Gloucestershire County Council: local authority assessment

The local authority had undertaken strategic work, engaged partners and undertaken projects with frontline teams to understand local need. The local authority and partners had undertaken a Joint Strategic Needs Assessment (JSNA) which looked at health and social care needs alongside demographics data across the county to inform anticipated demand. We saw how this work, as well as data from adult social care and public health, was used to inform commissioning priorities, such as around enhancing complex care for older people in both homecare and residential settings or developing the workforce to address anticipated demographic challenges.

There was a new whole market position statement (MPS) for 2024 which set out how the local authority would respond to changes in demand as a result of changes in the population. For example, this MPS identified a need for more homecare and residential provision because of an aging population and the need to increase capacity and workforce. The local authority recognised where there were gaps in available data and their understanding. The MPS also described a lack of information about people who funded their care privately, which limited the local authority’s understanding of the demand for community care.

The local authority also carried out smaller projects to understand the local market. Staff told us about a recent gap analysis in which they looked at homecare, including complex care in the community. Through this, they identified a need to review contract length which resulted in an improved training offer to provider staff, to better support providers to deliver complex homecare in the community. The local authority carried out impact reports to understand gaps in the community and voluntary sector so they could target grant funding to these areas. They told us how they had recently targeted funding to reduce social isolation and support people to find meaningful occupations after gathering feedback from community groups. These priority areas also aligned with the priorities of public health, which showed a coherence across the local authority in this area.

People had access to a range of choices of housing and care or residential provision, but the local authority was still working to overcome gaps in homecare provision in parts of the county. We saw examples where care was delayed due to lack of provision, which was reflected in the local authority’s data of waiting times for brokerage. Partners gave positive feedback around housing and care options, but also said some areas lacked sufficient choice, such as commissioned services for social activities for people. National data from the Adult Social Care Survey (ASCS) for 2023/24 said 69.00% of people who used services felt they had choice over services. This was not statistically different from the England average (70.28%).

The local authority had set out its commissioning priorities in a market position statement (MPS) and used this to develop strategies to meet commissioning need. The ‘whole market position statement’ the local authority had recently published set out the local authority’s aims and expectations when it came to commissioning. It described plans to overcome challenges presented by the aging population in the county, including the anticipated impact on residential and homecare provision. It described an anticipated rise in demand for complex care at home and nursing care as well as workforce challenges, as people lived longer and the population of people aged over 65 grew. The MPS identified 6 core challenges and outlined 14 actions to respond to them. These included developing an all-age carers strategy, developing nursing or dementia care as well as refreshing approaches to prevention and refreshing joint approaches to housing and care models. This work was all underway at the time of our assessment but had not yet been fully implemented.

Whilst much of this strategic work was recent, there had been ongoing research into local need but we heard how the coronavirus pandemic had delayed some of this work from reaching implementation phase. The local authority had identified a need to renew commissioning strategies in response to their findings and there was work underway to address this. For example, the market position statement for people with a learning disability and autistic people was last published in 2014 and a new commissioning strategy was being worked on and due to be published after our assessment.

The local authority alongside health, housing and community partners had published a Housing with Care strategy in 2020. The strategy outlined plans to develop specialist housing across specialist groups, including development of extra care housing for older people and supported living services for working age adults. Through this strategy the local authority had implemented actions that were successfully meeting the needs of people with a learning disability and autistic people. The joint strategy focused on work with housing to develop the housing and care offer in the county, including development of more supported living. We heard from staff how these projects had increased the availability of specialist housing provision and led to instances of people moving to a more independent model of care after spending time in hospital or within residential provision. The local authority was able to meet demand for provision for people with a learning disability which meant out of area placements were rare, and usually only took place when people chose to move to a new area and not because of any shortfall in capacity.

The housing and care strategy had also led to the development of more extra care provision which helped to address challenges around community capacity and complex care at home. Leaders told us how housing could be a challenge across the county, with housing functions sitting within the district councils and housing had been an area of strategic focus for a long time. Staff and partners spoke positively about this work and we heard how it had meant people and staff had a variety of choices when looking at long term care options. Work was underway to refresh the housing with care strategy, overseen by the Gloucestershire Strategic Housing Partnership.

There was a well-established integrated commissioning model in place between the local authority and the integrated care board (ICB). The model encouraged innovative approaches to commissioning. We heard from partners, staff and leaders how work across the system enabled them to identify commissioning approaches, such as the use of technology, to overcome the anticipated increases in demand for community care alongside workforce pressures. For example, staff told us about a virtual ward initiative being jointly funded with health through the digital social care funding stream that was designed to overcome these types of challenges. We also heard examples from frontline staff of partnership working within commissioning for discharge home from hospital and finding people the right housing and care. The integrated model was well established across the ICS with an integrated commissioning director in post covering both the local authority and the ICB to ensure this work had shared strategic oversight.

Staff told us about different ways the local authority shaped the local market to ensure it stayed up to date with best practice. Staff described how the housing and care work had used best practice guidance to design services for people with a learning disability and autistic people. The local authority had recently decommissioned some residential care in order to recommission a model that would better meet current need and enable the local authority to commission services that were better designed for the use of technology, in line with the local authority’s strategic ambition.

Providers gave us mixed feedback around the local authority’s approach to market shaping. Providers spoke positively about the work the local authority had done to involve them in strategic planning through co-production and engagement, but we heard that concerns they raised were not always acted upon by the local authority and some mistrust had developed. The 2024 MPS outlined feedback from providers and presented these issues openly, but the feedback we received from providers showed they did not yet feel like issues they raised with the local authority would always be addressed.

The local authority was working to overcome challenges associated with their geography. The dispersed nature of some communities in more rural areas made it difficult to find and commission homecare because of the impact of travel time and availability of staff to carry out homecare calls. There were also specific capacity challenges around workforce in some of the urban districts, which the local authority was aware of and was working to overcome.

The local authority had recently introduced a hyper-localised commissioning model. This was a model of commissioning for homecare where one provider who is established in a small, defined local area is commissioned to deliver all or most of the commissioned care hours there, to provide better reliability to people who lived there because it intended to provide improved availability to staff. The local authority told us how the provider was commissioned for a block of hours which they used to meet local need. The local authority had also implemented this because it would improve environmental sustainability through initiatives with providers where staff used active travel such as bicycles to travel between calls.

The hyper-localised commissioning model was still becoming embedded and we did hear feedback that this had led to some challenges for providers when plans had changed in a region. The local authority and providers said they recognised the initiative was new and needed some time to develop. Despite being new, the local authority told us the hyper-localised commissioning approach had ensured that between August 2022 and October 2024, there had been a 40% increase in people receiving homecare services. Local authority data showed 26.2% of over-65s receiving homecare did so under this model.

Feedback about the level of choice and availability of care provision was mixed. We heard some people were provided with choices when planning their care, but we also heard from unpaid carers and partners that provision for unpaid carers and from community services was sometimes limited.

Local authority data on waiting times for brokerage showed 34% of people waited three weeks or longer for care across the county, with longer waiting times in certain localities. There were also concerns shared by some staff that embargos on poorly performing homecare providers were lifted too early.

There was sufficient capacity in both residential and supported living provision for people with a learning disability and autistic people which meant people were rarely placed out of county and if they were it was due to it being their choice. The local authority monitored anyone placed out of county, including the reason for the placement. The local authority prioritised overdue reviews for people placed out of county.

Whilst capacity was good in some areas, we also heard about challenges. Partners said hospital discharge was sometimes delayed because of a lack of specialist provision for people living with dementia. Staff told us about occasional difficulties finding mental health provision and shared examples of situations where people’s placements had broken down up to five times. There was strategic work to look at this as part of the integrated commissioning approach. We also heard about current initiatives to prevent placements from breaking down. For example, the local authority had a dedicated team to support providers in developing their positive behaviour support (PBS) approaches and training, to support providers of complex care.

The local authority had identified that current demand for reablement services through their Home First model was higher than their capacity. They used the hyper-localised procurement framework to commission providers from the wider market to deliver reablement to keep up with demand. However, staff and leaders told us there remained gaps in reablement provision. Leaders told us redeveloping the reablement model was a current strategic priority.

Community partners said day services and activity provision was a challenge in some areas, with people not having access to free or low-cost provision. We also heard that voluntary partners had struggles with funding, with some funding streams coming to an end. They told us how this had led to gaps in areas such as activities and essentials such as warm homes and food provision. The local authority told us they provided information to people and community partners about access to household support or warm spaces through their ‘Know Your Patch’ networks.

The local authority told us about a number of established and new initiatives with their voluntary and community sector, such as around low-level mental health support and support for people with a hearing impairment commissioned by the local authority to be delivered by community partners. Alongside this, we saw how grant funding had recently been used in areas such as to reduce isolation and improve outcomes for young families.

Data showed that 83.78% of locations within the county were rated good or outstanding by the Care Quality Commission, with 16.22% rated requires improvement and none rated inadequate. The majority of people whose care was commissioned by the local authority were using good or outstanding rated services. The local authority told us in March 2024 they had 4449 people using good or outstanding rated services, and 810 people using requires improvement rated services.

There were teams and systems in place to monitor services and we heard how a service with a requires improvement rating would be closely checked. However, people said they were not always sure where to raise provider quality concerns and that action was not always taken when people or relatives raised concerns with residential services. The local authority told us they were working to improve their processes for providers of care to people who were aged over 65, to align them with their longer-establish processes for providers of care to working age adults.

There was a disabilities provider quality assurance team, who worked closely with providers of care to working age people, and an older person’s contract management team who worked with providers of care to people aged over 65. At the time of assessment, work was underway to align these two processes because the local authority had identified inconsistencies in approach that they wanted to address.

These teams worked with locality and safeguarding teams to support providers and respond to any concerns about quality. The team carried out welfare checks or full quality visits in response to safeguarding concerns raised by teams. Providers received regular visits, with high-risk providers receiving visits at least every three months. For those performing well, risk levels were reduced, and follow-up visits became less frequent. The team also involved people with lived experience in their work and we heard how quality visits were completed by experts by experience.

There was a disconnect between how the local authority and providers understood electronic call monitoring systems worked. We heard concerns about how the local authority used electronic monitoring from every provider we spoke with. The local authority used an electronic system to monitor funded care hours to ensure they were being delivered as agreed, but providers felt this system was being used in a way that limited their ability to be flexible in how they used people’s hours and that this could impact on choice.

The local authority told us the system was not introduced to work in this way, but they had taken action in situations where significant discrepancies had been identified. The local authority told us the system would not prevent a person from using their hours differently, for example to change daytime hours to nighttime hours if a person wished to choose a different activity. We saw evidence from contracts to show that monitoring was designed to allow flexibility for people and the local authority provided examples of where it had been used to enable personalised care for people. The feedback from providers demonstrated there was an inconsistency between provider understanding and local authority intention around electronic call monitoring.

There was a visible strategy for ensuring services were sustainable, but providers faced some challenges around fees and invoicing. The local authority carried out work with providers to understand challenges in the market. We heard how commissioning processes focused on understanding a fair cost of care which considered costs for paying staff a living wage and providing sufficient training. Providers said this worked well in some areas but also that rates did not match the cost of the care they were commissioned to provide. The local authority was aware of this and told us they had considered cost of care when working out their rates. The local authority’s ‘Gloucestershire Market Sustainability Plan’ published in 2023 included a cost of care exercise which found that the cost of care was significantly higher than the cost that the local authority paid providers across all areas, but more so in their bed-based care provision.

We also heard examples of late payments to providers, including one example in which a significantly large debt was accrued. The size of this debt could only have been absorbed by a larger provider and would have significantly impacted on a smaller provider’s ability to continue operating. The local authority was aware that late payments were an issue and they told us work was underway to improve their process of paying invoices in a timely way.

The local authority had developed a Proud to Care team who worked with providers to promote sustainability by supporting them with recruitment, retention and training staff. The initiative was used to share best practice and showcase positive examples of staff proactive self-development in health and social care skills to support career development and share ideas.