London Borough of Harrow: local authority assessment

People had mixed views on how easy they found it to access the local authority’s care and support services. They could request support using a range of different methods, for example by phone, online, in writing or face to face through the ‘Conversation Café’ The Conversation Cafe was a drop-in hub where Harrow residents could meet local authority staff and other partners such as staff from the local Citizens Advice Bureau (CAB) for advice and support. Local support organisations told us some people found the pathway to gain access to support was not always clear and that they often struggled to find information about local authority services.

We received mixed feedback from people about the local authority’s methods of assessing their needs. Some people told us their assessments had been holistic and included looking at adaptations to their homes, future planning, financial advice, and signposting to other services. However, some unpaid carers said they found their carer’s assessments to have been unhelpful, unsympathetic, and financially driven. The local authority had a ‘carer lead role’ with a dedicated phone number and email address who unpaid carers could contact if they had any concerns.

Some people told us their preferences had been considered by their social worker when identifying services to support them. For example, 1 person explained how their social worker had found a local placement for them so they could still visit a family member regularly. They confirmed options had been discussed with them during a review and their personal preferences were considered.

By contrast, some unpaid carers told us they felt they were not always consulted on their loved one's assessments, and carer’s assessments were not always carried out sensitively. People also told us they often had to repeat their stories when speaking with local authority staff as they did not have a single point of contact which meant they routinely spoke with different staff each time. People also told us that assessments carried out over the phone were commonplace as opposed to face to face. The local authority offered staff flexible working hours so they could undertake face to face assessments out of hours.

National data showed that 56.10% of the people surveyed who lived in Harrow were satisfied with the care and support they received and the England average was 61.21%. 70.13% of people felt they had control over their daily life. The England average was 77.21% (Adult Social Care Survey 2021/2022 ASCS). This data reflected what people told us during our assessment.

In January 2024 the local authority introduced a new integrated neighbourhood social work team structure. The new teams were based in specific neighbourhoods which covered Central, West and East Harrow. Staff in the neighbourhood team worked locally within that neighbourhood. Each neighbourhood team also contained individual specialist sub-teams who worked across the borough.

Staff told us they believed the new structure of the teams was effective and working well. They felt they were able to respond to requests in a timely manner, which allowed them to work closely with the same people as and when they needed. They hoped in time as the new structure took effect, this would also reduce the need for people to repeat their story.

When an initial referral was received by the local authority, this was allocated to a neighbourhood team to undertake the assessment. The referral was triaged using a Red-Amber-Green (RAG) rating system according to risk and priority. This enabled the teams to respond quickly to people identified as being at most risk, whilst lower risk referrals were transferred to a weekly allocation list to be picked up when staff were available to do so. Staff told us that once a referral had been RAG rated at the point of triage, they would only review that priority rating if someone contacted them again to report a change in the person’s condition. This meant there was a risk of a delay in carrying out an assessment of a person who had been triaged as at low risk if their health declined further while they waited to be assessed. Senior leaders told us that welfare calls were made on regular intervals to people and their carers who were on low risk. This was to check their well-being and ensure their needs had not changed.

The ‘three conversations’ assessment model was first introduced and used in Harrow in June 2019. This nationally recognised model, is used by social workers to identify and understand people’s care needs, helping them to support people to remain at home wherever possible, replacing the traditional assessment for services approach.

We heard that some social workers found the process of using this model to be time consuming when in some cases a simpler process could enable people to receive the support they needed more quickly. They suggested that conducting the three conversations model over three visits took too long to identify solutions and carers had asked for a simpler process. This had been acknowledged by senior staff who supported the social work teams to take a flexible approach when assessing people’s needs, move away from that model where appropriate.

National data showed that 40.26% of surveyed people who lived in Harrow reported they had as much social contact as they desired. The England average was 44.38% (ASCS). People we spoke with did not raise any concerns regarding their level of social contact. One person told us how their current placement was meeting their needs well and that they felt much safer than they had been prior. Their health had improved, they received support to maintain their independence and they no longer experienced social isolation. Warm Hubs were introduced to address social isolation but were so successful they had also been used as citizen’s forums to record people's feedback and influence change.

Some people gave us examples of how their experiences of care and support ensured their human rights were respected and protected, they had been involved in decisions and their protected characteristics under the Equality Act 2010 were understood and were incorporated into their care planning. For example, 1 person told us about the options they had discussed during their review and how their personal preferences were taken into account regarding a change in placement.

Interpreter and translation services were readily available to support teams and people when working with people for whom English was not their first language.

There were clear pathways and processes to ensure people’s support was planned and co-ordinated across different agencies and services.

All staff undertaking assessments were competent to do so. The specialist teams were utilised by the wider social work staff group for their knowledge. Training and development opportunities were available for staff to support their skills and development. Some frontline staff were being trained to become ‘trusted assessors’ which would enable them to undertake basic occupational therapy assessments to help reduce occupational assessment waiting times for people. This enabled the occupational therapists to support people with more complex needs.

The local authority’s data showed that requests for support were responded to in a median average of 1 day (next day) at the first point of contact over the past year, however the longest actual waiting time over the past year was 258 days. For Care Act (eligibility) assessments to begin if required, the longest actual waiting time over the past year was 76 days (11 weeks) and it was expected that this would be the longest waiting time for people currently waiting. The target timescales to begin work at the first point of contact was 5 days.

A new borough wide planning and reviewing team had been introduced to help tackle a backlog of incomplete annual reviews. The local authority’s target was to complete 75% of reviews by the end of March 2024. Annual reviews were scheduled using a traffic light system to understand which reviews were due.  Staff told us the approach of having a dedicated reviewing team was working well and had been driven by the desire to improve quality. National data from Short and Long-Term Support (SALT), showed 67.66% of people living in Harrow who had long-term support had been reviewed (planned or unplanned). The England average was 57.14%.  Some people we spoke with told us their requests for reviews had been responded to in a timely manner.

Whilst people were waiting for an assessment, they could be provided with information, advice and signposting to relevant services and support from Access Harrow and other voluntary and community organisations. These provided advice and support to people which covered a range of different areas, including housing, finance management and healthy living, as well as connecting people to community activities and groups.

The local authority had a waiting list for mental health reviews which they were seeking to address. We were told there were additional requirements staff needed to do when mental health referrals for assessments were made which were not required for people who did not have mental health needs. This was an inequity in processes, as the additional checks and information requested was not required for people who did not have mental health needs. This made the review process more challenging.

They had reorganised the mental health team after it had been brought back in-house, following the termination of the section 75 agreement of the Care Act 2014. Staff told us the restructure had helped improve workflow, although it was now harder to access information about people’s needs held by the NHS. Senior staff were aware of this and were working to address and resolve the issue.

The local authority’s expected wait time for care assessments from hospital (new people with no prior care packages) was 7 days. Once people had been discharged from hospital, they could expect to wait approximately seven weeks from the point when the hospital social work team ended their involvement and the start of any post-discharge assessment work carried out by the neighbourhood teams. People could then expect to wait between 3 and 4 weeks for a full care Act assessment to be completed, where needed, following a referral from the social work team. The neighbourhood teams were working to reduce this time.

The local authority told us people would receive a bridging service for 1 week then receive reablement service for up to 6 weeks during this period. A Care Act assessment would be completed if there was a need for long term or if the person’s needs could not be met in the community.

One person told us they had experienced a delay in discharge from hospital of approximately 3 weeks in 2023, this was due to their previous placement no longer meeting their needs and their social worker having to find a more suitable placement for them, although they felt the social worker supporting them worked hard to support them to be discharged as quickly as possible. 

The local authority’s website contained specific information for unpaid carers, including how to request an assessment. There were also many other routes for people to be identified as carers and to request an assessment, for example through their GP and council staff and voluntary sector organisations, using the Making Every Contact Count (MECC) tool designed to help identify when people needed support through everyday conversations. Young carers were identified by the local authority working in partnership with schools, further and higher education institutions and there were specific young carers support groups.

The local authority recognised the needs of unpaid carers as distinct from a person with care needs. They had clear internal process guides for staff relating to the assessment of carers. Social work staff undertook assessments, support plans and reviews for unpaid carers and a new Borough Partnership Carers Strategy was launched in 2023, to deliver specific objectives to unpaid carers.

Access Harrow screened all referrals made to the local authority with a view to identifying any unpaid carers and offering them a carers assessment. Social workers told us they also asked people about whether they received support from an unpaid carer as a standard part of their standard assessment process. The local authority told us they aimed to ensure at least 75% of carers in receipt of services for more than a year received an annual review, which placed some carers at risk of never receiving a review if they were repeatedly one of the 25% who may not be reviewed during a year. It was not apparent what mechanism was in place to prevent this happening. National data showed that 29.27% of carers in Harrow were satisfied with social services. The England average was 36.27% Survey of Adult Carers in England (SACE).

In February 2024, the local authority identified 44 unpaid carers as having received support as a carer for more than 1 year, who had not had an annual review. Staff told us this had been identified by an audit, which had in turn led to increased staff training. This shortfall was reflected in what we heard from several unpaid carers, who told us they had either not been offered an assessment, or they had had one several years ago but had not had any kind of a review from the local authority since. Most unpaid carers we spoke with had been waiting over 6 months for a review, with the maximum being 5 years. Of those unpaid carers waiting for a review, the local authority said they did not have tracking in place to go back to previous years in order to calculate exactly how long unpaid carers without outstanding reviews had been waiting.

Only 1 unpaid carer we spoke to had a contingency plan in place for their loved one in case something happened to them. None of the unpaid carers we spoke to told of improved health outcomes following their carers assessment.

Staff told us they believed many unpaid carers received support from voluntary groups directly, so had not sought support from the local authority. Some of the carers support groups were commissioned by the local authority to support unpaid carers through a range of services including support to maintain their health, wellbeing and resilience, support with completing forms, access to preventative support and benefits advice.

National data showed that 38.46% of carers in Harrow had access to a support group or someone to talk to in confidence. The England average was 32.37% Survey of Adult Carers in England (SACE).

The local authority told us they now wrote to people’s carers who were known to them as unpaid carers, twice a year; to check their whether needs were still being met. Local authority leaders said they were aware of the need to improve their support for unpaid carers in Harrow. The local authority was addressing this in several ways, including reviewing the assessment process for unpaid carers, and learning and acting on intelligence identified in case file audits.

There were multiple points of entry for people to access care and support, which was triaged through Access Harrow. Once people were screened and deemed to have non-eligible care and support needs, they were given advice and information for community resources, where appropriate.

The local authority had a ‘determining eligibility’ process in place in line with the Care Act 2014, Care and Support Statutory Guidance. If people were dissatisfied with decisions made, there was a clear adult social care complaints procedure available for them to follow.

Voluntary and community groups told us people sometimes felt that reviews of their care were used as an opportunity to reduce the amount spent on their support. One unpaid carer with multiple caring roles told us they had a review where they were told the purpose was to reduce their personal budget. They said respite care had been reduced and they had to raise a complaint with the local authority to eventually have this reinstated. We were not clear if the local authority had any understanding of their decisions in relation to people’s ethnicity. We did not see if the local authority held information to show where people may be at risk of having inequity in access.

The local authority told us the role of the panel was to ensure that professional practice complied with their statutory obligations and ensure delivery of the most appropriate, personalised outcomes for the person and the carer. The social worker worked closely with the person and unpaid carer to explore and agree the most viable and appropriate options, which was the presented at panel. Any challenges on decisions made were reviewed with the person and unpaid carer.

Concerns were raised by people about the funding panel. People were not always confident their views would be heard by the panel. They expressed that they believed they should be involved in it themselves, given the impact the decisions could have on them. They described barriers to seeing the assessments that panel reviewed and felt they were excluded from the process in some cases. Local authority staff said this was something that has been escalated before and staff had been reminded to always share assessments with people and unpaid carers before a panel presentation.

We were told by an unpaid carer that when they were struggling with providing care, there was not always funding available to increase package of care. National data showed that 60.71% of survey respondents who receiving support from the local authority in Harrow did not buy any additional care, or support privately or pay more to 'top up' their care and support. The England average was 64.63% - Adult Social Care Survey (ASCS), for England.

The local authority told us they did not monitor the length of time people waited for their financial assessments to be carried out and that they were not aware of any local or national target timescales relating to their completion.

Between 28 September 2023 and 30 January 2024, the local authority received 28 appeals from people against their assessed contribution, 9 of which resulted in a reduced contribution. People’s grounds for appeal covered a range of themes, including the person requesting more support than offered to meet the identified need, the cost of care to the person arising from the outcome of financial assessment contribution, the person disagreeing with the type of service offered i.e. care home, extra care support and the person disagreeing with the reduction of care provision where an assessment has deemed this appropriate.

We spoke with one person who said they had submitted everything that had been requested by the local authority for a financial assessment, but it seemed to be taking a long time and they were now worried about the delay.

A community group who supported people with issues including support with benefits and debts highlighted the amount of people in financial difficulty due to delays in completion of financial assessments. For example, where people had started to receive care before the financial assessment was completed, and subsequently found it to be unaffordable. Some people had received correspondence relating to their financial assessments without contact information in case of queries or concerns. Senior staff confirmed they were aware of the error were addressing the issue.

Timely, independent advocacy support was available to help people participate fully in their care assessments and care planning processes. An advocate can help a person express their needs and wishes and weigh up and make decisions about the options available to them. They could help them find services, make sure correct procedures are followed and challenge decisions made by local authorities or other organisations. A commissioned statutory advocacy support service had been provided by Community Connex across the borough since 2015. In 2023, they had carried out an engagement exercise with over 100 social workers to promote their service and increase understanding of their role. The service subsequently saw an increase in referrals, leading to more people receiving support from an advocate in the borough.

Local authority staff gave positive feedback about the advocacy service. They told us it was easy to access, and they recognised the importance of advocacy when dealing with complex family dynamics.