed us they had now recruited to full establishment and were resourced to manage the increase in service demands. However, staff told us there was limited Health funded, community-based resources to aid rehabilitation, for example the integrated stroke services had limited resources and finding suitable specialists rehabilitation services was difficult.

The community developments within the Technology and Reablement Intervention service (TRI) were still being embedded and senior leaders said they hoped to build on the established post-discharge reablement offer, so that more people could benefit from a reablement approach to explore technology enabled care and access to specific therapy support.

Safe and good quality housing can have positive impacts on peoples’ wellbeing. Therefore, senior leaders within adult social care directorate were raising the profile around the importance of housing, access to equipment including technology at home and appropriate home adaptations being a preventative approach in maintaining peoples’ independence to live at home. 

The adult social care housing team had an occupational therapist who assessed and equipped individuals at risk of homelessness to help them stay in their homes. If unsuitable following OT support, the homelessness team supported rehousing. However, one staff member described housing and adult social care as 'incredibly divided', and there were plans to improve working relationships now they worked within the same directorate. One person told us their accessibility issues resulted in them needing to leave their home and move into a new home that they and their family sorted out with no support from the local authority. However, they said they had received support from the local authority for minor adaptations in their new home despite remaining to have accessibility issues in their new home.

Staff told us there were waiting lists for major adaptations to peoples’ homes funded by Disability Facilities Grants (DFG). Occupational Therapists (OTs) who worked within locality teams had stronger links with housing colleagues to work together as early as possible in the DFG process. We heard staffing resources were challenging, however close collaborative working supported a focus on peoples’ outcomes. OTs held cases until the DFG adaptations were completed.

Simple equipment was prescribed from various sources such as the single point of access team directly after a phone assessment, people with care and support needs could be invited to the Equipment and Demonstration Centre where aids and equipment could be tried, bought or prescribed which supported people to find their own solutions to maximise independence. People could also attend a ‘Disabled Facilities Grant clinic’ which were offered monthly. Senior leaders told us grant officers from housing team were also present at clinics to provide a ‘one stop shop’ for grant applications.

According to the local authority’s data, occupational therapy activity and outcomes were recorded and displayed within a visual dashboard, available for manager oversight, and was formally reported to the Principal Occupational Therapist every 6 weeks. There were some limitations, as the activity did not include historic data for median wait times. However, we heard there was work underway to further improve data recording and analysis to inform decision making and strategic insight.

In June 2024, the highest number of people waiting were from the Single Point of Access (SPA) team with 254 out of a total 475 people waiting. The longest wait times for people were 7 months in the North locality team in comparison to the single point of access team longest wait times being 2 months, South locality team being 3 months and the Technology and Reablement and Intervention team having no waits in June 2024. The local authority had differing wait time targets depending on the screened risk and priority, and which team the assessment was waiting within. According to the local authority’s own timescales and data submitted they were not meeting their targets which could leave people waiting at risk.

Senior leaders told us staff vacancies, slow recruitment and staff sick absences were often cited as overall reasons for increased wait times. A publicly funded NHS services partner had recently fully withdrawn health employed occupational therapy staff from the single point of access team to de-integrate from social care. Staff and senior leaders told us the impact of this had been additional time screening and referring between health and social care services, to ensure the person was supported by the right organisation. The local authority also had a small number of trusted assessors (non-therapy staff that could prescribe from a small list of equipment) within adult social care teams and provider services. However, due to staff turnover there was more to do to increase the numbers of trusted assessors to make an impact on people’s outcomes and experiences around wait times.

In contrast the equipment review times were meeting targets, with 1250 reviews created in August 2023. These were all risk rated and prioritised, and staff resource was allocated to focus on reviews. Project work was underway to further understand trends and make future plans around managing waiting times.

Provision of equipment and Technology Enabled Care (TEC) was seen as essential to achieve the local authority’s maximising independence agenda. Senior leaders told us occupational therapy staff were well placed to deliver on this agenda using their skills alongside consideration of the persons environment and personal goals. There were processes to support OTs in their work, staff told us this was different to the social workers new ‘Eligibility Resource Forum’. OTs told us they had an equivalent 'equipment panel forum' once a month also attended by health colleagues, this was held virtually and was a space to critically reflect on situations and ideas to improve peoples’ lives describing it as more than a cost saving exercise. One person with care and support needs told us, the local authority put in place some unexpected additional adaptations that met their needs. They said this was a pleasant surprise and the staff had gone ‘the extra mile’ such as widening of doors and adjustments to the door openings, to accommodate their wheelchair which enabled them to stay at home and be as independent as possible.

Staff and senior leaders told us about the best practice work around seating for people. One senior leader told us a recent audit showed that in all cases where seating was provided, it improved peoples independence and reduced carer stress. Another staff member gave an example of how they applied strength-based approach, when assessing and prescribing the right seating which had made a ‘huge difference’ on a person’s life. The person previously could not independently adjust their glasses on their own face to be able to see properly and be comfortable because of a poor seating position. The seating that was assessed and prescribed which had made a bigger difference than they imagined, enabling the person to eat their favourite food ‘meat’ independently, due to this simple improvement that had a big impact on their wellbeing.

The local authority had been awarded funding through NHS Transformation under the digitising social care agenda. TEC was an area the local authority was proud of and was an area that was high on the integrated care systems agenda. A health partner told us health organisations were behind on moving forward with this type of technology and were keen to learn from the experimental work of the local authority.

A senior leader also told us they were proud to be the only Integrated Care Board TEC accelerator local authority in the country. This had supported a number of TEC projects and pilots. There was a TEC strategy that staff, senior leaders and partners were proud of. It was limited to 3 years due to the local authority’s awareness of ever evolving technology. Staff told us technology enabled care (TEC) was evolving, there had been a focus on encouraging care providers to adopt ‘TEC-first approaches.’ There was a new TEC strategy with linked pilots and service development initiatives. For example, acoustic monitoring in care homes had been introduced, supported by a TEC panel that met regularly. These panels explored a wide range of technologies aimed at improving access to care, especially in rural areas, and promoting independence through tools like online banking and medication prompts. This could support people to regain skills and manage or reduce need where possible and avoid only responding when people reach a crisis point.

The projects and pilots work were ongoing, and any analysis of people’s outcomes and experiences was in the early stages. However, staff told us they valued the benefit of having the TEC and Reablement Intervention service (TRI) as technology changes often. Staff agreed it was a challenge to advise people about the ‘pros and cons’ of technology enabled care (TEC) when it changed so often and we were informed that staff did not replace care with technology.

Staff knowledge on TEC varied within teams, some knew less about technology options and felt if they knew more, they could further promote technology within their contact and assessments. For example, staff told us there were challenges for older people with using technology enabled care. Although staff told us that when they referred individuals to the TRI team, the team conducted comprehensive, needs-based assessments using clear clinical reasoning to determine the most appropriate and effective equipment for each person. While individuals might have had a specific piece of technology in mind, the in-depth assessment process ensured that they received the most suitable assistive equipment to support their safety, independence, and well-being. For example, in some cases where GPS monitoring was initially requested, the assessment identified that a pendant alarm would provide a more effective and personalised solution based on the individual's specific needs and circumstances. This approach reflects the commitment to person-centred care, ensuring that individuals receive tailored support that enhances their daily lives. The TRI team were a source of knowledge through research and training to keep up to date with the latest technology, to ensure the right technology was available for individual personal needs and to support with care. Staff in the TRI team told us they did not just assess for technology that might be recommended by a referrer, instead they had the skills and resources in the team to also offer equipment aids and signposting to other services. Staff gave examples of using technology to understand people's needs and risks which informed assessments. Staff told us technology was not a quick fix, the TRI team looked at holistic needs, breakdown presenting issues and find solutions with people.

There was poor feedback about how easily people could access information and advice on their rights under the Care Act and ways to meet their care and support needs. National data showed 62.93% of people who used services in North Somerset found it easy to find information about support, which was somewhat worse than England average of 67.12% (ASCS, 2023-2024). The local authority recognised they had more to do to link and align strategic intentions and focus within staff practice to ensure people had access to the right information at the right time.

We heard from unpaid carers who were not aware of how to access support from the local authority. Another person shared experiences of being increasingly frustrated with the process of navigating the local authority, highlighting the challenges and difficulties others may face when seeking support. And another person described navigating the local authority system as challenging, particularly due to a lack of understanding about what support was available and how to access it. At times, they likened the experience to "hitting a brick wall," where progress was made with one service, only to face setbacks with another.

Staff told us the local authority’s website was where people could access information, however they said some people who use drugs or alcohol, people who are homeless, people hard of sight, and many older adults don’t have access or cannot use the internet to gain information and advice. Staff preferred when the local authority had a reception area to ensure accessibility for all people trying to access information and advice, particularly in the North of North Somerset where there were said to be more challenges and areas of high deprivation.

There had been a review of the adult social care front door services, which was due to be moving to a co-owned model with the local authority. The new model would provide the local authority with improved data for analysis, decision making and resource planning. The local authority had also started a ‘person’s journey project’, to map out current pathways and improve peoples’ experiences. There was a ‘Funded Virtual Hub’ pilot, designed to support health, social care and the wider public to navigate and refer to social prescribers.

Staff told us people were given information to decide whether they wish to request a direct payment to meet some or all of their needs. Although, this information was not routinely available at all points in the process to ensure people had the best opportunity to consider how direct payments may be of benefit to them. For example, frontline teams told us people were less likely to be given this information when they first contacted the local authority, or on review of a commissioned package of care. Another person told us they did not receive support with their direct payment. In North Somerset 22.78% of people who used services received direct payments, this was similar to the England average of 25.48% (Adult Social Care Outcomes Framework, 2023-2024).

Some carers we spoke with told us they had not been given information or advice about direct payments, and we were informed that only a small number of unpaid carers had accessed direct payments and grants. In 2022-2023 the local authority invested in a project to develop the direct payments offer in North Somerset. However, the end of year report for the development project showed there had not been any impact on the number of people receiving a direct payment since the start of the project. The report identified data inaccuracies, improvements not yet embedded and issues with recruitment for PAs. The project involved people who use direct payments, personal assistants, and staff who developed practice guidance along with a ‘Personal Assistant Support Service’ which commenced in November 2023. The aim of the ‘Personal Assistant Support Service’ was to support people to find personal assistants who have the skills to meet their needs.

Staff also gave mixed feedback, we heard good examples of how direct payments had made a difference to people’s lives, for example, one staff member told us a person they had supported had gone on to write a book and access further education due to their direct payment. Staff also told us there were challenges due to differing ways of working between the social care and the finance team. This was described as 'working separately' and caused delays and mixed messages for people with care and support needs, who use direct payments. Therefore, more could be done to consistently promote good quality and ongoing access to information, advice and support to use direct payments to improve people’s control about how their care and support needs are met. Senior leaders recognised the need to ensure staff are supported with clear information and accessible formats to aid communication with people about the use of direct payments.

In June 2024, the local authority reported 339 people accessed direct payment services, and between July 2023-June 2024, 79 people ended their direct payment. Of the 79 people who ended their direct payment, 49 people received an alternative service provision instead of a direct payment; whereby 26 people moved to a commissioned home care provider, 19 people moved to a care home, 2 people moved to extra care housing and 2 people were supported with shared lives placements. Senior leaders told us people with higher-level care and support needs tended to access direct payments, therefore, they said some people will eventually require increased care and support alternatively provided by a care home. Where people moved on to homecare support, this was said to be often related to carer breakdown for various reasons, such as personal assistants often being family members. Staff said there had been issues with the support for families managing direct payments budgets therefore people would instead be directed to brokers to manage the funds. Staff also told us about successful matching of people’s needs with PAs, and how PA recruitment had improved with targeted efforts at schools and colleges and increasing the monthly PA sign-up rate. However, there remained to be challenges with PA recruitment particularly in rural areas of North Somerset and in relation to competing roles and rate disparities between self-employed and employed PAs.