London Borough of Harrow: local authority assessment
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Care provision, integration and continuity
Score 2
2 - Evidence shows some shortfalls
What people expect
I have care and support that is coordinated, and everyone works well together and with me.
The local authority commitment
We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.
Key findings for this quality statement
The local authority had a Joint Strategic Needs Assessment which was an ongoing process by which local authorities, integrated care boards and other public sector partners describe the current and future health, inequalities affecting people and wellbeing needs of its local population and identify priorities for action process.
The draft Integrated Commissioning for Better Outcomes Strategy Action plan 2024- 2027 had number of overarching priorities for better outcomes for people in relation to specific groups including learning disabilities, transitioning to adulthood, mental health, increasing of market oversight to meet diverse needs, developing co-production, improving understanding of inequalities in the area and the improvement of the offer to working adults and older people.
In Harrow, people had access to a diverse range of local support options that were safe, effective, and good quality to meet their care and support needs. The strategic team worked closely with public health and business intelligence to understand the needs of the population.
National data showed that 68.56% of survey respondents living in Harrow and who used services felt they had a choice over services. The England average was 69.81% (ASCS). The local authority’s Market Position Statement dated May 2023 told us the population of Harrow had increased by 9% over the last decade and continued to grow, particularly in regard to the aging population, with people living longer with more complex needs. A key objective of Harrow was to support children and adults to live independently in their local community, supported by local agencies and community teams.
The local authority’s Market Sustainability and Improvement plan demonstrated they were aware of capacity gaps in the market. These were for suitable local placements in nursing, residential and nursing dementia, specific cultural needs and suitable provision for those with complex needs. An extra-care housing scheme was under construction, comprising of 60 additional beds which would reduce the need for out of area placements. Harrow were also working with 2 neighbouring local authorities on a supported living accreditation scheme to promote a consistent level of quality, for which the pilot had been completed.
Co-production was used to help develop the local service offer across the sector. For example, the Harrow Joint Commissioning Strategy for People with a Learning Disability and Autistic People had been developed with the involvement of people, their families and local health partners. They had helped to identify five key priorities based on what they felt were most important. Current work included developing supported accommodation, and local training and employment offers for people.
The commissioning team had held events for care providers to discuss the local care offer and to offer support to increase the range of locally available services.
Commissioning strategies included the provision of suitable, local housing with support options for adults with care and support needs and work with housing was ongoing. However, there was currently a lack of suitable housing for emergency placements, for example to facilitate discharge for homeless people who presented at hospital and needed short term care support with their mental health, rather than an acute admission.
The Carers Strategy 2023-2026 recognised the value of unpaid carers in Harrow. Services were in place to support unpaid carers including young carers in Harrow. These included education support, mental health, financial support, caring qualifications, access to information via 'carer champions’ and access to the conversation cafes.
However, some unpaid carers told us there were few supportive services available to them, and particularly noted a shortage of respite services. The local authority told us in 2022/23, 23% of unpaid carers in Harrow had some form of respite. The national data survey results (SACE) for short notice/ emergency breaks, breaks for 1-24 hours and for over 24 hours showed 12.5% of carers surveyed accessed support or services which allowed them to take a break from caring at short notice or in an emergency. The England average was 10.76%. In addition, 24.41% of carers surveyed accessed support or services which allowed them to take a break from caring for over 24 hours. The England average was 13.56%. Whilst 23.40% of carers who accessed support or services which allowed them to take a break from caring for 1-24hrs. The England average was 20.08% (SACE).
All the unpaid carers we spoke with praised the support they received from local carers support organisations. The local authority told us they wrote to carers registered on their internal data system twice a year with contact details if they needed support and to check their needs were met.
Care was commissioned in line with recognised good practice. Commissioning staff supported new approaches to developing care provision, where this led to better outcomes for people. For example, commissioners had carried out a redesign of mental health pathways with the involvement of people with lived experience, which they said offered greater flexibility to meet people’s needs.
The local authority’s Market Sustainability and Improvement plan demonstrated they were aware of capacity gaps in the market. These were for suitable local placements in nursing, residential and nursing dementia, specific cultural needs and suitable provision for those with complex needs. An extra-care housing scheme was under construction, comprising of 60 additional beds which would reduce the need for out of area placements. Harrow were also working with 2 neighbouring local authorities on a supported living accreditation scheme to promote a consistent level of quality, for which the pilot had been completed.
Co-production was used to help develop the local service offer across the sector. For example, the Harrow Joint Commissioning Strategy for People with a Learning Disability and Autistic People had been developed with the involvement of people, their families and local health partners. They had helped to identify five key priorities based on what they felt were most important. Current work included developing supported accommodation, and local training and employment offers for people.
The commissioning team had held events for care providers to discuss the local care offer and to offer support to increase the range of locally available services.
Commissioning strategies included the provision of suitable, local housing with support options for adults with care and support needs and work with housing was ongoing. However, there was currently a lack of suitable housing for emergency placements, for example to facilitate discharge for homeless people who presented at hospital and needed short term care support with their mental health, rather than an acute admission.
The Carers Strategy 2023-2026 recognised the value of unpaid carers in Harrow. Services were in place to support unpaid carers including young carers in Harrow. These included education support, mental health, financial support, caring qualifications, access to information via 'carer champions’ and access to the conversation cafes.
However, some unpaid carers told us there were few supportive services available to them, and particularly noted a shortage of respite services. The local authority told us in 2022/23, 23% of unpaid carers in Harrow had some form of respite. The national data survey results (SACE) for short notice/ emergency breaks, breaks for 1-24 hours and for over 24 hours showed 12.5% of carers surveyed accessed support or services which allowed them to take a break from caring at short notice or in an emergency. The England average was 10.76%. In addition, 24.41% of carers surveyed accessed support or services which allowed them to take a break from caring for over 24 hours. The England average was 13.56%. Whilst 23.40% of carers who accessed support or services which allowed them to take a break from caring for 1-24hrs. The England average was 20.08% (SACE).
All the unpaid carers we spoke with praised the support they received from local carers support organisations. The local authority told us they wrote to carers registered on their internal data system twice a year with contact details if they needed support and to check their needs were met.
Care was commissioned in line with recognised good practice. Commissioning staff supported new approaches to developing care provision, where this led to better outcomes for people. For example, commissioners had carried out a redesign of mental health pathways with the involvement of people with lived experience, which they said offered greater flexibility to meet people’s needs.
Staff told us there were some limits to commissioning, with some more complex cases requiring out of borough placement. However, they said usually they had care providers they could approach to accommodate people.
The social work team told us they would be overseeing placements at a new extra care facility, and they hoped this would free up some beds in nursing and residential care settings.
There had been difficulties with the new occupational therapy equipment ordering system leading to delayed hospital discharges. The local authority was working with providers to develop a wider range of services locally as part of the programme to bring people placed out of the borough back. Frontline teams were in the process of reviewing all out of borough learning disability placements to look at returning people to placements where appropriate in Harrow and in accordance with people’s wishes.
As of 31 January 2024, the local authority data, 354 people were placed out of area. Of these 116 were receiving nursing care, 153 were receiving residential care and 85 were receiving a supported living service. Reasons included, the individual’s personal preference, a request from the person to relocate closer to family members residing in another borough and insufficient care provision within the current market to meet the individual’s specific needs, such as culturally appropriate homes or specialised placements like bariatric and brain injury. Most out of borough placements were found in neighbouring boroughs.
Within mental health, the team were working with providers to develop a wider range of services locally as part of the programme to bring people placed out of the borough back. The decommissioning of the Mental Health Section 75 agreement in 2023 had given the local authority an opportunity to find out more about the local market. A Section 75 agreement allows a local authority to commission health services and NHS commissioners to commission social care. The local authority had commissioned a centre for autism and attention deficit hyperactivity disorder (ADHD) had been commissioned to support people in the community as part of the mental health pathway.
The local authority told us there were no delays for homecare, supported living or residential or nursing care due to capacity. We were not informed of any hospital discharge delays due to lack of service availability or. Any delays were due to the provision of community equipment.
The local authority monitored the quality and impact of services being commissioned, supported improvements where needed and they worked in partnership with other stakeholders including health partners.
At the time of our assessment, the Quality and Assurance team worked with 55 care homes, 54 supported living provisions and 70 homecare providers. Where people were placed beyond Harrow, the process for monitoring out of borough providers relied heavily on feedback from host local authorities regarding the quality of these services, except in exceptional circumstances when they would visit themselves.
Services registered in the London Borough of Harrow to provide CQC Regulated Activity had been rated at the time of our assessment had 4.76% and 85.71% residential homes rated as outstanding and good respectively. The nursing homes had 7.69% rated outstanding and 84.62% rated good. Supported living was rated 78.95% good and 5.26% rated requires improvement. 1.28% of homecare services had an inadequate rating, with 8.97% rated requires improvement and 69.23% of homecare services were rated good.
The local authority had not placed any embargoes on the services they commissioned with during the previous 12 months.
A team told us how they had close working relationships with each other teams, with whom they communicated regularly to share up to date information about the services they monitored. Staff told us the local authority did not always involve people’s views in their assessment of the quality of a service. For example, their quality assurance assessments of domiciliary care providers focused on reviewing records and speaking with staff but did not include any feedback from people using the service. They told us people’s views were sought by the review team during their annual reviews instead, but it was not clear how this fed into the work the quality assurance team carried out.
The local authority aimed to undertake an annual quality monitoring visit for each service. We were told by the local authority that if a provider was rated good by CQC and there had been no negative feedback shared with the council, they may not have had a visit from the local authority in up to 5 years. Staff arranged focused visits in response to issues or concerns they were alerted to, for example from the safeguarding team or complaints raised. They could not tell us what proportion of their workload was responsive rather than planned to quality assurance activity, but they indicated that a significant proportion was responsive.
This was in contrast with feedback from a community group who told us that they did not always feel concerns about care providers were acted upon robustly. One person said they raised a complaint about funded care, and they were directed to the provider with no input from Harrow. They said they did not feel this was a helpful response.
The quality assurance team held regular provider forums to share information and any learning/best practice. They also invited external speakers to forums to share advice on key areas. For example, representatives from the Home Office had attended a recent domiciliary care forum to talk about visa requirements and Skills for Care were due to attend an upcoming forum to talk about workforce training.
The local authority collaborated with care providers to ensure that the cost of care was transparent and fair. They had not had any contracts handed back relating to care homes, home care or supported living during the previous 12 months and we were not made aware of any providers who had left the market in the last 12 months.
There were 13 residential homes and 11 registered nursing homes in Harrow. The occupancy rate was of 93% and 82% respectively, with some of the vacant beds being used for respite. Most care homes in Harrow were occupied by self-funders. Harrow had a wide spread of placements across about 110 different providers, in and out of Harrow.
Most placements for bedded care, supported living and home care were commissioned as spot placements. The local authority told us they used eight providers to place ten or more people but were looking to increase its proportion of block beds for consistency. The new commissioning structure continued to support providers to maintain a high standard of service provision.
The local authority was aware that recruitment, retention, and development were essential to increase capacity and to respond to demand. The national shortage of experienced social care staff remained a challenge. Harrow were supporting national recruitment campaigns, attending jobs/career fairs, and undertaking local recruitment activities to target demographic groups and shortage occupations and roles. International recruitment is also underway.
The local authority acknowledged there was a lack of provision for people living with dementia or those with more complex needs and dual diagnosis. There were also challenges in brokering culturally specific provision at an affordable price. Providers had told the local authority they had issues providing services which meet the ethnic, cultural, and high needs and for people living with dementia.
The local authority understood its current and future social care workforce needs. It worked with care providers, including personal assistants and other agencies, to maintain and support capacity and capability.
The local authority ensured registered the providers operated a robust safe recruitment and retention processes ensuring sufficient suitable qualified, competent, skilled and experienced staff, and carrying out relevant checks. The local authority told us the training records of staff were checked to ensure staff were trained to meet the needs of the people using the service. Harrow confirmed that their procurement and contract management documents stated their requirements regarding modern slavery and the national living wage.
All registered providers were invited to the quarterly provider forums, which were chaired by a Commissioning Manager and a Provider representative. The forum discussed a range of topics such as staff retention and international recruitment.
National data showed that 49.65% of ASC staff in Harrow had started working towards the care certificate, had partially completed, or had completed it across all jobs, in all sectors (Skills for Care Workforce Estimates). The England average was 53.72%.
The local authority had a good working relationship with providers. They invested in free training and upskilling of care staff. This included working in partnership with the NHS who delivered training to providers on challenging behaviours in dementia and managing frailty. Nevertheless, the challenge with staff turnover including registered managers and deputy managers was ongoing. Some providers were using the Health and Care worker Visa scheme to address their recruitment challenges and further recruitment support was offered by the council and use of local job fairs.
There was no guarantee to homecare providers of new care packages and the local authority recognised the need to address homecare through a new procurement exercise. 52% of care staff in Harrow were on zero-hour contracts and the local authority did not pay London Minimum wage. Provision from council cost of care grant was used to uplift many placements to support sustaining the market.