St Helens Borough Council: local authority assessment

St Helens Our Borough Strategy (2021-2030) and the Annual Report (2023-2024) set out how the local authority worked with local people and stakeholders and used available data (for example the JSNA) to understand the care and support needs of people and communities. The Our Borough Strategy focused on health inequalities leading from the high levels of deprivation recognised in the area.

However, engagement with seldom heard groups and people in the community with protected characteristics was less robust. This included people who were most likely to experience poor care and outcomes, people with protected characteristics, unpaid carers and people who fund or arrange their own care, now and in the future. Partners told us due to the high levels of deprivation within the Borough the care market had a limited proportion of self-funders, with the Office for National Statistics (ONS) data for 2022 suggesting 85% of care service placements in St Helens were state funded.

St Helens’ Community Engagement Strategy (2021-2026) identified how the local authority had improved community engagement though the promotion of Community Champion roles to increase participation in consultation and coproduction activities. Staff and leaders told us the local authority planned to strengthen the revised Partnership Forums by establishing equality groups to engage with underrepresented communities such as the LGBTQ+ community. However, at the time of the assessment it was unclear what impact these changes were having on the engagement with these and other seldom heard groups such as the small communities of people from Eastern Europe, refugees, and the Roma, Gypsy, and Traveller community in St Helens.

Senior leaders told us one of the main priorities within the Our Borough Strategy (2021-2030) was to promote good health, independence, and care across communities, supported by integration with health and social care partners. During 2023-2024 the local authority developed a new vision and strategy for adult social care, which was co-produced with input from more than 300 people across the Borough. The Adult Social Care Strategy (2024-2027) reflected what people felt was most important to them and set out how senior leaders would communicate, listen, and interact with people and their families to support and enable them to remain living as independently as possible within their own communities.

As well as continuing to improve the local authority’s prevention and early intervention arrangements through the Care Contacts team, staff and leaders told us the Home First model was being supported by joint investment with partners in occupational therapy, reablement and intermediate care, as well as specialist services for people with dementia. St Helens’ People’s Plan (2024-2027) identified a number of ‘all-age’ objectives, and ‘life-course’ priorities to meet the health and social care needs of local communities. At the time of the assessment the strategy was at an early stage and needed time to embed.

St Helens All-Age Market Position Statement (2024-2027) had been designed to encourage providers to consider how they delivered care and support, with a focus on the local authority’s Home First model as well as addressing the increased demand for specialist dementia and nursing care within the Borough. Data provided by the local authority showed 20.4% of people in St Helens were living with 2 or more long-term health and social care needs.

Senior leaders told us data collected from local consultations, surveys, and feedback, supported by the JSNA was used to target commissioning and procurement strategies throughout the private and voluntary sector. For example, the local authority expected the percentage of people aged 65 and over to rise to 24.5% by 2040, compared to 20.6% in 2021. Staff and leaders told us they used IT systems to assist with demographic predictions, and to support them to look at what provision would be needed in the future. This fed into the Market Position Statement and had led to the recent recommissioning of a number of provider services, including homecare providers.

Senior leaders told us with the local population of St Helens anticipated to continue to experience a growth in people living with dementia the intention was for St Helens to disinvest in residential care, making more effective use of their Home First model, including individual flats within services such as extra care and supported living to meet the needs of people with higher levels of support using assistive technology and joint-funded reablement schemes. However, at the time of the assessment there was a shortage in services supporting people with more complex needs such as dementia nursing care, and complex mental health needs.

Partners told us the local authority had recently completed a social prescribing project, to support people to take greater control of their own health and wellbeing by connecting them to activities, groups, and services in their local communities. For example, the retendering of Extra Care services had been implemented to address the link between high areas of deprivation and increase rates of osteoporosis in the Borough. This had led to targeted falls prevention training, increased identification of need and the provision of strength and balance classes for the wider community.

People told us they had access to a range of local support options to meet most care and support needs. National data provided by ASCS (2024) showed 78.38% of people who used adult social care services in St Helens felt they had a choice over which services they used. This was a positive variation to the average for England of 70.28% but did not reflect the shortage of complex support placements in the Borough.

Senior leaders shared their plans with us for a geographically led provider model for homecare services starting in 2025 to enable the local authority to meet fluctuating capacity and demand issues during times of increased need, for example during winter pressures. This included consideration for the provision of services to meet the needs of unpaid carers. National data provided by SACE (2024) showed only 14.20% of unpaid carers in St Helens were accessing support or services allowing them to take a break from caring for 1-24hrs. This was tending towards a negative variation compared to the England average of 21.73% and showed the need for an improved carer respite offer within St Helens which senior leaders told us had been part of the new Carer Support Service tender.

People told us they were given the opportunity to be actively involved in the redesign of services, with provision based on need and evidence of effectiveness, rather than task-led commissioning. People and partners told us the local authority supported new and innovative approaches to care provision to improve outcomes for people receiving care and support. For example, during 2025 the local authority planned to pilot a new cost model which had been independently developed in collaboration with providers to ensure consistency and transparency when setting fees and rates. Partners told us this would support services to be delivered safely and effectively by ensuring the workforce skills base was suitable and consistent across the Borough.

Partners told us commissioning strategies included the provision of suitable, local housing with support options for adults with care and support needs and an accommodation panel meeting fortnightly to consider vacancies in commissioned services to match people to places. The Cheshire and Merseyside Housing Needs Assessment report (2023) identified a predicted rise in people living with learning disabilities, and autistic people requiring support, with the most significant increase in people over 65-years-old. Senior leaders told us how the provider model for supporting people living with learning disabilities and autistic people was being reviewed, with a plan to move towards individual flats using assistive technologies to support people’s independence. Staff and leaders told us they were also reviewing the offer for people with mental health needs who were transitioning from a period in hospital, or who were at risk of readmission. This included a review of accommodation and floating support options.

St Helens Market Position Statement (2024-2027) identified the need to continue to develop services to reflect the local authority’s Home First approach by working with providers to ensure an integrated prevention approach and to increase the use of assistive technology. Whilst the local authority had clear plans to address gaps in service provision, at the time of the assessment there was not always sufficient care and support available to meet demand, or to allow people to access services when, where and how they needed it.

Partners said there were big challenges finding support for people with more complex needs such as people who were homeless, had drug use, or mental health needs. There was a complex care panel every Thursday which was attended by the drugs service and housing to discuss people with these needs. Senior leaders told us the local authority recognised there were limited options for people with mental health needs to step up/down when they were in crisis.

People told us there was an oversupply of homecare services in the Borough but a shortage of support for people living with learning disabilities, people with mental health needs, and older people with complex needs. There was sufficient capacity for unpaid carers to have access to replacement care for the person they cared for, in both planned and unplanned situations.

Staff and leaders explained how St Helens block-purchased residential nursing and dementia care home beds for step-down and hospital discharge support. Outside of these transitional services, St Helens contracted most of the residential care and nursing home beds on a spot purchase arrangement, with 25 residential and nursing care homes in the Borough supporting older people.

Data provided by the local authority suggested current capacity for long-term residential care was sufficient to meet current and future demands within the market. However, senior leaders estimated there was a gap in the capacity for complex nursing home care as well as a deficit in the number of dementia specialist residential care beds available. The local authority and ICS were working with residential homes to create additional capacity for dementia nursing beds and the local authority were supporting homecare services to upskill their workforce to support people with mental health and dementia needs to remain at home.

Partners told us some hospital discharges were delayed due to a lack of nursing care, complex dementia placements and services providing support for people with mental health needs. Senior leaders said the new Market Position Statement, which focused on homecare providers to support the local authority’s Home First model, was expected to ease pressures on more complex services and reduce waiting times.

Staff and leaders explained the average occupancy in the care home market was currently 95+%, which impacted upon timely hospital discharges and resulted in out-of-borough placements being utilised. Data provided by the local authority showed the average number of people waiting for nursing care placements between April and June 2024 was 14 people, with an average waiting time of 13.8 days. The main reason for delayed discharge was cited as due to a lack of capacity within the Borough to meet dementia care and more complex care needs, representing a 14.0% delay with requests for bed-based provision and had increased use of out-of-borough placements to meet people’s care and support needs. Senior leaders told us this was a regional issue, and they were working with other local authorities and with the ICS to address any immediate capacity issues.

Staff and leaders told us capacity for supported living placements, traditionally supporting people with learning disabilities, autistic people, and people with mental health needs, were currently experiencing similar delays in hospital discharges. Data provided by the local authority showed the average number of people waiting for supported living placements in April to June 2024 was 5 people, with an average waiting time of 9 days. Senior leaders told us about the figures for supported living which were due to a lack of available capacity in the Borough. Matching the compatibility of people to the available placements within the Borough was also a challenge. For example, age and gender-related profiles were difficult to match to services designed for communal living, prompting the local authority to look at more individualised flats as part of the future provision of support living services.

Partners said dedicated step-down nursing, dementia, and residential beds had recently been blocked-purchased to facilitate improved, effective discharge rates from hospital when people were unable to return home. An enhanced contract was in place which supported extended admission periods and closely monitored response timeframes to both referral and transfer times. Staff had been employed to support hospital discharges and there were clear roles and accountabilities for monitoring the quality of the services being jointly provided and the outcomes for the people using them.

Staff and leaders told us whilst there was some need for people to use services or support in places outside of their local area, these placements were carefully monitored and there were plans to improve service provision in the local area, so people could move back there if they wished to do so. Data provided by the local authority showed there were 40 people supported in out-of-borough supported living placements, with the local authority’s Market Position Statement highlighting the opportunity for providers to support and increase in the availability of services locally. For example, the local authority had recently worked with the ICS to provide a new specialist service for people with learning disabilities to living in St Helens.

Staff and leaders also told us there were 103 people aged over 67 in out-of-borough residential or nursing placements, with a further 112 people under 67 years old also in placements away from St Helens. All current out-of-borough placements were within a 20-mile radius of St Helens, with the majority being in neighbouring authorities.

Staff and leaders explained all placements, regardless of location, were subject to quarterly contract-management and quality assurance scrutiny. Senior leaders told us they had identified gaps in market availability, in particular specialist mental health provision and in complex dementia need, we they were working with partners to ensure the correct provision through the Market Position Statement.

St Helens had clear arrangements to monitor the quality and impact of the care and support services commissioned for people and it supported improvements where needed. The local authority had reviewed and updated their contract monitoring process to enable a more robust approach to working with providers commissioned by St Helens. A new contract monitoring toolkit had been developed, with data analysed and compiled into quarterly monitoring reports which detailed actions required to mitigate risk or to identify good practice.

Care providers had key relationship managers assigned whose role was to check on quality, maintain relationships with service providers, and audit care and support records. Staff and leaders told us quality assurance visits took place quarterly, with additional focused visits where concerns were raised. Collated information was RAG rated to indicate themes and trends which were then shared with senior managers and key partners such as the ICS and CQC. Actions to promote safe, quality services were based on risk, with safeguarding concerns, complaints and feedback from partners used, as well as ‘desktop’ data and quarterly provider self-assessment submissions.

Staff and leaders told us the local authority were proactive in addressing quality and safety concerns. Where quality concerns were identified these were tracked and monitored using action plans. Local authority staff would then visit weekly for progress reports and work closely with registered managers to ensure staff had the skills and training needed to improve care and ensure people were safe.

Staff and leaders told us the local authority offered support and advice about the quality and effectiveness of provider staff training and the impact on people receiving support. For example, staff told us they had recently picked up an issue around medication administration with a service provider. They looked with the provider at the quality of the training and supported them to make their training more robust and bespoke to their service.

At the time of the assessment there were 90 provider services in St Helens registered with CQC. Data showed 80% of nursing care and 75% of residential care services were rated Good or Outstanding by CQC. 79.5% of homecare services and 80% of supported living services were also rated Good or Outstanding. Data provided by the local authority showed there had been no enforced provider suspensions in the previous 12 months leading up to the assessment.

St Helens worked with providers and stakeholders to understand current trading conditions and how providers were coping with them. Engagement and monitoring arrangements enabled the local authority to get early warnings of potential service disruption or provider failure; contingency plans were in place to ensure people had continuity of care provision in this event.

St Helens Market Sustainability Plan (2023-2024) shared data from providers highlighting the homecare market had been significantly impacted by inflationary costs and the increase in the cost of living. The total number of domiciliary care hours commissioned were expected increased significantly over recent years, resulting in a significant financial implication for the local authority. The cost and complexity of overseas recruitment and the increase to minimum salary requirements were also factors considered by the market. Updated information received from the local authority showed the increased cost in homecare had been offset by the corresponding savings from the reduction in residential service use.

Partners told us the local authority collaborated with care providers to ensure the cost of care was transparent and fair. In 2023 St Helens offered providers enhanced rates for the payment of the Real Living Wage (RLW). Take-up across the market was varied and from 2024 rates were harmonised to single rates across adult social care. Providers were consulted prior to this change and invited to take part in a survey and engagement meetings.

Partners told us the local authority’s contracting arrangements were efficient and provided stability for providers, allowing them to plan for future service provision. Consultation and communication were through quarterly Provider Forums. These were well attended & supported by slides shared after the event with all providers. Senior leaders said they were also looking at introducing an online portal for information sharing including progress reports and quarterly returns.

Staff and leaders shared creative ways of addressing provider failures due to the lack of capacity in nursing care in the Borough. For example, one planned closure of a residential care home used a vacant service and a new provider so most people could move there and remain nearby. Staff also said they would potentially use out-of-borough placements where needed to ensure people continued to be supported. There were 8 care homes in nearby Boroughs which had previously been on the local authority’s framework who they had good relationships with. These were all within a 2-mile radius of St Helens.

The local authority was working closely with the homecare providers to reduce an historical oversupply and to redirect the spare capacity towards wrap-around and other bespoke services.

Senior leaders told us the local authority understood its current and future adult social care workforce needs. They worked with care providers, including personal assistants and other agencies, to maintain and support capacity and capability. Staff and leaders said care home managers had gone through a leadership programme supported by the local authority, and there was also an e-learning portal providers could access with lots of courses available for their staff. Data provided by Skills for Care Workforce Estimates (2024) showed a 0.19 rate of turnover of adult social care employees (all jobs, all sectors). This was tending towards a positive variation compared to the average for England of 0.25.