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Somerset Council Adult Social Care Preparation for Assurance peer challenge report

Feedback report: March 2024


Executive summary

The peer challenge found innovative practice in Somerset’s Adult Social Care service, strong performance in key areas of delivery, and commitment, culture, and values to support and extend this work. All those with whom the peer team met were enthusiastic to talk about their work, and open, honest, and frank about areas that are challenging or where they would like to see change or improvement. All of this represents a strong foundation for ongoing improvement and development.

The financial challenges affecting Somerset are well-documented and require difficult decisions to be taken at present and over the coming months. Whilst frontline delivery of core and statutory adult social care functions is protected, there will nevertheless be an impact from reductions in management and support functions (including across the wider council), future commissioning decisions around provider and other resources, and how uncertainty and additional processes will impact on staff energy and motivation. These impacts will need to be recognised, and built into existing plans as risks or mitigations, or where relevant as changes (to timescale or scope) and including through realistic prioritisation of transformation and improvement work.

The ambition and vision of the new unitary council needs time to be fully realised, for instance around community engagement and capacity, or integration or collaboration across wider service offers. Further work to develop corporate partnerships can support adult social care AND the wider work of the council, but this will need time to bed in and prove itself. Maintaining momentum and energy for this further development, or to consolidate existing gains, may be a challenge given the present financial situation and consideration should be given how to mitigate this, perhaps focusing on some concrete deliverables, including for instance the development of a shared housing strategy.

There is considerable ambition in the adult social care service in Somerset, and support to its development and improvement; this was demonstrated through the challenge in meetings with elected members, staff, senior managers, partners, and people with lived experience. This ambition could benefit from clearer articulation, and further clarification in terms of performance, outcomes, and the impact of any developments, and how these are felt, and owned, across the whole council. Finding ways to develop greater consistency across areas of strength (in delivery or leadership) can support improvement in those areas of performance that may be less strong; and showcasing positive stories may help to maintain motivation and energy for the necessary change. Prioritisation across key development or improvement areas could offer opportunities not only to prove their benefits, but also for “quick wins” which can build motivation, perhaps especially important when some challenges may feel or appear intractable.

The challenge found passionate, experienced, and committed staff and senior leadership which can be a huge asset for the council. However, there is also a potential risk in relying too much on strong individual leadership, perhaps especially at a time of acute financial pressure such as the council is presently experiencing. Finding ways to systematise and “diffuse” key knowledge, experience, or expertise, across a wider pool of staff, or in more standardised processes, would help to mitigate risks relating to the change or loss of key individuals within the management structure.

The challenge heard of strong partnerships with the local provider market, the Voluntary and Community Sector (VCS), and with the NHS, and there is a good foundation for coproduction. All of these can be used as a support for improvement, as well as to work collaboratively to address the financial challenge; market shaping development and links with the transformation plan will be of particular importance in this regard.

Background

Somerset Council (The council) requested the Local Government Association (LGA) to undertake an Adult Social Care Preparation for Assurance peer challenge within the council and with partners. The work in Somerset was led by Mel Lock, Director of Adult Social Care at the council, and supported on-site by a dedicated team.

The LGA was contracted to deliver the peer challenge process based on its knowledge and experience of delivering this type of work for over ten years. The LGA sourced the members of the peer challenge team and provided off-site administrative support.

The council was seeking an external view about the preparation and readiness of the Adult Social Care Directorate for the arrival of the Care Quality Commission’s (CQC) Local Authority Assurance inspections; as well as to inform their wider improvement planning.

The members of this Adult Social Care Preparation for Assurance peer challenge team were:

  • Hilary Hall, Corporate Director, Community Wellbeing, Herefordshire council.
  • Councillor Steve Darling, Torbay Council.
  • Kayleigh Bradford, Principal Social Worker, Commissioning, Devon County Council.
  • Juliette Garrett, Head of Commissioning – Older People, Adults and Health, West Sussex County Council.
  • Dan Wilkins, Head of Adult Social Care Transformation and Quality, Wiltshire Council.
  • Cheryl Hampson, Head of Quality & Performance Adult Social Care, Gloucestershire County Council.
  • Peter Fairley, Director for Strategy, Policy and Integration, Essex County Council.
  • Chris Rowland, challenge Manager, Local Government Association.

The team was on site from 5th – 7th March 2024, following supported access over two days earlier in February to carry out case file audits. The programme for the on-site phase included activities designed to enable members of the team to meet and talk to a range of internal and external stakeholders. These included:

  • interviews, focus groups, and discussions, with councillors, people with lived experience, managers, practitioners, frontline staff, and partner representatives; in total over 40 meetings were included on the timetable, and the team gathered views from over 150 people within these.
  • preparatory work including a bespoke case file audit covering 22 case files, and reading documents provided by the council both in advance of and during the challenge; this included a Self-Assessment of progress, strengths, and areas for improvement and more than 30 documents.

The findings and recommendations in this summary report are based on the presentation delivered to the council on 7th March 2024, and should be read with reference to it. The supporting detail and recommendations that it contains are founded on a triangulation of what the team have read, heard, and seen. All information was collected on the basis that no recommendation or finding is directly attributed to any comment or view from any individual or group; this encourages participants to be open and honest with the team. The report covers those areas most pertinent to the remit of the challenge only and has been structured around the CQC themes as confirmed by the CQC in November 2023; the challenge team grouped evidence with reference to these questions, and this report is structured around them. They are:

Care Quality Commission Adult Social Care Assurance Themes

1: Working with People

Assessing needs

Supporting people to live healthier lives

Equity in experience and outcomes

2: Providing Support

Care provision, integration and continuity

Partnerships and communities

3: Ensuring Safety

Safe systems, pathways and transitions

Safeguarding

 

4: Leadership

Governance, management and sustainability

Learning, improvement and innovation


Peer challenge is not an inspection, and it does not deliver a formal judgement; nor does this report suggest a definitive response against the CQC themes. Rather it offers a supportive approach, undertaken by ‘critical friends’, and an overview of key findings, with the intention of supporting the council to form its own view, and to continue its improvement journey where necessary. It is designed to help to assess current achievements and areas for development, within the agreed scope of the challenge. It aims to help identify the council’s current strengths, and examples of good practice are included under the relevant sections of the report. But it should also provide the council with a basis for further improvement in a way that is proportionate to the remit of the challenge, and recommendations where appropriate are included within the relevant sections of the report (as well as highlighted in the Recommendations section at the end of the report).

The peer challenge process offers an opportunity for a limited diagnostic approach to material which is provided (whether through written materials, or through on-site interviews, focus-groups, or observations), as well as a critical appraisal and strategic positioning of this. It reflects a balance of views within the team, based on their experience, and the material made available to them. However, the level of “assurance” (whether of quality, outcomes, or good / poor practice, etc) which can be provided through this format is strictly limited. A peer challenge, whilst intensive, is not comprehensive. peer challenge is not therefore an alternative to inspection, or indeed to routine or exceptional internal quality assurance, and the council is strongly encouraged to continue such work, hopefully informed by the findings of the challenge.

The LGA peer challenge team would like to thank councillors, people with lived experience and carers, staff, and representatives of partner agencies for their open and constructive responses during the challenge process. The team was made very welcome and would in particular like to thank Mel Lock, Director of Adult Social Care, who sponsored the challenge and Niki Shaw and her team for their invaluable and excellent support to the peer team, both prior to and whilst on site.

1. How the Local Authority works with people

Assessing needs: We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Supporting people to lead healthier lives: We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce future needs for care and support.

Equity in experience and outcomes: We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response.

  • I have care and support that is co-ordinated, and everyone works well together and with me.
  • I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.
  • I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally.
  • I am supported to plan ahead for important changes in my life that I can anticipate.

Quality statements and I-statements from the CQC Interim Guidance for Local Authority Assessments, November 2023

Somerset council h a strong focus on prevention, early help, neighbourhoods and communities; this aligns well with both strategy and the vision of the new unitary authority. This strong prevention approach supports demand management and enables choice, is supporting service delivery and reducing long-term need, enabling people to access community resources, and building community capacity. It is underpinned by an ambitious wrap-around equipment, technology enabled care (TEC), and Somerset Independent Living Centre Strategy, and supported by the Voluntary and Community Sector (VCSE) and wider communities. Whilst the prevention agenda is well developed, the peer team felt it was important to acknowledge that it is potentially at risk given the financial context, and ongoing work to prove impact and outcomes will be important to protect these gains over the coming months; any opportunities to look at return on investment, cost benefit analysis, or positive evaluations of work providing good outcomes for people and communities should be explored.

The prevention and community offer provided, promoted, and delivered through the Somerset Independent Living Centres (SILCs), Connect Somerset and micro-provision are a significant area of strength in Somerset, providing choice and flexibility. The strong relationships between the independent living centres, village agents, micro-provider networks, and wider VCSE is enabling people to live independent lives. This work is further supported by the focus on empowering staff to promote early intervention to help prevent, reduce, and delay future care needs, as evidenced by the high rate of people (60%) provided with information, advice or guidance when first making contact with the council. In addition, the Occupational Therapy (OT) Strategy focusses on triage and the use of independent living centres and advanced practitioner roles; this has seen the OT waiting lists reduce, and provides choice to people and their families, and quicker outcomes to support independence for longer.

Whilst the prevention offer is strong, it was suggested to the challenge team that the public are unclear about the offer since it’s not been communicated in a way that makes sense to them. There is a perception that different parts of the offer are not connected and with feelings of duplication, with similar messages coming from Health and Social Care but not joined up, and a general sense that the communication and engagement approach could be improved. Some work to align (maybe rationalise or join up where necessary), describe, and communicate the offer better and more widely, both within and outside the council, could therefore bring further benefits in use, outcomes, and perception.

The Customer Contact Centre has one number and uses artificial intelligence (AI) to support the public to navigate to the right place. There is the option for enquiries to be escalated without waiting if someone is in crisis (e.g. for carers or for people with increasing or urgent mental health needs) and this system is receiving positive feedback. The use of prompt sheets developed with services is ensuring consistency of approach and helping with customer journey. Where people are signposted to information, advice, and guidance, the customer contact centre follows up one week later to check this met their outcomes; this is good practice, and important to prove the benefits of this frontline service. However, there may be an over-reliance on the Customer Contact Centre to provide information: navigation of the Somerset council website to find information and to help people to self-serve is reported as challenging; there are numerous public website directories for information; and there were reports that the online assessment can take too long and cause delays. Opportunities for streamlining these systems would make information easier to find, thereby providing and promoting better opportunities for people and their families to self-serve, and this should be a priority.

There is a good foundation for coproduction, with the Working Together Board established as a forum to develop improved engagement, communication, and ultimately coproduction. It will be important to ensure that this is joined up to wider processes and “sites” of engagement or coproduction, as well as the wider transformation programme, and with governance arrangements to support this. More generally across the challenge the team heard of opportunities for people to feedback, a sense of taking account of what was said, and areas of coproduction across wider parts of the service. Overall, whilst there is work to do in this area, the challenge team heard and saw strong commitment and energy to push forwards on this journey, and values, culture and approach in key elements of delivery (e.g. direct payments and care planning) that evidence an openness to the expertise gained from lived experience.

A Carers’ Strategy has been refreshed and co-produced with carers, and is about to be published, and this will be overseen by the Carers’ Strategic Partnership Board. The council’s recognition that support for unpaid carers should be a priority has led to the development of this joint strategy, with the ambition to address waiting lists, information and advice, and access to respite support. There is a desire from carers to have their voices heard and to be seen as a stakeholder within planning for services, including considerations around the impact of any changes or decommissioning of services. The challenge team heard that transparency from the council in showing service costs and risks allowed carers representatives to inform changes and improve service delivery and financial stability. Consideration could therefore be given to how Somerset utilise arrangements such as the formation of the Working Together Board to support a “no surprises” culture, so that carers are able to influence areas of work which impact them, and to ensure valued involvement within discussions and processes.

There are still some challenges for carers at the present time, and it was noted in evidence documents that carer satisfaction from surveys was comparatively low in comparison to other areas. Many carers don’t identify themselves as such (and the council is actively working to address this, for example, providing free parking for carers in hospital, information through libraries, and support for adult carers of people with mental health issues). There was positive work with carers when they contact the Customer Contact Centre, and an understanding of the pressure they may be under, with priority given to those calls (instead of the 30–40-minute wait when busy). However, it is not evident that support and priority (and therefore positive experience) is consistent when carers are transferred to teams for assessment or ongoing support: waits can be long for assessment, and carers reported that such delays add to the pressures they feel, increasing the risk of carer breakdown (and with resulting detrimental impact for people who use services). Similarly, carers reported that follow-up after triage and assessment is an area for improvement as they can feel forgotten; more work to consider universal supports and options for carers whilst they are waiting for assessment might be beneficial, as well as ongoing communication post-assessment.

The challenge heard that there is lack of clarity for carers on what will happen to the person they provide care for when they as a carer have an emergency. Emergency arrangements weren’t clearly understood, and carers may not be aware of their legal rights, and there are risks around carer breakdown that could be missed if carers do not identify themselves as a carer or don’t have a plan for what might happen if they are unable to care. Carers reported that the respite offer could be improved, and it appeared that there may be insufficient market options around respite (the challenge team heard of attempts to provide short term crisis accommodation, but that this was sometimes “blocked” by ongoing needs), and the council should assess whether the existing respite offers adequately meets the needs of those with a lived experience and their families for holistic support. Despite the hospital team working to identify and support carers, the challenge team heard from carers about a lack of awareness (from both carers and health professionals) of important forms such as hospital passports which impact the receipt of support in hospital. Therefore, further work with carers and partner agencies to raise awareness and improve outcomes for those in need of assessment and support could be helpful in this important area and offer wider benefits in terms of preventative support to those who use both health and adult social care services.

Notwithstanding the above, other examples of good and innovative practice to support carers were found. Somerset’s Open Mental Health project for carers is identifying and supporting adult carers of people with mental health needs; this is a really important enabler for good outcomes and is essential in ensuring that people with mental health needs and their carers are being well supported in the community. More widely, the Open Mental Health Alliance appeared to be very positive and its impact could be made even greater if it was promoted across neighbourhoods. Carers Champions in General Practice (primary care) are identifying and providing support for carers, seen as a really positive approach given that GPs are the gateway to public sector services for a lot of people, and the strong evidence about the importance of primary health care working in partnership with social care to meet needs.

Somerset Council’s proactive approach to equality is developing a strong culture of inclusivity within the organisation and more widely. There are good examples of the use of Equality Impact Assessments (EqIA) when new services are being developed and a strong relationship between the council and VCSE organisations. However, during the case-audit, it was identified that staff are not always completing protected characteristics in individual’s demographic pages, and this will need to be addressed as part of the council’s equality, diversity and inclusion (EDI) work. The importance of information being made available in an accessible format in a timely way, including for people who are visually and hearing impaired, was also noted.

Somerset is performing very well in its delivery of direct payments, for which its performance places it as one of the leading councils in the country. This is achieved through a well-developed approach to supporting choice for people at the interface between operations, commissioning, and the locally commissioned support organisation Enham; through good governance around managing the financial risks; and through strong leadership and culture promoted across the council teams. Micro-providers within Somerset are well established, and are seen as good practice nationally, with the council leading a national community of practice. And whilst some concerns were raised about adult social care operations teams understanding of how to access information about micro-providers, and their strengths and limitations, it was felt that this was an area that could be relatively easily developed, perhaps alongside some standard operating procedures in relation to direct payments.

There are high waiting lists for Social Work, Carers Assessment and Occupational Therapy (OT); this is causing delays (and concern) in people receiving assessment, and in the subsequent procurement of care. In addition, there are delays in processing the online referral form (up to 5 days reported) from the Customer Contact Centre. Overall, it was unclear where the delays were best described (i.e. assessment or support planning stage), and different approaches to triage across teams at neighbourhood, community and countywide teams were identified. The peer challenge team acknowledged the work to reduce the risk of people waiting and to offer alternatives (such as SILC), and that this work is having a positive impact, with reduced levels of people waiting for care. Nevertheless, the team would suggest that these assessment and review delays would benefit from further investigation and that ongoing management will be needed.

Teams are passionate about, and focussed on, providing good outcomes for individuals, and there is strong evidence of an outcome-based approach being developed within the council. In the case file audits there were examples of good use of goals to support people who use services to achieve positive outcomes. This included the use of contingency plans to support people in the community rather than admit them to hospital.

This ambition and strong performance could benefit from clearer articulation, and further clarification in terms of performance, outcomes, and the impact of any developments, with clearer understanding of targets and performance at a team or practitioner level. A more granular approach can develop greater awareness and ownership of the performance and improvement journey and help to develop greater consistency between areas of strength (in delivery or leadership) and those areas of performance that may be less strong. There was a concern within the challenge team that key staff within the organisation lead (and are depended on to deliver) strong performance, with a risk therefore of “multiple single points of failure”. Whilst celebrating the fact that staff within the organisation have good knowledge and understanding of their services and processes, and champion improvement and performance within these, there is a risk that if these are not turned into clearly articulated and “business as usual” processes, then if an individual staff member leaves, changes role, or is absent for an extended period, this knowledge and leadership could be lost or at least reduced.

2. How the Local Authority provides support

Care provision, integration and continuity: 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. 

Partnerships and communities: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement. 

  • I have care and support that is co-ordinated, and everyone works well together and with me.

Quality statements and I-statements from the CQC Interim Guidance for Local Authority Assessments, November 2023

There was evidence of an understanding of the profiles of communities across Somerset and of emerging challenges with demographics and population changes. Teams mentioned available data and information through Power BI and this information is evidently used in the Adult Social Care Strategy, the Commissioning Strategy and the draft Market Position Statement. These form the key documents for identifying priorities, and include increases in numbers of older people, in dementia prevalence, and in the age-profiles of adults with learning disabilities.

The peer challenge team did not, however, feel able to develop a clear understanding of what Somerset’s market shaping strategy is; there is a lot of information that identifies a significant number of intentions, and the data could be better used in support of these. Currently, for example, the Commissioning Strategy states: “our future forecasting based on our demographic profile shows us that by 2040 the Local Authority will need an additional 290 Residential Care beds and 266 Nursing Beds” (p28); but alongside a transformation plan centred on reablement and with targets to see “82 fewer Older Adults entering a residential placement per year” (MLMF Programme Pack); this could be confusing to developers, planners and care providers as to what is required to meet the health and care needs of people and communities now and in the future. There is a lot of ambition, and lots of plans for recommissioning, but it was unclear what the key priorities for development are: for example, the council could more clearly set out where it needs more or less market capacity, both in terms of type of care (e.g. residential, homecare etc) and in terms of geography; and consideration could be given to ensuring the ambitions in the transforming care plan are incorporated into other strategies, and how this can be communicated. There are plans to publish a refreshed Market Position Statement (MPS) which could support an understanding of priorities; focusing these on the intended audience and ensuring consistent communication, particularly to the market, will be important. Providers weren’t clear on this, and whilst there was an understanding that an MPS is being produced, it was not felt to have been co-produced, and some were not aware of what it might include in terms of priorities. Working closely with the market to develop the MPS and ensuring really clear and concise messages about priorities (that are achievable and realistic) will be important to avoid confusion, duplication with what the Commissioning Strategy is saying, and to enable a clear direction of travel.

Somerset has identified some areas for further market development that will be required for the future as the needs of the population change, for example, nursing and dementia, and support for people with a learning disability as they get older. With an ageing population, there will need to be a focus on demand management and a continued focus on prevention to mitigate the challenges. Planning and preparing for people approaching adulthood will be an important consideration for future market capacity, requiring closer working with Children’s Services and SEND, particularly around transport, respite, and housing provision. The transformation plan focuses on this area, as well as on reducing the focus on learning disability residential placements and implementing an improved reablement offer; and these are perhaps key priorities to draw attention to in the market position statement, in communications with providers, and in partnership with other council departments. In general, there are likely to be opportunities to further improve how the council shapes the market to meet complex needs, and the new unitary arrangements can support this, including notably around housing.

A clear approach to accommodation with support as part of a wider Housing Strategy will support ambition and opportunities in this area. Housing options can be limited and there are some known areas of geographical challenge, including in Bridgwater and Burnham. There is more to be done around market shaping and housing strategy to provide a range of solutions across the county, including key alternatives to residential care such as specialist housing and adapted accommodation for complex needs, supported living options, and Extra Care. It was acknowledged that adult social care and Housing are looking at opportunities for developing housing either in-house or via trusted providers, and identified opportunities for Disabled Facilities Grants for innovation to help people remain at home; but also that adult social care was delaying the recommissioning process for Extra Care to ensure opportunity for housing input. Extra Care wasn’t mentioned for people of working age, but examples of how this can provide a real viable alternative providing choice and control are available, for people with a learning disability for example, and learning from other areas on this may be useful as part of an accommodation strategy.

Regarding care homes there was an ambition from Commissioning to develop evidence packs to inform planning for housing, particularly to guide what provision is required and where (and conversely where it may not be). This has not yet developed, but housing as mentioned above is an essential part of providing a varied and resilient market for the future; using data and information to inform the development of a Housing Strategy and clear messages on accommodation requirements, with evidence to support this on a local level, could have a positive benefit in market shaping. The ambition to use the opportunities presented by the unitary structure were clear, and supported by commitment from Elected Members, and this would benefit from being a priority focus with an action plan and timelines. This was seen by the peer challenge as a key consideration for improvement, allowing better links to planning to develop the accommodation that is needed: flexible and adaptable to support complex need; developed in the right areas and to avoid reliance on any specific type of provision; and not reliant on an individual social landlord (as was identified in Learning Disabilities accommodation).

The micro-provider market is thriving, and there are impressive increases in Direct Payments, and the passion with which people talk about this area of provision is clear. There is more work to be done however, at the interface between this sector and more formalised care offers which support higher levels of regulated care. In particular it was mentioned that there are workforce tensions where home-care organisations experience staff leaving to set up alone as a micro-enterprise, or where the tasks they are focused on are more complex (regulated personal care) but with a lack of balance of activity for their staff, as lower-level tasks such as shopping and companionship are picked up by micro-providers. There are some risks, therefore, in the market around reliance on micro-providers, the sustainability of more formal care provision, and the dynamics between markets.

Sustainability in more regulated care provision is challenged, in particular in residential care, as a result of financial challenges, cost increases, and workforce pressures. There have been a number of home closures and whilst in some parts of the market that might not present a significant long-term challenge in terms of sufficiency of supply, there is a risk that this could happen where increased provision has been identified as being required – e.g. nursing and dementia care, or in certain geographical areas. In addition, the council is commissioning residential places for people with a learning disability out of county, whilst there is an identified oversupply in Somerset of this provision. It was identified that sometimes this is in bordering areas and due to customer choice, but this may be an area of consideration to link with the learning disability progression area in the transformation plan. There was some assurance of the plans in this regard, with a focus on higher-cost packages out of county aimed at reducing financial cost and enabling care closer to home; but there is further work to do in this area, and this will require a crucial focus on working in collaboration with the local care market(s).

In practice, sourcing is based in Commissioning which enables a good and close working relationship. Information from sourcing can be shared with commissioners, which allows a positive way of understanding the challenges in sourcing for the needs of customers and can inform strategic commissioning alongside the data and information collected. Similarly, the challenge heard about improving working across Operations and Commissioning, which is beneficial to ensuring a connection and understanding of the needs of people and communities. Providers that the challenge heard from could not as yet evidence the closer working between these two parts of the business, perhaps due to the restructure being recent, but this might become more apparent as working practices bed in and improved outcomes develop.

A recent development to utilise the Capacity Tracker and other information to map vacancies is a helpful way of identifying capacity in the market, and where there is oversupply or challenges accessing sufficient service provision, especially if this can be further utilised beyond day-to-day sourcing. It is noted that there can be some challenges with the Capacity Tracker in terms of holding the most up to date information, but Commissioning are encouraging providers to update through their active use of this to support referral and allocation.

Somerset’s approach to (operational) service provision appears to rely heavily on interpersonal connections. Whilst the peer team found staff at the council delivering good adult social care services to local people, there were also examples of systems and processes that were described as “not working” or were not enabling, so staff created effective workarounds, typically based on good personal relationships between individuals in different parts of those systems. While positive relationships are invaluable, the service management and wider council should consider how to also develop robust systems and standard operating processes in order to ensure services are consistently provided, even without specific relationships and individuals in place.

Quality Assurance is strong in Somerset and offers triangulating information and intelligence to respond appropriately. Weekly “soft intel sharing” meetings take place involving the CQC, Safeguarding, and NHS and council Quality teams. The challenge heard that whilst some information sharing remains reliant on the use of manual spreadsheets, the Eclipse system enables access to Rio (the local NHS System) to support good intelligence for key teams including Safeguarding. Continuing to explore how local systems including PAMMS, Eclipse and Rio can be used to triangulate concerns or quality issues will support ongoing work. In general, use of information from a range of sources does and will support this, including how the council utilises information from Healthwatch, complaints, audits, feedback, and QA concerns, to triangulate intelligence and to provide assurance that what they are doing is safe, effective, and as positive an experience for people as possible. And the good relationships between Operations and Commissioning can present an opportunity to share understanding of needs of people and communities which can feedback through to the Practice Quality Board.

The quality of regulated care is comparatively good, with high levels of CQC-rated Good services. There is a good and clear focus, process, and approach to managing quality assurance which may be an important contributory factor in this. There was a very evident joined-up and mutually supportive approach with the NHS on quality assurance (particularly around CHC), which presented very much as a unified team, sharing and acting on information and avoiding duplication. Working alongside providers in this area was evident from the approach described by the team, and providers reflected positively on the support provided from individuals within these teams. For providers, knowing outcomes of contract reviews was important and challenges with resource may have prevented them accessing feedback on occasions. Contract management has recently moved into Commissioning, and it would be interesting to review the comparative benefits and risks of having this function separate from quality, but closer to and informing the wider activities in the commissioning cycle.

The council has a business failure plan, whole service processes, and clear actions to take when a provider gives notice; this is managed by the Quality team, including communications, facilitation, and basing themselves in the service for support. There were also examples given of trying to support the impacted workforce (retained in health and social care), and other providers stepping in to support/take over business failures, whilst focusing on the primary aim of ensuring people are safe and have alternative solutions in the event of home closures.

Whilst there was evidence of leadership commitment to equalities and diversity, and this was clearly expressed in the approach to supporting the internal workforce, it was less evident (or the peer challenge didn’t hear so much about it at least) within the commissioning approach. Whilst there were some examples (e.g. understanding of some areas of deprivation in Somerset, matching specific needs of people with micro-providers that can help e.g. around language, and focus on advocacy for people with hearing loss) there was generally a fairly limited focus in interviews on how Somerset can ensure people with protected characteristics have access to solutions to meet their specific needs.

There is evidence of partnerships and collaboration, including for example with the Integrated Care Board (ICB) and VCSE, and a joint S117 with health and pooled budgets. However, the joint commissioning forum including health partners identified that improvements are needed too in these areas, and a review of the Better Care Fund (BCF) plan as part of this might help to drive that process.

The council and its partners recognise the complexity involved in providing Intermediate Care options to the residents of Somerset, but this would benefit from greater clarity. The peer team heard that teams with support and oversight of hospital discharges provide a regular review of the hospital stay position and work together to review sourcing options such as Intermediate Care. There is clearly some joining up of systems through weekly meetings regarding hospital discharges and transfer of care into the community which is positive, and the team did not hear about significant issues in this regard. However, the roles and responsibilities of the staff involved in discharge pathway decisions are presently unclear, resulting in over reliance on Domiciliary Care as the reablement offer is underdeveloped. Providing clear and accessible information about Intermediate Care is essential in ensuring people access the right support, and to help those with lived experience and their families to make informed decisions. Work to review outcomes of the transformation programme to deliver/commission a reablement offer might not only provide effective and timely support on discharge but could also reduce further demand for bed-based support and increase independence and earlier return to the community.

The absence of an Integrated Equipment Strategy could potentially cause disputes with clinicians over its appropriate use. The Peer team heard of challenges of governance of this pooled budget, and that decision-making across health and social care is challenging for officers and could delay improvements being made. Creating a comprehensive strategy to provide equipment efficiently will support both those with lived experience, family carers, and the care market, and a Joint Commissioning Manager for Equipment might be explored.

There is more to be done on integration in this area and to explore innovation in technology more widely, particularly the use of mainstream technology and opportunities for young people preparing for adulthood. This could form a part of the Technology Enabled Care (TEC) Strategy. TEC solutions are available, but bringing together District and Borough services has been a large piece of work, including to provide consistency of lifeline service across the county. For instance, there is currently only a falls TEC service in Bridgwater, and the council should consider expanding this service to other parts of the county to ensure equity of provision. Showcasing opportunities for those who can access the SILCs will be helpful in publicising equipment and technology. Coordinating such offers, and combining prevention with more formal care, could help to demonstrate their return on investment (how they can provide a solution instead of or alongside other forms of care to keep people independent for longer and avoid more costly provision).

3. How the Local Authority ensures safety within the system

Safe systems, pathways and transitions: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Safeguarding: We work with people to understand what being safe means to them and work with our partners to develop the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

  • When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place. 
  • I feel safe and am supported to understand and manage any risks.

Quality statements and I-statements from the CQC Interim Guidance for Local Authority Assessments, November 2023

The Safeguarding Adults Service comes under the oversight of the Principal Social Worker following the 2023 restructure and the service is included within the audit cycle, with outcomes feeding into the Practice Quality Board and Somerset Safeguarding Adults Board (SAB). The Service Manager has been in role for some time, and feedback was positive about service improvement, support for staff, and values instilled across the team for safeguarding adults. Centrally coordinated safeguarding processes maintain a focus on Making Safeguarding Personal, have oversight of timescales, and review quality in caused out enquiries. The challenge found thorough processes undertaken at point of triaging a safeguarding concern within the safeguarding team, including checking health systems as well as adult social care systems, reviewing background and gathering information regarding risks and once reviewed as meeting s42 criteria, setting the terms of reference for enquiry. There was good evidence of Making Safeguarding Personal in safeguarding, with ownership held within the safeguarding team to review timescales and ensure quality prior to closing, even when caused out.

However, the challenge team also heard about potential delays in referral and processing of safeguarding due to delays within the customer contact centre, and RAG-rating or triage within the safeguarding team; and concern was expressed across some professionals within the council and partner agencies about inconsistent quality of practice in completion of safeguarding enquiries, which would suggest that consideration be given as to how these are being escalated and addressed. Teams with skills and focus felt there was an over-reliance on their input due to lack of supervision and development in some local teams, and it might benefit to review such situations to identify the most appropriate professional to lead the safeguarding enquiry, including when sending to community teams and partner agencies.

There are established and supportive relationships with key partners to review concerns and manage coordinated plans to address risks with individuals and services. There is good attendance and involvement of partner agencies including providers in safeguarding and risk management meetings, processes and practice oversight; and safeguarding has regular peer support/check-in with key partners to raise awareness of issues across the patch, and this is being used to develop better links with CQC. Teams identify areas of learning or training needs for which the Advanced Practitioner develops sessions and good peer support. However, the question was raised whether improved understanding of social care safeguarding duties (and limitations) might be required by agencies such as the police to better manage risk in a collaborative way and avoid restricting options for the person at risk.

There is a positive focus on outcomes and practice quality improvements and the new Practice Quality Framework has introduced enhanced processes and focus on quality. Dedicated senior roles for the Principal Social Worker and Principal OT provide a visible and senior voice for practice on the adults leadership team, and there have been enhancements to the management capacity under the Principal OT. Principal Professionals have developed a Competency Framework for 5 roles which continues to be further expanded and developed, and this supports better career pathways for staff within adult social care. The Framework supports and enhances people’s awareness and understanding of what is needed for each role (i.e. training or development), with the aim for staff to use the document as evidence within supervision, or to feed into Continuing Professional Development (CPD) for registered staff. Whilst the lack of local universities is impacting on young people staying in the county (and therefore not applying for posts), training academy plans utilising significant funding received for health and social care have been established. And the Principal Professionals have aspirations to further develop opportunities with partners regarding recruitment, focusing on school leavers and colleges to enhance future recruitment opportunities.

The challenge heard about an open and safe culture and the ability to reflect on what is working well and areas for development, with processes in place to review risks and share learning from review processes, and to inform and agree actions to address areas of concern (for example informing learning and development offers). The launch of the Practice Quality Standards competency framework and audits has been a positive move for the council with an audit cycle which provides a good level of engagement, and also aims to improve the focus on quality in supervision. The supervision policy has been updated to incorporate aspects of appraisal and the aim is to help progression for people, reviewing the next level of the competency framework for instance.

Monitoring and support for supervision, mandatory training attendance, and development of skills for complex cases may benefit from further consideration. The team heard that there was not a central place to record supervisions, notes, and attendance; this might impact on how outcomes and learning from audits, training, and CPD sessions delivered by Practice Development Advanced Practitioners are being measured, whether they are routinely recorded, or indeed whether all staff are receiving supervision. This will be especially important given workforce pressures at the present time, and how these might impact on staff supervision and training attendance, and consequently on staff’s ability to engage in critically reflective practice and consolidation of learning. The challenge heard that mechanisms are in place to monitor these on an annual or audit basis: Supervision Audits are regularly undertaken as part of the Practice Quality Framework and auditing schedule, and planned as part of an annual cycle (next due in July 2024); a Learning Needs Analysis survey of staff took place shortly after the challenge, and will support training requirements and needs via the Learning and Development team; and the council utilise LGA Health Checks to monitor staff experience of CPD and Supervision (the most recent out-turn of which was pending at the time of the challenge), with the Principal Social Worker and OT progressing action plans in response. All of these provide assurance for the council in this important area, but consideration might be given as to whether there is a proportionate way to evidence (in a more ongoing / routine way) the completion of training or supervision and the quality of these; and how through these staff have their work reviewed and the opportunity for reflective practice, to set priorities and actions, support to understand their development needs, to ensure mandatory training is completed, to consolidate how learning impacts on quality of work, and manage risk and outcomes for individuals.

There are established training programmes and offers which support a flexible approach to both delivery of training and regular sessions with professional practice leads. The workforce development team, led by professional practice, proactively supports both a commissioned offer but also inform a flexible offer from practice leads. This includes CPD sessions, podcasts, webinars, and workshops (which are reported to be well attended and with positive feedback from staff). Mandatory training covering safeguarding and mental capacity is delivered in person to promote effective delivery of training for staff, and mental capacity training support and guidance is provided to internal and external partners and providers (including good work completed with ICB regarding self-neglect which was a positive action following learning from SARs). However, whilst E-Learning is provided for health, with a free training tool for adult social care colleagues, the challenge heard some feedback that take-up of this training was not strong, or not monitored, and that further feedback would be helpful. More generally, the issue of feedback and staff take-up was reported as a particular issue since the move to virtual learning, including for mandatory MCA and Safeguarding modules. This is something which should be reviewed not only to understand the effectiveness of the course content and delivery for the commissioned training offer, but also to evidence (to managers or for assurance) whether staff have the skills able to deliver safe practice, particularly in those areas holding risk such as MCA and Safeguarding (and including the impact on individuals supported).

Peers met with a number of members of the Somerset Safeguarding Adults Board (SAB) including the Chair, partner agencies and council officers. The Chair joined in January 2023 and is recognised as having a positive influence on invigorating the board and setting clear expectations. The SAB brings together wider partnerships such as Children’s and Safer Communities, and has identified clear priorities for 2024-2025, including a focus on raising awareness in the community (and the peer team noted the SAB website, carnival week and further aspirations for the coming year, although also wondered whether this was targeted more at professionals and whether further consideration could be given as to how best to target this for wider public awareness and engagement?). The SAB is delivering key statutory requirements such as an annual report, audits, and safeguarding adults reviews (SARs), and SAB Members report an improved approach to learning from SARs and tracking of SAR actions and recommendations.

There is an improved performance analysis within the SAB, and this is reported on a quarterly basis. However, the main focus of it is adult social care and less on other providers, and the SAB might also consider how it can maintain effective oversight and management of recommendations from a continued high number of SARs? It would be of benefit to consider how effectively the learning from SARs is being embedded, and how this is being tested with the SAB (e.g. around self neglect which remains an area for improvement for the council and partners). There was an awareness of SARs, and associated processes and actions, and identification of work undertaken to share learning from these including within the Safeguarding team. However, there are some areas for further development for instance regarding Trauma-informed practice, self-neglect and executive functioning which was also identified with some of the case audits. And whilst there is evidence of improved approach to learning the case file audits undertaken as part of the challenge suggested (albeit on a limited scope) that it is not consistently embedded into practice.

The peer team felt that there was a lack of lived experience feedback on safeguarding and risk management and that this could be used to more effectively inform areas of good practice and learning, both within the council and as an area for further development for the SAB. Similarly, further consideration and acknowledgement of hard-to-reach communities and EDI, including age and disability but also LGBTQ+ and ethnic minority communities, could support a wider understanding and ability to effectively and confidently address discrimination within risk management and safeguarding situations, both within the workforce and the community.

The SAB have developed a Risk Matrix Tool for professionals to use. There was initial concern during the peer challenge that this was a pre-screening tool completed within both the Customer Contact Centre and wider teams, and whether this impacted Somerset’s lower than average concerns numbers. However, there was assurance gained from senior governance leads that there is training for staff using the tool, spot checks completed to ensure its effective use, and that the Customer Contact Centre can access specialist teams (including the Safeguarding team) for support and advice in a timely and effective way via the use of MS Teams. Despite the lower-than-average Safeguarding Concerns, it was felt the tool has had a positive impact with regards to the conversion to enquiry rates being higher. The use of the tool at the Customer Contact Centre results in signposting referrals at the front door to other teams or services as appropriate such as Mind Line, Open Mental Health. Whilst there was an example described of the tool not being applied correctly last year, this was picked up when the same concern was referred and reviewed by the safeguarding team, and this was later reviewed for learning and understanding, and development completed within the Customer Contact Centre regarding this.

The Practice Quality Board provides governance and oversight of processes/reviews including Serious Incident Reviews (SIRs) and SARs, and leads to learning and actions, and there is a wide awareness and knowledge of this and how it informs actions. There is a new SIRs policy which has been recently signed off, and which allows for timely review of the incident with a focus on learning and practice via a 72-hour type report (and providing a central coordinated place for SIRs and SAR referrals via the PSW).

Somerset’s Quality Assurance Team are passionate about what they do, and whilst the team is small, feedback about their work is excellent: 2023/24 Stakeholder feedback analysis for adult social care in Somerset revealed that 15 per cent of all feedback was associated with this small team’s activity and 97. per cent of all responses rated the team’s support as Good or Excellent. Their support provides an effective response to concerns within providers both through planned forums and in response to immediate challenges. The challenge heard that the team work effectively with the safeguarding team, CQC, ICB and other partners to gather and record intelligence of any concerns, information relating to a provider to inform discussions, risk assessment and actions/ process decisions. The Quality Assurance Team has the level of training they would expect and has developed a Café for providers to have a safe space to discuss sponsorship practice and concerns (exploitation/modern day slavery). Whilst there is a challenge with not expecting micro-providers to be regulated, there is a requirement to sign an annual “doing it right” declaration understanding their boundaries. Weekly meetings with the Quality Team and partners provide the regular ability to discuss the system, provider concerns, update around Whole Service Safeguarding, and also to direct communication to community teams if restrictions are in place. There are clear business failure and whole service processes in place and use of the Quality Assurance Framework (QAF) as an early warning system for quality concerns is proactive, and the flexibility of resource with ICB colleagues is supportive when the quality team is focused on business failure.

All staff right through to senior managers complete audits which have a focus on practice and aim to contact the person for feedback. The ambition (which is work in progress) is to include every member of staff from frontline to senior management to do audits, focusing on the 10 practice standards, one theme per month over ten months of the year. This is a positive ambition, and it will be helpful to collect evidence of how this, along with other more routine quality assurance and audit processes are positively impacting on outcomes for local people, as well as how it affects their experience of adult social care.

Mental Capacity Assessments (MCAs) appeared to be strong with a good assumption of capacity, and training is offered to providers in this important area. The SAB monitors Safeguarding and MCA training completion and compliance on a quarterly basis via its multi-agency Performance and Quality subgroup, and this performance report and recommendations emerging from monitoring feed into the Board itself. Additionally, the SAB undertakes biannual organisational self-audits which require partner organisations to provide evidence on a range of matters of relevance including training compliance and application of the MCA (most recently undertaken in December 2023 with analysis informing the SAB’s new strategic plan).

In addition to assessment waits referred to under Theme 1, above, there are processes in place to monitor and manage the waits for Community Deprivation of Liberty Authorisations for which the assessments are managed by the community teams. There are resource issues impacting the ability to respond to the number of assessments, with hopes previously pinned onto the introduction of Liberty Protection Safeguards which has been further delayed by the government. There is a waiting list which is kept on a spreadsheet separate to Eclipse which is manually updated by admin following close working with Social Workers to check whether anything has changed. Where assessments for Deprivation of Liberty Authorisations are allocated and progressed, there is a reported challenge with access to Doctors for assessments, and up until recent recruitment, with support from permanent solicitors for legal advice and input into court cases. Therefore, the council will need to consider the efficacy of triage and monitoring of waits, and that the deprivations in place for individuals are in their best interests, least restrictive, and under continued review of impact on well-being.

Since the Approved Mental Health Professional (AMHP) Services were brought into the council, the service reports continued supportive relationships with the mental health teams and health staff through co-location of the team. The AMHP managers continue to use data from Eclipse to understand the work undertaken by the team, and how demand informs the service need and model; this has led to changes being made to the rota to match capacity to demand, to improve provision of 24/7 cover, to prevent handing off work, and to allow better management and completion of statutory duties, and oversight of priority and risk. The team report positive peer support and describe “good will”; however, it was suggested that the team might benefit from greater consistency and capacity in daily management and coordination. This was described as work in progress, with some current challenges being reviewed regarding inconsistent practice around onsite availability for referral coordination and leadership, which can be confusing for onsite referring professionals, and can compromise effective support for the team. The team is soon to be fully staffed with the approval of three trainees; the continued plans to support a trainee programme via recruiting trainees into vacant posts is required due to the present staff profile, an approach to succession planning and sustainability that is to be commended.

It was not clear during the peer challenge that the electronic system (Eclipse) fully covers needs within the service, with some practitioners reporting usability concerns or deficits e.g. risk tools are sent via email rather than being embedded into the system, data is not automatically transferred to support plans, and financial information is not included at present. It was noted that the Eclipse system (which was only introduced as a new care management system last year) is still under development, and with an active approach to on-site updates and change management, so with time (and ongoing resource) it is likely that these issues will be resolved; however, they are impacting at the present time.

The development of specialist learning disabilities, mental health, and transitions teams in the council is felt by staff to have improved practice and supported a more personalised approach. The specialist teams support the development of relevant skills and knowledge, and therefore focus on better outcomes for individuals. There is evidence of positive management of risks, with the council using a countywide risk tool; this promotes consistency and is supported by weekly MDT meetings to manage risks, and with case file audits being undertaken. The challenge team heard about examples of positive risk-taking to promote independence and work with people’s expressed wishes and outcomes with support from other teams and services to facilitate this. Cross-team working, with virtual support/contact available from safeguarding and mental health customer contact centres, allow the ability to work together to provide continuity in supporting people with complex needs, with a decision who is best to lead and work together to support, especially where there is dual diagnosis. They provide a joined-up approach with key partners including close operational links with health colleagues, VCSE and other teams, to avoid handover and instead share supporting knowledge where needed, all of which is seeing some tangible positive outcomes for people.

Preparing for adulthood has been highlighted as an area for improvement by Somerset and the peer team supported this: although there is specialist team provision, further work is required with Children’s Services and individuals transitioning (including family and carers) to better plan and inform. There is a concern that allocation at age 17 may be missing earlier opportunity to communicate the assessment and process of adult social care and the approaches undertaken such as promoting independence. Children’s and adult systems do not join up which creates risk at the point of transition from children’s into adult services, and it’s acknowledged that whilst the newly formed Preparing for Adulthood team will address some of this, the lack of access to children’s services information will have a negative impact on people transitioning between services. This has been included within the adult social care transformation programme with Newton support to improve processes and data dashboards (including SEND). Further work with SEND and Children’s Services around preparing expectations for adulthood, promotion of TEC, and independence at an earlier stage, can help the move to Adults, including the better management of any change in approach and reduction in support that this entails. It was described by a carer in one of the Peer interviews as needing to “remove the bubble wrap” caused by concerns about the different expectations and levels of support which can otherwise present a shock when they enter adulthood. This includes the view of risk and positive risk taking, which may not allow for effective listening and supporting of the young person’s views and wishes regarding their life. And for individuals with complex needs there is a need for risk management to provide a collaborative commissioning approach for both housing and the wider provision of support; this could prevent deterioration in behaviours, or impact on well-being that places the person and the short-term provision at risk.

The Out-Of-Hospital pathways could benefit from further consideration. There are some real positives including a Discharge to Assess (D2A) approach, a Standard Operating Practice, on-site presence at Community Hospitals, a focus on getting people home with their previous package where appropriate, and trusted assessors for care homes provided through the provider forum. However, there was a focus on bed spaces and the community home-based reablement offer felt unclear; there may be opportunities to review pathways to ensure they offer coordinated solutions, maximise opportunities to support people to return home, and reable to reduce longer-term care impact. The Transfer of Care Hubs provide a joined up multi-agency approach to determining discharge arrangements; in practice, however, there are different approaches at Musgrove Park compared to the out-of-county acute hospital in Weston-Super-Mare. In addition, the social work teams experience a challenging culture in the acutes, and ensuring a strong social work voice advocating for the best outcomes for the customer can be challenging in that environment. Teams were extremely passionate in this area about getting the right solution for people, but under difficult circumstances and needing high levels of resilience, this presents a workforce risk. This is an area for consideration as whilst partnership working and collaboration was very evident in some areas of the business, the pressures and challenges in hospital discharge made this feel very much more difficult.

The council has recognised the need to have awareness of risk across the journey and have developed Risk Management Guidance which seeks to address the challenges and concerns, with priority descriptors, actions and escalation. However, the challenge team heard concerns about a lack of consistency in application, and the challenge in effective continuity of support/safe transfer of care for those within a safeguarding process if they were not given priority in progress of assessment for support. There would be a benefit from reviewing risk from first contact through to allocation, how processes are effectively undertaken to manage this, and how practice risk is consistently assessed, managed, and recorded throughout adult social care. This appears on the risk-register and is being monitored by the Safeguarding Adults Board with reports submitted for assurance; it is particularly important to maintain this focus whilst capacity and demand challenges continue, to ensure that there is consistency in processes and therefore the experience of those awaiting assessment and support are not affected by where they are supported.

4. Leadership

Somerset is a new unitary council, formed in 2023 through the reorganisation of five councils into a new single organisation. This has involved bringing together two different types of councils – an upper-tier authority with responsibilities for services such as adult social care, and four district councils with responsibilities for services such as Housing and Planning. This brings big opportunities but also challenges, with multiple layers of change: becoming a unitary council; political and officer leadership changes; structural and staffing changes; and the context of emerging financial challenges. There has also been significant change external to the council, such as the development of a new Integrated Care Board (ICB) along with its own restructuring processes.

The leader and the lead members for adult social care are visible with officers and there is a positive culture of challenge and support between executive councillors and senior officers. There is understanding from the political leadership about the importance of adult social care for supporting vulnerable communities and unpaid carers, and officers have spoken consistently about the support and leadership that councillors give. Alongside this there is also a strong recognition from the political leadership that adult social care is the biggest area of council spend, and a significant driver of the financial pressures facing the council, and therefore there needs to be a focus on transformation, efficiencies, and ensuring that money is spent as well as it can be to achieve the best outcomes and sustainability.

 

More widely, all councillors across the board will need to understand the pressures, drivers and change priorities for adult social care, and how they can be supported to play an active and effective role in holding the service to account. This is particularly important because of the financial challenges facing the council, the significant proportion of council spending that any adult social care function accounts for, and the resulting danger that adult social care is regarded as a burden or a deficit, rather than as an asset. The new council has 110 councillors, coming from a variety of backgrounds and council experience, and with differing levels of exposure to adult social care. For some it may feel like a complete unknown; for others, it might be seen as an area of the council that is (negatively from a financial and demand perspective) impacting on other areas that they and their residents care about. For those councillors who do not sit on the Cabinet or on the relevant scrutiny committee, their exposure to, and understanding of adult social care might be limited, and there is an ongoing need to raise or consolidate awareness and understanding of the council’s new responsibilities and how these relate to adult social care. At the core of this is the legal responsibility to ensure that vulnerable people can be protected and supported. To promote this, consideration might be given to the development of an engagement plan that gives councillors at all levels opportunities to learn more about adult social care, through a variety of formal and informal engagement mechanisms.

The present peer challenge is explicitly designed to focus on preparation for CQC Assessment, and therefore, in line with that process, does not focus directly on finance. However, it would be short-sighted in the context of this process not to acknowledge the present financial context, the strain this places on the council, its leadership, and workforce, and the risks that it creates. The financial challenges affecting Somerset are well-documented and require that difficult decisions are taken; this includes a reduced workforce, and may well impact the scope of commissioned services, and the prioritisation of these. Whilst frontline roles in adult social care are being protected in the present round of voluntary redundancy (VR), adult social care services will depend for their effectiveness and efficiency, and for delivery of change and transformation programmes, on corporate support services and capabilities such as Business Intelligence, technology services, housing, finance and HR to name a few. All of these will be impacted in terms of capacity and maybe capability by the current VR process. It is important, therefore, that adult social care leadership defines the capabilities it needs and that the down-sized council can continue to support delivery of key change programmes that support not only adult social care improvement, but also the overall financial efficiency of the council.

Similarly, there is a risk that the impact of financial restrictions (for instance panel-controlled spending) or reducing services, or uncertainty, will affect both staff morale and energy, impacting on performance, transformation, or improvement processes. Alongside the transformation programme and preparation for CQC assessment, the financial position, unitarization, and ongoing recovery post-COVID will all impact, with a risk of cumulative fatigue. Maintaining momentum and energy for ongoing development in the new council, or to consolidate existing gains, may be a challenge given the present financial situation, and consideration should be given how to mitigate this. Prioritisation across key development or improvement areas could offer opportunities not only to prove their benefits, but also for “quick wins” which can build motivation, perhaps especially important when some challenges may feel or appear intractable. Similarly, finding ways to showcase positive stories of improvement or innovation may help to build motivation and energy for this change, as well as proving its benefits whether in terms of outcomes and lived experience, or return on investment or other efficiency measures.

There is an engaged workforce, and the DASS provides strong, positive, visible leadership for the service. The adult social care leadership team and DASS communicate this well with the wider workforce, clearly articulating the overall ambition and potential to change lives for the better, and the importance of adult social care continually improving and transforming. Officers have described the council as an open, supportive, and safe space. More widely, the challenge team found passionate, experienced, and committed staff and senior leadership which can be a huge asset for the council. However, there is also a potential risk in relying too much on strong individual leadership, perhaps especially at a time of acute financial pressure such as the council is presently experiencing. Finding ways to systematise and “diffuse” key knowledge, experience, or expertise across a wider pool of staff, or in more formal processes, would help to mitigate risks relating to the loss of key individuals within the management structure, whether through VR, retirement or moving on, or staff sickness and burnout (which is a risk when all are under pressure).

The council has started a transformation programme, ‘My Life, My Future’ which sets out ambitions for change and has significant savings targets attached to it; this is currently on track to delivery and there will be learning that can be applied to other parts of adult social care. There is comprehensive political and officer scrutiny over the progress of the transformation programme to ensure that it can, and does, deliver on the required benefits and changes. The work is being supported by Newton Europe and there was real positivity among the council officers with whom the peer team spoke about the programme. The programme started with a diagnostic phase which included surveys on change readiness among the workforce, and found a workforce that was receptive to change, and in some cases waiting for the change. council officers are being upskilled in the Newton Europe methodology and this provides a capability and skillset that can be further applied elsewhere on other adult social care and wider change programmes in the future. The council should consider how to retain and deploy its newly trained and experienced officers from this programme, creating a solid platform for transformation, identifying opportunities for improvements, transformational change, and savings, and self-sustaining approaches to such work in the future.

A Transformation Steering Group> has been set up, and this will encompass more than just the existing ‘My Life, My Future’ transformation programme. The challenge heard enthusiasm about many potential priority areas to work on, but also that people feel they lack “head-space”; and there was an acknowledgement from the adult social care leadership team that they need to remain on the front foot in terms of transformation so as to best support the council’s wider financial position. The challenge team felt that there might be a benefit for adult social care in setting out the next phase of transformation, focusing on a small number of priority or “big ticket” items as part of an overall plan. It is important that there is a co-ordinated process to define the biggest priorities and to protect the space and time to ensure the work can be scoped out, designed and delivered; and to work with the rest of the council to provide the capabilities that will be needed to support future and ongoing transformation. Similarly, it will be important that the council continues to get feedback from the workforce and also the voice of lived experience as these transformational changes are implemented, so that there is strong confidence not just that the savings are being delivered, but also that the changes are being embedded, and that the workforce and service users are ‘experiencing’ the benefits of these changes.

There is political and officer leadership support for EDI, and the leadership of the new administration, the new chief executive, and the DASS have all been particularly welcomed in this area of work. It was remarked that this leadership on EDI is “like we’ve never had before” and is helping to create a safe space and a consistent focus across the council. The peer challenge heard from both council officers and the voluntary and community sector (VCSE) that the council is responding to the changing demographics and profile of Somerset, and it was expressed by officers, members, and partners that EDI is now “at the core” of what the council does. The challenge team heard about a comprehensive approach to EqIAs as part of the council’s recent budget-setting processes and that councillors received training about how to use EqIAs and to ask questions on them. The approach to EqIAs appeared proactive and purposeful, helping to inform and shape decision-making, rather than simply a tokenistic add-on. All of this provides an excellent platform to build on.

There is now the opportunity to deepen the work on EDI using the voice of lived experience; Somerset’s population is changing and the council’s own workforce is also becoming more diverse. adult social care has been at the forefront of embracing overseas recruitment and has welcomed many new starters; this has helped the council to learn what support is needed for new recruits and also around the challenges that people settling into a new country can face. The council is working with the VCSE, including Diversity Voices, to promote EDI and to bring in the voice of lived experience. There is much good work going on but it was described by some closest to the work as an “invisible service”, showing that there are opportunities to make the work more visible and also embedded as “everybody’s business”, or business as usual, rather than be seen as the work of just one team or small group of people. The voice of lived experience – across the council’s workforce, service users and residents – can help to embed this work, encompassing all protected characteristics, so that these qualitative insights can be used to inform and shape thinking about how services and processes could be redesigned.

There are positive relationships with partners, including the Integrated Care Board (ICB) and the VCSE, but further work to do as leadership structures are consolidated, both in the new council, and in particular for the ICB. The Somerset Board brings together the Health and Wellbeing Board and the Integrated Care Partnership (ICP) in a committee in common, chaired by the leader of the council; this creates an opportunity to progress work on shared vision and priorities, with political oversight. There are some examples of strong integration, especially around the health interface service and intermediate care. The challenge team heard from the council and the VCSE that there are strong collaborative and trusted relationships and multi-year funding, and that the relationships have improved over recent years. These positive relationships between council and the VCSE are an excellent platform to build on and should not be taken for granted or taken lightly, and it felt important to acknowledge the potential risk to some of this work, and these relationships, in terms of the present financial situation.

The joint director of public health role between the council and ICB is also an excellent example of system collaboration and provides a good opportunity to address the wider determinants of health and improve population health, making optimal use of the Somerset pound. There is an ambitious programme around population health management and there are some potential opportunities for joint roles and teams being explored and advanced. Further opportunities for integration with the ICB are being, or might be explored, including around joint roles, a new data and intelligence function, and further development of joint commissioning of intermediate care.

The peer challenge team heard throughout the challenge of the opportunities afforded by bringing housing alongside adult social care responsibilities in the new unitary council and felt that it would be helpful for the council to clarify its ambitions in a Housing Strategy. The housing team were highly self-aware about the areas of strength (e.g. around housing revenue account) and around the challenges both of addressing housing provision for people with disabilities, and of bringing four separate housing authorities into one. There were some examples of innovative use of Disabled Facilities Grants (DFG) through Help to Move grants. Positive relationships between adult social care commissioners, OT’s and housing are also being formed. There was recognition from the housing team and from adult social care commissioners that it will take some time to realise the full benefits of unitarization, not least because of the four different starting positions of the previous housing authorities, and there is a risk of frustration if not everyone is signed-up to the same ambitions and delivery timescales. The development of a Housing Strategy to define and manage ambitions and delivery priorities, timescales, and political and officer ownership can help to ensure all parts of the council and partners are signed up to the journey, and the peer team felt that a clear timescale should be set out for the development and publication of this strategy and associated delivery plan.

Preparing for CQC Assessment

The council worked very hard to prepare for and facilitate an excellent peer challenge process. Dedicated time and resource and leadership were identified at an early stage and were available consistently throughout the process. There can be a risk of under-estimating both the lead-time (including for different aspects of the preparations) and necessary resources needed to prepare for a peer challenge (or future CQC assessment process), but this was not the case in Somerset.

The council developed a well-structured self-assessment which helped to guide the challenge team in line with the CQC Themes; this was supported by a prioritised, but nonetheless comprehensive set of further evidence materials. These were delivered in a timely way, and referenced in the self-assessment, providing a helpful means of aligning evidence to key statements or sections. All the materials were made available on the council website (but on a non-public-facing page), along with other materials pertinent to the challenge; this made the materials easy to access but might not be a fully secure way of sharing sensitive materials. (This is unlikely to be an issue with CQC assessment however, given that they have developed a portal for uploading all relevant materials in advance of the on-site work.)

Consideration had obviously been given how to provide evidence of outcomes for people who use or have contact with council services, aligned to the self-assessment and CQC themes, with video clips, and “stories” included where relevant. This might be further developed and linked with the routine use of care management systems and future case file audits, as well as through inclusion of lived experience feedback in regular reporting on transformation and improvement plans. Evidence of this kind will also come through contact and conversation with front-line staff, so ongoing support to all staff (not only those working in adult social care, but more widely across the council) to answer the “so what?” question, will support any future assessment team in hearing about positive outcomes, and the reason for, and impact of any changes or improvements that are happening.

Perhaps similarly, ongoing consideration could be given as to how to more fully involve people with lived experience in the preparation for future assessment processes, as well as in the process itself. This is work in progress for all councils at the present time, but early consideration of how to routinely engage a strong lived experience voice as part of ongoing work will support not only the developing approach to coproduction, but also provide good evidence of this in CQC assessment.

The team were made to feel welcome, and many small details were planned for and delivered: staff were available to support access to the council offices (and IT / care management system for the case file audit); car parking access was made available; access needs were appropriately addressed and supported; refreshments and lunch were made available each day; and IT resources and wi-fi were made available whilst the team were on-site.

The area of the council offices where the team were situated is presently not in regular use due to financial constraints and required the on-site leads to make a business case for their use in advance of the challenge. However, once on site the space that was provided allowed plenty of room for the peer team, along with dedicated meeting rooms nearby for interviews and focus groups.

The challenge team was aware that briefings for staff and partners supported engagement with the challenge, and this was to large extent successful: most of those invited to attend interviews or focus groups did so, and participants showed good engagement with and understanding of the interview and focus group process, as well as of the wider challenge, its process, and purpose. There did not appear to be a formal process for debriefing staff following meetings on-site, something which is sometimes included as part of a feedback loop in e.g. OFSTED Inspection, and this may be something that the on-site team may wish to consider in advance of a future CQC assessment visit.

There was very positive feedback about the process and the on-site team, and the engagement and positivity with which the challenge was received was certainly evidence of the positive attitudes and openness of staff towards the process, and indeed more generally within and around the council.

Whilst the initial presentation from the council was kept “in house”, the final presentation from the peer challenge team was open to wider invitees who had been involved in the challenge, including partners and staff. This showed an openness and transparency in the process, and a desire to engage with stakeholders around assurance and improvement. It is understood that a further briefing to disseminate key messages from the peer challenge was held immediately after its completion, and that plans are in place to further disseminate the findings, and the resulting action plan, through formal council processes.

The council would benefit from quantifying the resources deployed in terms of staff time, and at all levels, both in preparation for the challenge (e.g. in preparing the self-assessment and supporting evidence, development of timetable and diary management for invitations, etc), and whilst the team were on-site. Whether this may need to be built into CQC preparation either as a standing resource, or some kind of “on call” team with responsibility, experience, training, and allocated time as and when called on, could be something for future budgetary and role considerations. Those who were involved in preparing for and supporting the challenge will have developed good knowledge both of the process, and of resources in the council which are required to prepare for and support it, and consideration might be given as to how to protect, harvest and grow this knowledge in advance of any future assessment process.

Recommendations for next steps

The peer team appreciate that senior political and managerial leadership will want to reflect on these findings and suggestions in order to determine how the council wishes to take them forward. In due course the LGA will be pleased to work with the council to consider progress in line with wider sector led improvement work, and there is an offer of further activity to support this, including through ongoing engagement with the South West Region Care and Health Improvement Advisor (CHIA), and Paul Clarke, the LGA Principal Advisor.

Specific recommendations are included in the detailed report above, but the summary below outlines those areas where the peer team believe effort could best be concentrated in order to address the issues that they have seen during their visit:

The peer challenge found ambition and innovation in the council’s approach to delivering adult social care, but in a challenging financial situation, and at an early stage in its growth as a new organisation. Prioritisation across key development or improvement areas could offer opportunities not only to prove their benefits, but also for “quick wins” which can build motivation for the whole council. The next stage of the transformation programme might be used to clearly articulate this vision, to establish clear priorities around “big ticket” items, and to engage the whole council in this journey.

One of the “big ticket” items which can show the value of the new unitary structure is in the join-up across adult social care and Housing, and the development and implementation of a Housing Strategy for Somerset would be strongly encouraged.

The prevention agenda is well developed, but given the risks associated with the present financial situation it is urgent and important to prove impact and outcomes, and to maximise the effectiveness of this offer. This will include working with Public Health, first contact / information advice and guidance (and other early intervention), and the VCSE and wider community or whole population offer.

Consideration might be given how to ensure that everyone in the council (not just in adult social care) can answer the “so what?” question in relation to service developments and their impact; to be able to explain what good looks like for adult social care, why it is important for all people and communities in Somerset, and their part in this journey. Building on the work that has been done in preparation for this challenge, further work to collect and showcase positive stories from local people affected by council services can help to maintain motivation and energy.

Engaging more widely with local people and the voice of lived experience can support both improvement and transformation, and this is something adult social care can model and lead for the whole council. This should involve work to thread EDI through all the work of the council, including a strong voice for those with lived experience of accessing adult social care services, and engaging with all the diverse and sometimes disadvantaged communities across Somerset.

The peer challenge did not find any areas of immediate concern, but this is always a limited process, and the council will continue to benefit from ongoing quality and practice assurance work. This can help to further assure and mitigate risks associated with waiting lists, to improve consistency in practice, and to bring learning from areas of strength (in delivery or leadership) to support improvement in those areas of performance that may be less strong.

Contact

For more information about this Adult Social Care Preparation for Assurance Peer Challenge in Somerset Council please contact:

Mel Lock
Director of Adult Social Care<
Email: [email protected]

The LGA Programme Manager for this programme of Adult Social Care Preparation for Assurance peer challenges is:

Marcus Coulson
Senior Advisor – Adults peer challenge Programme
Local Government Association
Email: [email protected] Tel: 07766 252 853

For more information on LGA Adult Social Care Preparation for Assurance peer challenges please see our website: Adult social care peer challenges | Local Government Association