Sunderland City Council: local authority assessment

Safety was a priority for everyone, the local authority understood the risks to people across their care journeys; risks were identified and managed proactively. Policies and processes about safety were aligned with other partners involved in people’s care journey. This enabled shared learning and drove improvement. Information sharing protocols supported safe, secure, and timely sharing of personal information in ways that protected people’s rights and privacy.

The effectiveness of these processes in keeping people safe was routinely monitored. Systems around quality assurance were supportive and included regular reviews and audits to maintain high standards. Staff told us about changes in practice approach such as an emphasis on face-to-face assessments and upholding human rights in mental capacity assessments which was learning implemented following a safeguarding adult review. Other safety measures were embedded in the electronic recording system such as flags that presented to staff when repeat data patterns were identified. For example, medication errors management in provider services generated specific triggers if there were more than 3 occurrences for 1 person.

Proactive discharge planning was a focus, and teams concentrated on ensuring community support was in place before discharge. Data shared by the local authority showed increases in reablement capacity. For example, in 2022/23 there were 788 periods of reablement for 684 people and in 2023/24 there were 1335 periods of reablement for 1099 people. However, staff told us that more reablement provision was needed to enable the team to get the best outcomes for people. 

There were admission avoidance projects to prevent unnecessary hospital admissions through integrated working. These complemented a larger piece of work around reframing people’s expectations of care and what options can look like, which was born from the local authority’s overarching vision and strategy. The local authority was particularly proud of the falls prevention work led by the falls lead, which significantly reduced hospital admissions due to community falls. People and staff told us about the work and the positive impact it was having. There were also hospital discharge grants to support discharge and prevent readmission. There was also a step-down unit which offered a supportive environment for patients to gradually regain their independence. For the previous year it had received 474 referrals. Outcomes following step down stay showed that 244 people were discharged home, 59 moved to permanent placements and 54 people had another hospital admission.

The local authority told us about their Care Home and Community Care Services Partnership (CHCSP). This was a forum for representatives working within the CHCSP to share experiences of collaborative working across all providers, and where city-wide solutions could be discussed, and resolutions sought from across the health and social care sector.

Care and support were planned and organised with people, together with partners and communities in ways that improved their safety across their care journeys and ensured continuity in care. This included referrals, admissions and discharge, and where people were moving between services. There were examples of collaborative approaches between adult social care, children's services, and the ICB all of which evidenced person-centered planning and tailored support plans for individuals with complex needs transitioning from children’s services to adults services. Assessments were centred around people’s wishes and needs, and staff were encouraged to be creative in their approaches to meeting needs, making innovative use of technology to support independence.

There were early intervention strategies, for example identifying and supporting young people with potential future needs and adding young people to commissioning intentions database from 16. The strategy was reinforced by a governance structure that included transition management groups with regular meetings to discuss and coordinate transition plans. We heard about strong levels of partnership working, including collaborative relationships with external partners to ensure smooth transitions. Staff told us that the transition process did not automatically end when a young person became 18, and that it often continued beyond this point for example, to allow a trial and test period for different service options, until the right support was in place.

Staff explained that most young carers were already known to their service due to joined up working and the focus highlighted to all adult social care and carers centre staff on identification. This meant that transition could commence at an early stage, or new referrals could be made by social work teams. Transition staff described the Carers Centre as an all-age service, meaning the adult carers element and the young carers element (0-25) worked together. They told us one of the challenges was working with young carers whose voices are seldom heard, or from seldom heard groups. Staff told us there were plans to make more effective use of their digital offer to young carers, enabling them to make contact out of office hours.

They also told us that the commissioning team supported them to identify and reach out to any relevant Voluntary and Community Sector (VCS) groups, such as Young Asian Voices. Another challenge was finding ways to inspire young carers during transition to set and achieve their own goals. They have worked with the college to run an event for young carers that highlights opportunities - this was successful and a number of carers that attended started college or are now employed locally.

Specific consideration was given to protecting the safety and well-being of people who were using services which were located away from their local area, and when people moved from one local authority area to another. Some teams had access to various grants which included the Home Safety Grant, Hospital discharge Grant and Innovation Grant. Staff explained the grant provision was not means tested, it was available for everyone, and they were able to use the provision creatively to support safe transitional discharge home. Staff shared a person-centred example of using the home safety grant for a person who was prone to falls and with his consent they changed the internal glass doors to solid wood doors.

A piece of research was completed by Healthwatch in 2023-2024 about people's experiences of hospital discharge. The research led to the hospital trust developing a 24-point improvement plan. The local authority introduction of more streamlined and technology enhanced review process was part of the work to support this.

Providers told us that ahead of any package moving to their service they were provided with an assessment of need, liaising, and communicating with the social worker. Where people were transferring from an existing service, and where appropriate they were invited to planning meetings, or to meet the person and their care team in their current environment, to ensure a safe and effective transfer of service.

The local authority had clear pathways detailed in their hospital discharge business process which provided a guide for staff to follow within the process. To support hospital discharge, the local authority had direct payment grants which people could access for up to four weeks and use flexibly. This approach was intended to speed up the person's ability to leave hospital and was considered by social work staff as part of the initial assessment. Staff gave examples where this had supported people to return home and maintain their dignity and independence.

The local authority had a clear process and guidance for staff to follow when utilising out of area care and support which staff said helped them to provide and source appropriate support. Staff told us the commissioning data base was used to help staff plan for people’s safe return from out of area care.

The local authority undertook contingency planning to ensure preparedness for interruptions in the provision of care and support. The local authority knew how it would respond to different scenarios; plans and information sharing arrangements were set up in advance with partner agencies and neighbouring authorities to minimise the risks to people’s safety and wellbeing.

The local authority had established business continuity plans to mitigate potential disruptions resulting from adverse situations such as widespread IT failure, floods, or pandemics. These included (but were not limited to) their safeguarding and therapy teams/services. There was a list of people, their designations and contact details for who to contact in an emergency. These details were not embedded within the business continuity plans themselves but were available to all staff. There was also a provider failure plan which detailed email addresses for people but not their job designation.

The local authority had a risk management plan with example scenarios for each commissioned portfolio. Levels of risk were attached to each scenario and possible actions to take to mitigate the risk were available. Staff were aware of this plan which was designed to support staff to make decisions and manage risk efficiently and effectively.