London Borough of Southwark: local authority assessment

Arrangements to prevent delay or reduce the need for care and support were set out in the local authority’s Adult Social Care Plan, and aligned with the Southwark Joint Health and Wellbeing 2022-27 Strategy and Southwark 2030 vision. Prevention priorities were tracked through performance indicators and outcomes outlined in the JSNA. There was ongoing work with system partners to develop effective shared outcome measures to demonstrate impact. Although this activity was not always supporting early intervention and prevention.

The local authority provided several prevention-based activities and interventions and ASC worked closely with the Public Health team and other partners to improve the health and wellbeing of residents. The local authority had taken steps to identify people with care and support needs that were not being met. Neighbourhood teams used a range of population health tools including ASC and health data to identify vulnerable people and communities, and worked with the voluntary sector to reach into different communities to understand their specific needs.

The Partnership Southwark health and care plan 2023-28 included priorities that spanned people's lives, including 'start well', 'live well', 'age well' and 'being cared for well'. Priorities supporting Live Well included access to support for mental health, smoking cessation, alcohol intake, and healthy weight. Priorities supporting Age Well and Being Cared for Well included a coordinated and integrated frailty pathway to maximise mobility and reduce crisis support and hospital admissions.

Public Health commissioned and funded a variety of services aimed at prevention and early support. For example, 160 volunteer Community Health Ambassadors outreach, advice and signposting service supported communities to address health inequalities such as cancer prevention, cost of living information and mental health support. Public Health also delivered prevention programmes including vaccinations, health screening and healthy living initiatives. The Public Health team delivered staff training sessions on making every contact count, suicide prevention, and mental health first aid, specifically targeted at front line staff. This was based on learning needs identified by ASC.

The local authority managed community hubs across the borough to deliver prevention services and support people to access care. A dedicated wellbeing hub provided mental health support to prevent and reduce people's needs for care and support, including signposting to statutory services, digital inclusion initiatives, drop-in sessions, therapeutic activities, group meetings and peer support. People told us they were grateful for the wellbeing hub because it provided a space to connect with people with similar lived experiences. Support was tailored to each person’s needs for up to 12 weeks, after which people could continue to access services within the hub. The wellbeing hub provided ‘pop-up’ outreach sessions targeting specific communities to promote mental health services.

The local authority provided 21 'warm spaces' across the borough. Warm spaces were free places to keep warm in the community, with some also offering cost-of-living advice, free hot drinks and food. The local authority also partnered with Southwark Community Support Alliance to help vulnerable people experiencing hardship with food and basic needs and promote healthy living. The service could be accessed via the local authority's website, completing an online referral form, or by telephone.

The local authority supported several peer support schemes and self-management groups including the Southwark Disabled People's Action Forum and Together for Mental Wellbeing. Social prescribers were embedded in primary care teams and provided advice and signposting to services provided by VCSE and other local organisations. The local authority had a loneliness strategy and worked with VCSE groups in Southwark that provided community choirs, exercise groups and befriending to reduce social isolation.

The local authority supported vulnerable people to access paid employment and voluntary work. Staff with specialist knowledge and local connections supported people to access education, training and work opportunities. People spoke of the positive impact of this support in providing them with a sense of purpose and routine.

There was particular focus on supporting vulnerable families to stay together, with family early help and holistic support. The Positive Behaviour Support Team led on early intervention and preventative measures, crisis support and training for young people with behaviours that may challenge. People provided positive feedback about the service, reporting the positive impact it had on reducing family and carer relationship breakdown. The local authority had an extensive team of psychologists, which supported initiatives such as PAUSE – a family support programme for women who have had, or are at risk of having, more than one child removed from their care. Senior leaders explained this had transformed many families’ lives locally, helped them take control of their lives, and reduced the need for more intensive interventions.

The local authority considered the specific needs of unpaid carers and recognised the need to maintain carer health and wellbeing and prevent isolation. This included outreach events to support carers in recognition they were less likely to come forward for support. There were carer peer support groups and online ‘cuppa’ mornings to seek advice. Although many carers were not aware of all available support.

The local authority worked with a dedicated GP service for care homes focused on prevention of hospital admissions. There was also a joint ASC-health funded ‘mini therapy’ team placed in care homes to support admissions and reduce stays in hospital. However, NHS partners highlighted that health and social care needed more enhanced pathways to support people on the frailty pathway in the community to enable earlier and quicker identification of deterioration to enable more preventative support to be put in place.

Some of the local authority’s national data indicators for prevention were worse than England averages. Data from Adult Social Care Outcomes Framework (ASCOF, December 2025) showed 56.80% of people reported they spend their time doing things they value or enjoy, lower than the England average of 68.80%. 91.90% of people who used services described their home as clean and comfortable, also lower than the England average of 94.05%. 69.85% of people who received short term support no longer required support, worse than the England average of 79.39%. This indicated the local authority’s preventative services were not having a positive impact on wellbeing outcomes for all people, although there were significant improvements in performance over 2023-24 data and the local authority recognised this as a continued area of focus. For example, data provided by the local authority showed the proportion of people needing no or less support after reablement had risen from 69.85% in 2023-24 to 77.00% in 2024-25. This meant more people regained independence, reducing demand on long-term support, and showed how the local authority had responded to areas needing improvement and taken action to improve people’s outcomes. Better Care Fund (BCF) data submitted to the local health and wellbeing board highlighted the role of the local authority’s prevention activities in a 15% reduction in the number of unplanned emergency hospital admissions locally in 2024-25.

The local authority was a housing authority and had statutory responsibility under the Housing Act to provide suitable housing for people. However, we received consistent feedback that current housing stock did not always meet people’s expected standards or needs, including safety risks such as damp and mould, and the negative impact this had on people’s health. The local authority provided funding to address these issues and there was an audit of housing stock condition. OTs worked to manage risks, stabilise people’s living conditions and make people’s homes more accessible and safer. There was a Health and Housing Care Board for public health, adult social care, and housing leaders to address shared challenges and find solutions. Local authority data showed a significant reduction in the number of overdue damp and mould cases from 673 in March 2025 to 223 in October 2025. The local authority had invested £2m from the Public Health team to support this priority work. The data also showed 93% resident satisfaction rate with housing repairs and responsiveness.

The local authority worked with NHS partners to deliver intermediate care and reablement services to support people to return to their optimal level of independence, after a hospital stay for example. It helped prevent, reduce and delay the need for long-term care. The local authority had 6 reablement beds in local care homes and 5 extra care housing schemes for step-down care. There were also 8 discharge-to-assess beds for people awaiting further assessments, such as those needing a CHC assessment. This facilitated discharge flow, ensured people were placed in safe environments, and prevented further deterioration. The local authority’s outcomes data for older people completing reablement during 2024-25 showed 77% required no ongoing support, 10% required reduced support and 13% required the same of greater support. This indicated the local authority’s investment of £1.8 million in the service successfully supported more 85% of people achieve outcomes of reduced or no on-going packages of care.

National ASCOF data (December 2024) showed 7.12% of people aged 65+ received reablement or rehabilitation services after discharge from hospital, significantly better than the England average of 3.00%. National data from Short and Long Term Support (SALT, October 2024) showed 87.23% of people aged 65+ were still at home 91 days after discharge from hospital into reablement or rehabilitation care, in line with the 83.70% England average.

The integrated reablement service included nursing, occupational therapy, and physiotherapy to support people to remain out of the hospital. Practitioners applied nationally recognised reablement goals to support people’s recovery. The service provided reablement support for six weeks, with options to extend this where needed. Some people received reablement support for longer than six weeks, partly due to delays completing Care Act assessments by the local authority. Social workers made additional referrals, for example to the community falls service, if needed. There were trusted assessors in local residential and nursing care homes where the local authority commissioned ‘block beds’ to support intermediate care capacity. The trusted assessor approach supported direct discharge of people to any of the block beds for an assessment. This had reduced delays.

There was an urgent community response multi-disciplinary team to support people in crisis and prevent avoidable admissions to hospital or emergency nursing care. A duty worker undertook face-to-face assessments and liaised with relevant professionals such as mental health and learning disabilities to ensure that the person receives a holistic assessment and received suitable support. There was also dedicated intermediate care for people who have had a stroke and needed a period of rehabilitation. The commissioned service provided 24-hour care placements for specialist stroke rehabilitation assessment within a suitable care environment.

There was specific mental health reablement provision, which staff praised for reducing the need for long-term care. The local authority provided people with up to 10-weeks mental health reablement support. There were 10 mental health peer mentors with lived experience of mental health care. They completed joint home visits with a social worker and provided ongoing advocacy, support and guidance. In 2024-25 73% of people finished mental health reablement with no ongoing care needs. The local authority also worked with the local NHS mental health trust in a mental health ‘recovery college’, which was co-delivered by people with lived experience. This showed the local authority invested in preventative support by people with lived experience.

People could access equipment and minor home adaptations to maintain their independence, continue living in their own homes and prevent, reduce or delay the need for care and support. However, there were long waits for Occupational Therapy (OT) assessments, and some people waited a long time to have their needs met.

There were no waiting lists for equipment provision, with an average delivery time of 1-5 days. Staff could access emergency and same day equipment deliveries. The local authority procured equipment through an external provider and had recently completed a rapid commissioning exercise when the previous provider ceased trading. This was managed well to ensure people could access equipment without delay. Staff could submit evidence-based requests for specialist equipment, such as robot wheelchairs to improve people’s independence and quality of life. Staff gave as an example of working with a person nearing the end of their life and with young children. The person’s primary goal was to be able to go down the stairs to take their children to the park. OTs worked with housing to install a stairlift within eight days, enabling the person to fulfil this important goal.

To address wait times the local authority had actively recruited OTs with a focus on development and support for innovation. The local authority hosted a national OT conference which helped promote Southwark as a place to work and demonstrate the local authority valued OTs. At the time of our assessment there was 1 OT vacancy, reduced from 17 in less than a year. The local authority also employed 3 OT apprentices to provide lower-level support and interventions. However, this was not yet showing a reduction in OT assessment waiting lists. The local authority was in the process of implementing an online portal called AskSARA for people to self-assess their equipment needs. This provided impartial advice about equipment for different needs such as mobility, pressure care and personal hygiene, and where to purchase them. People could also submit requests for OT and equipment assessment on the portal.

The local authority supported over 3500 people with technology enabled care (telecare) and assistive living devices, including personal alarms, activity monitors and home environment sensors to help people stay independent or get help in an emergency. At the time of our assessment 1 person was waiting for a telecare assessment, with a median wait time of 32 days and maximum of 32 days. The local authority had completed the transition from analogue to digital ahead of schedule to support more people to access telecare without needing a landline. Staff reported that telecare was rapidly installed, often while a person waited for a Care Act assessment. The telecare supported the assessment of their needs with real time data to help families and professionals make informed decisions about people’s care and support needs.

OTs were integrated into the local authority’s front door contact team to assess and approve equipment, minor adaptations and preventative support early in people’s contact with ASC. Some customer support officers were trained as trusted assessors which also supported prevention activity. People on OT waiting lists were risk managed and prioritised based on level of support needed. There was support whilst people waited, including a designated person in the contact team. There was an OT in the review team and OTs were located on the same floor as other frontline teams to support joined up working.

OTs advocated a ‘home first’ approach to support people’s independence. They carried out detailed assessments focused on preventative measures. OTs discussed people’s needs and concerns with them, explored different types of equipment, and offered solutions for safely navigating and using amenities within the home. This included providing minor equipment like bath boards and steps, as well as exploring other mobility aids. OTs conducted joint assessments with other social care professionals where needed to ensure holistic review of people’s needs. Some of the local authority’s VCSE partners were trained as trusted assessors, which also supported more timely support.

When OTs assessed a person’s home environment, they addressed the identified needs in the referral and also assessed the overall environment for safety and accessibility. For example, they suggested alternative kitchen appliances for people with mobility difficulties. They also planned for people’s future needs, advising people with progressive conditions on the support and equipment they may require in future.

The OT team worked closely with the local authority housing team to support adaptations in people’s homes, utilising the ring-fenced Disability Facilities Grant (DFG). In 2023 the local authority completed 123 major adaptations including level access showers, bathroom alterations, stairlift installations and building alterations. OTs liaised with housing when people’s needs or risks changed and to support prioritisation of adaptation waiting lists. As well as major adaptations, the DFG also funded a handyperson service which worked closely with the hospital discharge team to enable people to return home from hospital when their home needed minor repairs. However, there was no clear process to ensure OTs were informed when adaptations were completed. This meant OTs could not easily check if adaptations were meeting people’s needs and being used safely.

However, many ASC staff told us the relationship with housing needed to improve as there was a reported disconnect between ASC and housing. This resulted in work often sent from housing to ASC staff that should have been addressed by housing. Staff told us it was difficult to communicate with housing as they did not have direct contacts to seek support in a crisis. High turnover of housing staff limited opportunities for effective working relationships and hindered case management and risk management. ASC staff frequently acted as conduits between housing and residents which impacted on their capacity to support people’s care needs. This indicated the systems currently in place were not adequate to support joint working between ASC and housing, resulting in silo working and delayed information sharing which negatively impact coordinated support. In response, the local authority had set up housing clinics for ASC and housing staff to find solutions to people’s housing needs which were impacting on their care, for example delayed hospital discharges due to pest control issues in the person’s home. There was also a multidisciplinary (MDT) housing health and care partnership board with representation from ASC, housing, public health, mental health and VCSE organisations to improve information sharing. Housing leaders attended the safeguarding board to improve shared involvement in addressing priorities such as hoarding, cuckooing, and adaptations.

People, including unpaid carers and people who fund or arrange their own care and support, could access information and advice on their rights under the Care Act and ways to meet their care and support needs, but the local authority identified this as an area for improvement and recognised it needed to make information more accessible. People could contact the local authority by telephone, online or in-person.

National data from the Adult Social Care Survey for 2024-25 showed 68.47% of people who used services found it easy to find information about support, similar to the England average of 67.09%. Although the Survey of Adult Carers in England 2024 showed 37.50% of carers found it easy to access information and advice, significantly worse than the England average of 59.06%. 73.33% of carers found information and advice helpful, also significantly worse than the England average of 85.22%. This indicated the local authority was not meeting all people’s information needs.

We received mixed feedback from people about the local authority’s provision of accessible information. Some people told us social care staff explained things clearly in ways they could understand. They repeated and rephrased things to support people’s decision making. Although other people reported limited information and follow-up by staff, which meant they had to search for information about services and providers online, or rely on family members to contact the local authority.

People’s support plans and assessments were available in different formats such as easy read, Braille and translated into community languages. Local authority documents were also available in accessible formats, for example an easy-read guide to direct payments.

The local authority’s website included information and contact details for different adult social care teams, links to external support organisations and briefly outlined assessment arrangements. People could self-refer to ASC using an online form. The local authority also provided drop-in services at two community locations, with staff on hand for self-referrals and in-person Care Act assessments for people not able to access information online. The local authority’s disability hub opened in 2025 for residents to seek in-person advice and support from various services in a single location. People could attend the resource centre to have a wide range of their needs met without having to travel from place to place.

Some people found the local authority website inaccessible and difficult to navigate. There was a local authority-wide programme to improve provision of clear and accessible information to help people make informed decisions. Priorities included promoting digital up-take and increasing self-service. However, some people and partners told us the local authority’s online forms were not accessible for those who were digitally excluded. This resulted in some people not accessing support from appropriate services.

The local authority circulated some information in printed newsletters and posters throughout the borough, which gave people access to information about available services and support. Partner organisations told us the local authority could improve its outreach efforts to ensure everyone has access to information and to identify unmet needs. Elected members articulated a need for better information sharing and cross-referencing of council data to reach vulnerable people more effectively.

There was ongoing work to improve accessible information and advice for unpaid carers, following feedback from carers that information was not clear. The local authority’s recommissioning specification for the carers service included improved information advice, guidance and outreach. The local authority had created an information booklet about universal support for unpaid carers. This was shared with local GP surgeries and health organisations to communicate the different ways unpaid carers can access support and contact details for further information and advice. It was clear and easy to understand. Unpaid carers in Southwark could access to a 24 hour helpline for confidential, professional support and advice around health and wellbeing, money worries, self-care and respite, consumer and legal issues, family, home and work issues.

Direct payments were available as part of the local authority’s assessment and provision of care, but uptake was much lower than the England average. People eligible for direct payments were offered the option of managing the direct payment themselves or a third-party could manage it on their behalf. There was early work to support the local care market to increase opportunities for people to use direct payments, for example ensuring personal assistants (PAs) were paid London Living wage. Senior leaders attributed low uptake to complicated internal processes and systems, but there was limited evidence the local authority was actively addressing this or promoting the benefits of direct payments.

National ASCOF data (2025) showed 13.27% of people in Southwark received direct payments. This was a slightly worse than the England average of 24.51%. Similarly, 18.99% of people aged 18-64 received direct payments, which was worse than the England average (35.53%), and 6.69% of service users aged 65 years and over received direct payments, also slightly lower than the England average of 13.64%.

Staff told us some people struggled to manage their direct payments well. We heard feedback about people not utilising sufficient care hours, limited understanding of financial implications on their welfare benefits, or expected personal contributions. People with mental health needs found it difficult to manage direct payments, and some people’s family members employed as PAs experienced overwhelm managing their needs.

However, frontline staff gave examples of using direct payments creatively to support people’s individual care needs. For example, supporting a person to have swimming sessions, day trips, gym memberships and spa treatments for carers. People with specific cultural needs utilised direct payments to employ PAs with specific culture understanding.

The local authority commissioned multiple providers to support people to manage the administration of their direct payments. Although some staff told us improvements were needed because of frequent issues with people’s understanding of the cost of care packages. There was staff training to improve understanding of direct payments, but staff reported low attendance for this.

The local authority’s direct payments online guides and procedures were clear, comprehensive and easy to understand. They detailed what direct payments involve, how they may be used and the responsibilities of receiving and managing one. It provided information about having a support provider to help manage direct payments. The local authority monitored usage of direct payments and recouped any unspent budgets. There was a risk-based monitoring framework and direct payments were monitored monthly by way of a user return. The document also covered usage rules and payment methods.

There were robust process to ensure direct payments were spent on agreed things/activities as documented in people’s support plans. The direct payments team worked with people’s allocated social workers to ensure issues were addressed quickly. In the year up to our assessment 22 people stopped using direct payments to meet their ongoing care needs. Of these, 8 chose a directly commissioned service, 9 stopped at the request of either the person or their next of kin. In 5 cases direct payments were stopped following monitoring, which revealed funds were not being used to pay for care or support as intended. Alternative care and support arrangements were put in place for all people.