Oxfordshire County Council: local authority assessment

The local authority worked with local people and stakeholders, and used available data, from the Joint Strategic Needs Analysis (JSNA), to understand the care and support needs of people and communities. This provided insight into the current and future health and social care needs of the people in Oxfordshire. The JSNA was used to provide the evidence base for the Health and Wellbeing strategy. This included people who were most likely to experience poor care and outcomes, unpaid carers, and people who fund or arrange their care, now and in the future.

Oxfordshire’s Market Position Statement 2024 outlined the demographic challenges which included an increasing and aging population, this was set in the context of the significant workforce challenges. Providers told us Oxfordshire County Council had the desire to listen to providers to shape and understand the market. However, providers felt the local authority needed to work more closely with them to create a better understanding of people’s needs in the changing context.

Oxfordshire County Council operated in a diverse context, the JSNA highlighted Oxfordshire’s population grew by 10.9% since the last Census in 2021. The population of older people aged over 65+ increased by 48%, against the 20% increase of the total population. There had also been an increase in adults in Oxfordshire receiving long-term care and support, and an increase in demand for adult social care services as a result of the aging population. The JSNA estimates 900 more people would need care by 2031. The local authority had identified that 13,636 people were providing over 50 hours of unpaid care per week in Oxfordshire, many of whom were not in good health. Oxfordshire was aware of the challenges, and they were outlined in the JSNA. However, partners felt the data from JSNA was not always used to help providers understand what was needed in the future. Providers felt the authority needed to be more data efficient to build a picture of what could happen in the long term.

Oxfordshire operated an integrated approach to commissioning services with one of the largest pooled budgets between social care and health in the country. There was a renewed focus on delivering services through the s75 agreement which promoted a collaborative approach to prevention which underpinned the plans to deliver the Oxfordshire Way.

Oxfordshire County Council was designated a Marmot Place in December 2024; this would ensure the wider determinants of health drove cultural, and system change by prioritising health equity in the system. Senior leaders felt whilst the local authority had a social perspective on issues, they required improved data and analytics to look at future planning and understand how to develop as the demographics of the population changes.

The authority had identified the gaps in accommodation and support for people with complex needs including serious mental illness, including psychosis, acquired brain injury, poor physical health and long-term health conditions, addictions, and dual diagnosis. Partners told us that there could be improved care provision for people who lived with a physical disability or sensory impairment. The local authority had plans to develop a complex needs delivery site for people with learning disabilities and autism specifically. There were plans in place to develop an autism strategy. There were gaps highlighted in the market position statement which highlighted the lack of local provision in Oxfordshire to meet the needs of people who had severe and enduring mental illness, challenging behaviour, or complex health needs. The availability of homecare for people with mental illness was also identified as challenging.

Oxfordshire County Council updated its market position statement in 2024. The strategic approach which underpinned the Oxfordshire Way and supported the development of “I” statements was developed in 2022 to support the quality assurance of commissioned services. Senior leaders told us there had been a lot of change in the commissioning team, and the newly formed joint commissioning team has been fundamental in shifting conversations as a system concerning the commissioning of services. The commissioning team (HESC) was a joint commissioning function that oversaw and delivered the Joint Commissioning Executive’s program for Oxfordshire with a total budget of half a billion pounds. Commissioning jointly worked to fulfil the priorities of both adult social care, and the ICB. The local authority had plans in place to produce commissioning strategies for Autism, Learning Disabilities, Prevention, Tech-Enabled Care, Housing, Accommodation, Mental Health, Physical Disabilities and Sensory Impairment, and Dementia. At the time of the assessment, most commissioning plans were identified as either work in progress or due to begin which demonstrated that they local authority was at an early stage in its strategic journey with these.

Oxfordshire Council’s Market Shaping, Development, and Management document outlined several objectives including a shift from residential to homecare and reduced waiting time for care and support and sourcing​. The authority also detailed a focus on reduced waiting time for discharge from the hospital ​and improving outcomes from reablement. The local authority had re-commissioned and developed several new frameworks, to shape and manage the market. The homecare and the Live Well at Home framework were among these developments and had delivered a 6.8% increase in hours in the last 12 months up until June 2024 and had successfully contributed to reduced waiting times for people. Senior leaders acknowledged that bold decisions were made concerning commissioning to ensure a sustainable market. Leaders acknowledged that the authority was data-rich, but it was not as well used as it could be. Providers felt the new framework had presented challenges to the market and recognised the local authority sought to strike a balance between sustainability and its obligations. Their concern was that the local authority would not be able to manage the number of providers there were currently on the new frameworks. The local authority had acknowledged that managing and monitoring a high number of providers could be an operational challenge for internal teams going forward and had been developing better reporting on Power Bi to support the management of providers.

There were also noted restrictions for the mental health step-down pathway, as there were issues experienced due to access to long-term housing, particularly for those having been "multiple excluded" from both general needs and supported housing. The local authority spoke positively of plans to complete the mental health strategy. Senior leaders told us they were currently managing an increased volume of mental health work and planned to respond to this with health partners

The local authority had identified that improvement work was needed to successfully work with the local community to further develop commissioning strategies. It had also identified that there was a need to increase the scope and impact of commissioning and market development by working in partnership on both strategy and implementation. The Adult Social Care Survey for 2023/24 shows that 68.75% of people expressed choice over services, this was similar to England’s average of 70.28%. Both staff and providers recognised gaps in the provision for mental health, learning disabilities and autism. There were future plans in place to work with providers to support unpaid carers better from a prevention point of view. National data from the Survey of Adult Carers in England for 2023/24 showed 11.26% of carers accessed support or services allowing them to take a break from caring at short notice or in an emergency. This was similar to the England average of (12.08%).

Oxfordshire County Council understood areas where there was a need for greater capacity and had plans to meet the care and support needs of the people in the county. Data submitted by the local authority for July 2024 stated that 54% of homecare referrals were sourced within 48 hours, and 23% were sourced within 3-5 days. 48% of care home placements were sourced within 48 hours, and 24% within 3-5 days. The data provided demonstrated that there had been a reduction in the number of people waiting over the last 12 months.

In July 2024, 33% of referrals were sourced within 6 weeks, and 67% were sourced within 3 months for supported living. The local authority was aware that a number of factors affected the time people waited for housing including requests to live in specific locations in Oxfordshire.

Oxfordshire County Council had identified the gaps in accommodation and support for people with complex needs. Senior leaders told us that there was a lack of appropriate housing options in the area, specifically for people who were veterans and people with physical disabilities resulting in people who had been placed in accommodation as far as Bristol to meet their needs. Leaders told us housing developments were happening in the area as they were aware of the need to provide an adequate amount of care and support. The authority had plans to work with health partners and providers to review future options.

Data provided by the local authority showed 270 people were placed out of the area of Oxfordshire. Fifty nine of the placements were made within the last 12 months. One hundred and four people were placed in neighbouring authorities and 166 with other authorities. The majority of placements were because the authority was unable to identify a provider within Oxfordshire who could meet a person’s specialist requirements. This was more prevalent in people under 65 and people with learning disability and autism diagnoses. Staff told us there were challenges with finding appropriate placements for people with learning disabilities, especially those with conditions that may be more complex. They told us it could sometimes take several months to find suitable support, and people may have to be placed out of Oxfordshire.

Oxfordshire worked in partnership with the district councils and care providers when sourcing extra care housing. There were 1,082 units of extra care housing (ECH) at 20 schemes in Oxfordshire. The data provided for June 2024 showed that 21% of ECH placements were sourced within 48 hours, and 26% were sourced within 10 days. The local authority promoted ECH as an alternative to residential care to enable people to live well in their own community. The local authority had seen positive outcomes for people as a result of using extra care, with a reduced rate of residential care admissions in 2022/23. There had been a 9% increase in people being supported in extra care housing over the last 12 months, the local authority had commissioned additional ECH.

The authority had plans to improve reporting around waiting numbers for supported living and ECH referrals in the future. There were current restrictions to the data available concerning housing which affected the authority’s ability to view real time data.

As of July 2024, the median waiting time for homecare referrals was 3 days. 54% were sourced within 48 hours, and 23% were sourced within 3-5 days. The local authority acknowledged that finding homecare for people with mental health problems was challenging, and plans included adding an additional 9 providers that would be able to support people with forensic needs, in addition to mental health needs.

Staff told us that there were gaps in provision for working-aged people outside of education. With limited availability of services specifically in day services, and community engagements, what was available often had larger waiting lists for access. This had been fed back to the commissioning team, who were actively working with the market to address this gap.

Some areas of Oxfordshire had little or no care home provision. In more rural areas there was a limited choice for people who needed care homes. In contrast, some areas had high levels of provision, above the forecasted needs of the local community. However, whilst there was adequate capacity across Oxfordshire some people from areas with no or little provision would need to move to another area of Oxfordshire to access care home provision.

At the time of our assessment visit there was no one waiting for a Care Act assessment under the s75 arrangement for people who met the health criteria. However, staff told us people who needed support to live well with their mental health issues in the community had to wait a long time to receive social care services which often meant their mental health deteriorated, and they ended up in hospital. Staff felt adult social care locality teams did what they could within the scope of their competence, but they recognised they needed specialist skills to support people adequately, which they did not have. They said there was insufficient accommodation, care and support provision available in Oxfordshire to meet the needs of people who had a severe and enduring mental illness, or people with complex mental health needs to prevent them needing admission to hospital. Other staff raised concerns about large gaps in mental health provision not being available to people of working age, as the thresholds were so much higher than Child and Adolescent Mental Health Services (CAMHS). Staff told us there was a lack of support and provision for people with a primary diagnosis of autism, and no specific autism-only provisions available. Partners also told us that there was a gap in service provision for people with mental health needs in Oxfordshire. They felt there were no services for people moving on from rehabilitation or for people with lower-level needs requiring a service to maintain their well-being.

Senior leaders were aware mental health had been a challenge for the local authority. In addressing issues, the local authority had taken steps to use Better Care Funds to embed housing workers in a local hospital to support homeless people and had improved provision with the new Mental Health Prevention Framework. Some reductions in hospital presentation and in discharges back to the streets had been seen but it was still too early to assess the full impact of the new framework.

The local authority had arrangements to monitor the quality and impact of the care and support services being commissioned for people and it supported improvements where needed. The Quality Improvement team used 3 levels of formal reviews, self-assessments, desktop reviews, and on-site reviews. Each provider had an allocated officer. Staff told us they used a red, amber, green (RAG) rating to assess the performance and standards of services in line with CQC regulations. They use the Provider Assessment and Market Management Solution (PAMMS) system to generate ratings of services based on available information and they engage in quarterly contract monitoring of providers.

Based on the team’s assessment of the quality of services, they could take action to support providers and ensure people received appropriate care and support. The commissioning team tried to ensure they were balanced and proportionate in their approach. Providers’ experience of the system had varied with some stating that some providers had quality assurance visits but no report back and felt they were in limbo. Some providers felt quality assurance from the local authority was not always effective. For example, some providers felt there was a lack of knowledge and understanding among quality assurance officers about their services. In response to feedback from providers, from 1 January 25 the local authority had introduced timescales to ensure providers received timely feedback within 2 months. Providers acknowledged there was a positive relationship with senior leaders which they found supportive.

The local authority had processes to ensure people were involved in assessing the quality of commissioned services. VCS partners supported the local authority to conduct quality checks of learning disability settings, supported living and residential care homes. Working with 'expert by experience inspectors' supported the authority to monitor processes to ensure the environment was satisfactory. Providers highlighted that the inclusion of experts by experience, as part of the quality assurance visits, always added value and insight. The Community Support Service (CSS) had quality checkers, and their details were displayed on CSS sites to make them identifiable to people using services. Quality checkers were a diverse group of people with lived experience in Community Support Services, with physical and learning disabilities, mental health conditions, and physical health conditions. Their role was to speak to people who used CSS to get their views on the quality of the services that they receive and then make suggestions for improvements.

In addition to this, My Life My Choice also had a quality checking role in the supported living services. They were part of a project which involved the Quality Checkers visiting supported living settings, talking to managers, staff and people with a learning disability and their families to look at the quality of the service using the ‘REACH’ supported living standards.

The local authority was improving the use of data to inform work and provide better insights into the quality of local services. For example, the use of the power BI platform, which provided a digital visualisation of data dashboards. Staff told us there was variation in the knowledge and understanding of CQC regulations amongst local providers and the planned improvements would inform their approach to providing quality assurance. For example, they had previously focused more resources and efforts on services that performed poorly and learned lessons and had shifted their model to ensure adequate input and support were provided to all commissioned services.

At the time of our assessment, 7.50% of residential homes were rated outstanding by CQC, 77.50 % were rated good, 7.50% were rated requires improvement, 0 were rated inadequate and 7.50% had not yet been rated. Of the homecare services in Oxfordshire, 6.86% of homecare services were rated outstanding, 57.14% were rated good, 6.29% were rated requires improvement, 0.57% were rated inadequate, and 29.14% had not yet been rated. 9.89% of nursing care was rated outstanding, 78.02% of nursing homes were rated good and 9.89% were rated requires improvement, 1.10% inadequate, and 1.10% not rated.3.13% of supported living services were rated outstanding, 71.88% Good, 6.25% were rated requires improvement, 0 were rated inadequate and 18.75% had not yet been rated.

Data was provided by the local authority for the termination of contracts due to provider performance, quality, or falling below the required standards. Between July 23 to July 2024, this affected 289 people for homecare (6 providers), and 2 people for Supported Living (1 provider).

The local authority recently changed how it recorded contract hand backs to better understand themes and trends, this was to support providers and provide insight into the local authority’s ability to manage the market and any associated risks.

Oxfordshire County Council undertook a comprehensive review of the Care Home Framework which had resulted in new care and funding model for purchasing care home beds for adults in Oxfordshire. The Care Homes Framework was developed in partnership with NHS partners and with local care homes. The care home bandings defined levels of need from 1 (residential) to 4 (complex nursing) and the inputs required from the care home provider to meet these needs. The cost of care for each care band was fixed. Providers bid to join the framework at the care banding they delivered; they were evaluated against the care banding criteria and paid at the designated rate. Some providers were on the framework for more than one banding.

Following the review of home care provision in Oxfordshire in 2019/20 the Live Well at Home Framework was developed as part of the approach to supporting people to live independently. The ‘Home First’ framework was an approach to support people to live independently at home for longer.​ The local authority had acknowledged that it had supported more people through the framework compared to previous home support contracts with a 16.5% increase in home support over the last 4 years. The new framework was supporting it to meet demand but required improvements to both contract and quality management. Senior leaders told us they worked to develop a sustainable marketplace and had to make bold decisions to change to ensure a sustainable market for the future. Staff felt improvements to commissioning frameworks, and standardisation of care costings had a positive effect on the availability of services at an operational level. This had also led to better relationships between providers.

Oxfordshire County Council had worked closely with providers to gather feedback on the new open care home framework. There were mixed feelings about the new framework. Some providers felt they had more risk than they had before as they were working with people with more complex conditions and behaviours, and a higher risk of falls. Some care providers told us they were working hard to maintain people’s independence but when people’s needs changed, delays in reviews meant that they were still providing care at the initial assessed level where people’s needs had clearly changed.

The local authority understood its current and future social care workforce needs. Oxfordshire had experienced continued high vacancies in health and social care. Oxfordshire County Council’s objective was to reduce vacancy and turnover rates across the adult social care workforce. The staff turnover rate in the independent health and social care sector was 40.7%, higher than the local authority which was 12.2% and significantly higher than the national average for the sector at 28.3%. The local authority had identified a number of challenges that contributed to the vacancy rate such as the increasing demand for care and had developed targeted plans to address concerns. Providers recognised Oxfordshire’s commitment to partnership working and recognised proactive work on the workforce issues seeing it as a joint challenge.