North Yorkshire Council: local authority assessment

People could easily access the local authority’s care and support services through multiple channels, including online and self-assessment options. People told us communication was good, and they knew how and where to access support.

National data from the Adult Social Care Survey for 2024 showed 83.01% of people who used services felt they had control over their daily life. This was better than the England average of 77.62%. 66.59% of people were satisfied with their care and support. This was better than the England average of 62.72%. And 49.35% of people reported they had as much social contact as they wanted with people they liked. This was similar to the England average of 45.56%.

The local authority’s practice model was a person-centred, strength-based, community asset approach. It aligned practice quality and outcome ambitions with the “I” and “We” statements embedded in the 'Making It Real' initiative, which is a practical framework developed by Think Local Act Personal, a national partnership to drive forward personalisation in health and social care.

The model was underpinned by investment in prevention and early intervention, and a commitment to engage people with their care and support needs, ensuring their voice was heard throughout the assessment process, and identifying the outcomes they wished to achieve through their support plan. The focus was on achieving the ambition to see more people supported to live fulfilling lives in a home of their own, connected to family, friends and their community as described in the Health and Adult Services 2030 Plan. To support its delivery, practice was underpinned by the local authority’s approach to embedding high- quality, values-led practice across its workforce, often referred to as the Confident and Consistent Practice model.

Overall people’s experiences of care and support ensured their human rights were respected and protected, they were involved throughout in decisions and their protected characteristics under the Equality Act 2010 were understood and incorporated into care planning. For example, one person told us staff explained things clearly and acknowledged their need for time to process information before making decisions. Another person said their assessment was a positive experience. They felt the social worker was working with them, as they were asked what they wanted and their opinion on areas where they needed support. They added, they really felt listened to during the experience.

Staff ensured effective triage of referrals before proceeding with assessments, working closely with colleagues, including two assessors and two staff triaging referrals on duty daily to maintain adequate coverage of incoming referrals. Recent changes made to the Emergency Duty Team availability in the late afternoon helped manage the demand on staff resources more efficiently. Two AMHP hubs were created to ensure resilience and equity for AMHPs in terms of the amount of rota responsibilities, travel time and geographical spread. It also enabled them to respond to referrals in a timelier way. Decisions on which duty staff should respond to emergencies were based on specialisms, caseloads, knowledge of the area, and available services, with staff collaborating to overcome rural travel challenges.

Staff prioritised preventative measures, working alongside crisis services and exploring onward referral options early in the triage process. For example, in rural settings, they adapted to people’s locations, utilising community taxi groups to provide affordable transport for appointments. Strong connections were maintained with GP surgeries, social prescribers, and voluntary and community sector groups, which responded well to identified resource gaps. While rural IT infrastructure remained a challenge for people, improvements in Wi-Fi and telephone signal enhanced service delivery.

Pathways and processes ensured people’s support was planned and coordinated across different agencies and services. For example, the emergency duty team had robust systems for working out-of-hours to ensure handovers were effective and clearly communicated with recorded actions taken by the team. Staff could work autonomously to put support in place for people if services were required, and they were supported by an out-of-hours manager.

Partners told us assessments were often conducted jointly with social workers and supported by the voluntary and community sector (VCS) to ensure a person-centred approach. Overall, partners felt the local authority was responsive to people’s needs, by knowing which VCS services to contact to meet people’s needs.

The local authority had assessment teams who were competent to conduct assessments, including specialist assessments. Staff were qualified in their area of specialism such as Approved Mental Health Professionals, Sensory Impairment and Occupational Therapy. Staff told us they were given many opportunities for specialist training, practice development and career development opportunities.

People told us they had not always received copies of their completed assessments and they were not always notified by the professional carrying out the assessment that they were entitled to receive a copy. They shared that if they had known this information at the time of the assessment, then they would have liked a copy.

At the time of our assessment, the local authority was actively working to improve timeliness in assessments, care planning and reviews, having identified this as a key area for development. While wait times varied across teams, the local authority had already taken steps to address the challenge, implementing clear strategies to reduce waiting lists and enhance responsiveness. Data provided by the local authority showed at the end of April 2025, 502 people were waiting for a Care Act assessment. The median waiting time was 41 days, against a target of 45 days. In 2024/25, 620 care needs assessments were completed on average each month.

A range of development work continued to target improved waiting list management. For example, a new online self-assessment tool had been launched in September 2024, informed by the national trailblazer project for charging reforms. Engagement with people with lived experience and their carers helped explore how assessment experiences could be improved and how online tools could be rolled out effectively for more people, providing greater choice, control and flexibility. North Yorkshire’s Local Resilience Forum (LRF) resilience framework was being reviewed to ensure there was an effective response to emerging service pressures, making the best use of available resources to support areas seeing most pressure. The resilience framework is a plan that helps local organisations work together to prepare for, respond to, and recover from emergencies. It focuses on six key areas: risk, responsibility, partnerships, communities, investment, and skills. The local authority had started using an early contact model to help people access support more quickly and avoid long waits. This approach allowed teams to offer timely advice or low-level support without needing a full assessment in every case. Team managers had been upskilling their Advanced Practitioners to take on more of this work, such as making triage decisions, doing proportionate assessments and planning short-term support. These changes helped reduce waiting lists, freed time for more complex cases, and ensured people felt heard and supported from the start. A workshop took place in early 2025 with a group of people with lived experience to define what a good wait looked like. The feedback was used to inform practice.

Staff acknowledged the importance of timely assessments and were committed to supporting people as fully as possible, even under significant pressure to reduce waiting lists. While some reflected on the process-driven nature of the system, their dedication remained evident. In contrast, people shared positive experiences, noting their assessments had been delivered promptly and without delay.

The local authority had identified a shortfall in completion of assessments. North Yorkshire had faced some challenges recently which affected social care services. Rising care costs and limited availability of placements had made it harder to meet demand, especially in more rural areas. On top of this, more people were needing support after leaving hospital, putting extra strain on social care pathways and sometimes leading to delays in assessments. Leaders had identified waiting times as 1 of the 7 adult social care improvement priorities. To reduce risks, leaders had implemented a ‘Waiting Well’ initiative to ensure there was a proactive approach to risk management to support wellbeing while people waited for an assessment of their care and support needs. The task of undertaking welfare calls to people on a waiting list had been delegated to staff in the reablement team, to ensure people were waiting well, risks were mitigated whilst they waited and to check circumstances had not changed. Senior leaders were overseeing waiting lists using weekly performance reporting, tracking team-level performance in progressing new referrals to assessment and the timeliness of completing new assessments, which aimed to bring timescales back in line with the 45-day target.

Data provided by the local authority showed completed annual reviews of adults’ support plans for 2024/25 totalled 4,286 compared with 3,784 for 2023/24, a 13.3% increase year on year. As at the end of April 2025 there were 2674 people waiting for a care review, with a median wait time of 119 days. These figures had significantly improved since the introduction of an insourced county-wide review team who had focused on completing residential care and nursing care reviews, with a completion rate of 72.4%. This action had expedited those reviews as workers were able to review multiple people in one care home and had significantly reduced the size of the waiting list.

The local authority did not have a target timescale for how long people should wait for their annual review. The improvement target for 2025/26 was for all service areas to progress to 70% of annual reviews being up to date. As part of an evaluation of the review team’s work and impact, they were now prioritising work on the most overdue reviews for community- based care packages. The wider work of the improvement priority was exploring the potential use of trusted reviewers and developing new guidance for conducting reviews for people placed out-of-county.

The needs of unpaid carers were recognised as distinct from the person with care needs; assessments, support plans and reviews for unpaid carers were undertaken separately. We received lots of positive experience examples from unpaid carers. However, leaders recognised support for unpaid carers could be improved further. Although more carers assessments were being carried out than ever before, some feedback showed carers didn’t always feel supported or valued. In response, leaders had expanded the carers assessment offer by including this responsibility within the Living Well team’s remit, restarted an online assessment project, and established a Carers Round Table, which all aimed to make the carers offer more consistent and meaningful. All staff demonstrated the importance of identifying unpaid carers.

The 2021 Census data indicated that 53,723 people across North Yorkshire were involved in providing unpaid care for someone. Health and Adults Services, sharing an integrated budget with Children's Services, commissioned several services and specialist support for carers. The services were a Carers Support Service which was an all-age service to support young carers, parent carers and adult carers, and a Carers Break Service which arranged for volunteers to spend time with the cared for person either in their own home or in the community. It was delivered by 3 lead voluntary and community sector providers working in partnership with 11 community-based organisations.

Data provided by the local authority showed at the end of April 2025 there were 45 people waiting for a carers assessment with a median wait time of 27 days. The target timescale was 45 days. Referrals for carer support in 2024/25 totalled 2,101, compared with 1,593 for 2023/24, a 31.9% increase year on year (508 referrals).

Partners told us support for unpaid carers was a key priority for the local authority, including through the provision of ongoing support and development of the 2 commissioned carers organisations. They were aware the local authority had discussed future contracting to ensure timely renewals with carers organisations, supporting effective planning and sustainability.

Partners were also positive about how the Living Well team recently adapted to the increasing level of demand for carers assessments, and the team was now completing statutory carers assessments. They described how the local authority was reacting to carer needs and was currently trialling a digital offer of an on-line carers assessment platform. One partner described how the local authority had recognised there were many older people who were digitally excluded and had acknowledged their work to ensure the on-line assessment was accessible and people were totally supported to use this offer.

People were given help, advice and information about how to access services, facilities, and other agencies for help with non-eligible care and support needs. Staff were knowledgeable about the prevent, reduce, delay agenda, and had embedded this into their team culture, ethos, and way of working, to signpost and advise people.

The Living Well Service provided the initial help for people to meet their non-eligible care and support needs, including carers. The service received 2879 referrals in 2024/25, with 31.7% coming from NHS partners. Staff told us they also signposted people to the care directory on the local authority’s website as well as other voluntary and universal services such as the Citizens Advice Bureau.

The local authority’s framework for eligibility for care and support was transparent, clear and consistently applied. Decisions and outcomes were timely and transparent. Appeals were managed through the complaints process.

Staff told us they ensured there was consistency in their decision making, for example, by using a structured risk assessment process to prioritise. In relation to out-of-hours calls relating to homelessness, staff used risk assessment protocols and decision-making tools when assessing housing eligibility and securing temporary accommodation. For young people transitioning to adulthood, Care Act assessments were carried out at around 17 years of age to ensure continuity of support into adulthood. Key agencies, including health services and direct payment advisors, contributed to the process.

National data from the Adult Social Care Survey for 2024 showed 62.09% of people did not buy any additional care or support privately or pay more to ‘top up’ their care and support. This was similar to the England average of 64.39%.

The local authority’s framework for assessing and charging adults for care and support was clear, transparent, and consistently applied. Decisions and outcomes were timely and transparent. The process for appeals against financial assessment decisions were handled via the complaints process.

Financial assessment processes were in place which detailed the customer journey from point of assessment, through to financial assessment, relevant payment arrangements and how to appeal. People could complete a care cost calculator online prior to a referral to Health and Adults Services.

Cost concerns were common, the online system helped simplify the process and reduce uncertainty. While financial assessments sometimes took time, they did not delay people from receiving services, as costs would be backdated from the assessment date. Staff told us the benefit of having financial assessments conducted online provided people with a quick estimate of their contributions.

One person told us their financial assessment was explained to them, and they had no concerns about finances and funding for the adaptations. They felt supported by the Occupational Therapist who conducted their financial assessment, after identifying the need for home adaptations. The outcome was a Disabled Facilities Grant being submitted for a stair lift and shower room.

Data provided by the local authority showed at the end of April 2025 no-one was awaiting allocation for a financial assessment. 127 assessments were awaiting completion with a median wait time of 2 days and maximum wait time of 4 days. The target timescale for the end-to-end financial assessment process was 10 days; performance at the end of April 2025 was an average of 10 days.

The local authority commissioned an external provider to deliver advocacy to help people fully participate in care assessments and care planning processes. The contract included provision of Relevant Persons Representatives (RPR), Independent Mental Health Advocacy (IMHAs), Care Act Advocacy, and Independent Mental Capacity Advocacy (IMCAs). The advocacy provider worked in a collaborative way with the local authority and key partners. Most recently, the advocacy provider had participated in the work carried out by a sub-group of the Safeguarding Adults Board to co-design the Safeguarding Policy.

Staff had good knowledge and understanding of advocacy services, what their role was, the benefits of advocacy and how to make a referral. Most staff were not experiencing any difficulties in accessing advocates. Staff said once an advocate was allocated to a person, the process was completed in a timely manner, and advocacy staff arranged joint visits with professionals but also met with people independently where appropriate. However, one team said they were experiencing delays in obtaining advocacy involvement for Mental Capacity Act (MCA) assessments during hospital stays, which they said prevented hospital discharges from taking place sooner. Leaders told us these situations were usually when people had complex needs or safeguarding issues, which were very rare. A refreshed practice guide had recently been shared with all staff in discharge hubs to support a shared understanding of MCA and Best Interest decisions and set out when the NHS should intervene to minimise any delays in hospital discharges.

Staff felt advocacy was particularly beneficial for people transitioning into care homes or unfamiliar settings. Advocates ensured autonomy, facilitated communication, and helped secure appropriate care arrangements. In cases where family disagreements over legal decision-making arose, advocates were appointed to protect people’s best interests and challenge actions which did not align with safeguarding principles.

The commissioned advocacy provider told us they had not been able to provide non- statutory advocacy since December 2023, due to lack of capacity, lack of time to allocate an advocate and also due to the increase in demand of service. They had also raised concerns about their ability to provide safe RPR advocacy. They had made the local authority aware of this, and measures had been put in place, with the provider sending the local authority the waiting list each week detailing the names of the people for urgent allocation. The provider used their own triage tool to manage the waiting list.

The local authority had recognised they needed to address, as a priority, the issues which the advocacy provider had highlighted. Leaders told us a full-service review was being undertaken during 2025/26 in anticipation of a re-procurement of advocacy services in the county to meet increasing demand. The local authority had implemented short and long-term investment plans to ensure the contract remained sustainable pending re-procurement. This had enabled the commissioned provider to continue with their statutory advocacy role and make in-roads into the waiting list. Local authority staff were supporting people with non-statutory advocacy wherever possible.