Preparation for assurance peer challenge report: East Sussex County Council

East Sussex County Council requested the Local Government Association to conduct an Adult Social Care Preparation for Assurance Peer Challenge within the council and in collaboration with partners. The work was commissioned by Mark Stainton, the Director of Adult Social Care and Health. The primary objective of the peer challenge was to solicit an impartial viewpoint on the council's efficacy in fulfilling their legal obligations as outlined in Part 1 of the Care Act 2014.

A peer challenge is designed to support an authority and its partners assess current achievements, areas for development and capacity to change. Peer challenges are improvement focused and are not an inspection. The peer team used their experience and knowledge of local government and Adult Social Care to reflect on the information presented to them by people they met, and material that they read. 

As Preparation for Assurance Peer Challenge teams typically spend three days onsite conducting the challenge, this process should be seen as a snapshot of the client department’s work rather than being a comprehensive review.

All information was collected on a non-attributable basis to promote an open and honest dialogue and findings were arrived at after triangulating the evidence presented. 

The members of the peer challenge team were: 

Lead peer director of adult social services (DASS): Sarah Scott, executive director of Adult Social Care, Wellbeing and Communities, Gloucestershire County Council

Lead peer member: Colin Nobel, Suffolk County Council, Member of LGA People and Places Board

Area director peer: David Coleman-Groom, Cornwall Council

Head of service peer: Leanne Bobb, London Borough of Croydon

Head of service peer: Di Manning, London Boroughs of Richmond and Wandsworth

Principal social worker (PSW) Peer: Vickie Minkiewicz, Kent County Council

Peer challenge manager: Abbie Murr

The team were in East Sussex County Council for three days between the 27^th and 29^th February 2024.  In arriving at their findings, the peer team:

• Spoke to circa 233 people including a range of council staff together with members, partners, carers and people who draw on services. 
• Read all documents contained in the councils information return and completed a case file audit of 12 cases.

Specifically, the peer team’s work was focused on the Care Quality Commission (CQC) single assessment framework consisting of four assurance themes and ‘we’ quality statements. 

The peer team were given access to at least 200 plus documents including a self-assessment. Throughout the peer challenge the team had more than 37 meetings with at least 233 different people. The peer challenge team spent over 184 hours with the council, the equivalent of 24.5 working days.

Initial feedback and an overview of key themes was presented to the council on the last day of the peer challenge. This report builds on the presentation and gives a more detailed account of the findings of the peer team. 

There are a number of observations and suggestions within the main section of the report. The following are the peer team’s key messages to the council:

Message 1: The council knows itself well

The council has a clear understanding of its strengths and areas for improvements and has a robust transformation and improvement plan in place.

Message 2: Integrated adult social care front-door

Health and Social Care Connect (HSCC) is the single point of access for adult social care. The service is a best practice example of collaborative and integrated working between adult social care and health that has been in existence for the last decade. 

Message 3: Waiting lists

A standardised approach regarding those adults/carers on waiting lists and how their safety and wellbeing are monitored whilst awaiting an assessment is required across the adult social care and health directorate.

Message 4: Workforce

The peer team witnessed an adult social care workforce that were skilled, knowledgeable, passionate and committed to the residents of East Sussex.

This relates to assessing needs (including that of unpaid carers), supporting people to live healthier lives, prevention, well-being, and information and advice.

Quality statement 1: Assessing needs

Strengths 

Integrated front door

Health and Social Care Connect (HSCC) is operational twenty-four hours a day, seven days a week, three hundred and sixty-five days of the year and can be accessed by both the public and professionals via a direct phone line and/or self-service portals. Referrers can access multiple health and care pathways, with qualified nursing staff triaging referrals when required. HSCC provides access to out-of-hours urgent response services from adult social care and community health. HSCC consists of three service areas: access, health and safeguarding.

The service is staffed by registered nurses, occupational therapists, a registered social worker and Access and Assessment Officers and Senior Resource Officers, who do not have a professional registration' and receives in excess of 2,000 referrals a month.  Referrals are triaged and referrers are provided with information, advice and signposting and where appropriate referrals made to the most appropriate service(s) including adult social care and community health services.

With regards to the prevention agenda HSCC can quickly put life lines in place, refer directly to the Occupational Therapy Clinic and access urgent community health services with a rapid response of two hours. One of the key aims of the Council and health partners is to have a ‘no wrong front-door’ approach. Although, this ambition has not yet been reached there is significant evidence to demonstrate that ongoing progress continues to be made.

HSCC staff reported a significant number of people contacting the service to ‘chase up their assessment’. This may suggest that the arrangements in place to manage waiting lists and keep people informed whilst awaiting assessment are not effective and review of current practice and process is recommended. Furthermore, HSCC staff noted a significant number of 'repeat callers', indicating that the initial information, advice, and signposting provided may not have adequately addressed the requirements of these people. A thematic review is recommended to determine the underlying causes for the significant number of repeat calls.

Strength-based practice and approaches

A strengths-based practice model was introduced in 2019/20 across the adult social care and health directorate. Staff have access to a comprehensive range of practice guidance, tools, frameworks, training and a local asset library. Casefile audits undertaken by the peer challenge team showed significant evidence of the promotion of an adults wellbeing, risk enablement, choice and self-direction.

Occupational therapy

As of January 2024, the waiting list for an occupational therapy or sensory examination was 333, with 1,955 assessments completed. Data reporting has been used to modify the occupational therapy approach to assessment waiting times, and clinics have been established, resulting in a considerable reduction in wait times.

Occupational therapy clinics can see 8 people a day, the home visiting assessment list is smaller, and people will often wait longer, especially if they reside in more rural areas of the County. The average wait for assessment as of Feb 2024 was five weeks. The Council are aware that there are a number of people who may not be able to get to clinics and as such, could be unfairly disadvantaged as they may have to wait longer for their assessment. Work is underway to see how this can be addressed.

Occupational therapy is viewed as an important component of the Council's preventative strategy with occupational therapists located at HSCC undertaking assessments on those adults with low-level needs or referring to the Occupational Therapy Clinic. The council's Occupational Therapy Team focuses on more complex and long-term needs and also oversees the Occupational Therapy Clinic. Occupational therapists are also located in District Council Housing Teams, where they lead on disability facility grant major adaptations.

Furthermore, urgent cases can be referred to the Health Community Response Team who can offer a same day assessment if required. The councils occupational therapy offer is indeed innovative and responsive and provides joints visits and case discussions where necessary with good working relationships across the council and with both primary and secondary health partners.

Carer’s breaks and engagement team

The council's Carer’s Breaks and Engagement Team specialise in providing post-diagnostic support to people with dementia living in their own homes and their carers. In 2022/23 a total of 1,433 carers assessments were completed and 1,815 carers reviews. Over 2,827 people were receiving support at the end of the year 2022 to 2023. In addition the service offers a Carer's Respite Emergency Support Scheme (CRESS) where carers can register an emergency plan with the service to ensure short-term support can be put in place in an emergency. The service is available 24 hours a day, seven days a week and emergency plans can be set up as part of a carers assessment or review or by completing the emergency plan on line.

Emergency duty service

The Emergency Duty Team consists of seven highly skilled and dedicated full-time equivalent Approved Mental Health Professionals (AMHPs), some of whom act as Best Interest Assessors. The team works outside of office hours and provide assessments under the Mental Health Act and effective crisis intervention, ensuring that adults with care and support needs are kept safe until the following working day.

Although a highly skilled group of staff after 6pm the team have no access to AMHP management and or legal advice which is a significant concern given the complex nature and high level of risk they are dealing with, especially concerning cases relating to detention under the Mental Health Act and or complex high risk safeguarding situations. The National Workforce Service Standards for AMHPs (National Workforce Plan for AMHPs, 2019) states that AMHPs should have access to both legal and management advice out of hours. As such, the Council may wish to consider implementation of a duty legal rota in addition to a management out of hours duty rota.

Carers assessments

The council has an estimated 69,000 plus unpaid carers in East Sussex. Carer’s assessments are undertaken by adult social care and health directorate practitioners which may result in provision of advice, guidance and information or delivery of services. Eligible carers can receive a personal budget as a Direct Payment enabling them to use it flexibly across the year. During 2022/23 the Council undertook 1,433 carer assessments. January 2024 reporting shows that 76.1% of carers assessments were completed within 28 days from the date request for assessment was raised.

Care for the Carers

Care for the Carers provides a wide range of services, including: four carers centres across East Sussex, one to one and peer support, counselling, carers breaks, companionship support, and cover for healthcare appointments. In 2022/23 the service provided information, advice and support to 9,717 carers which included 2,448 carers not previously known to the service. The council provides a fund for small grants, administered by Care for the Carers, which supports a range of carer focussed community projects across East Sussex with a value of up to £15,000 per year, per grant. 

The service also offers a carers mental health project offer which promotes understanding of the experiences of carers and promotion of their voices within the mental health and social care system. Since the project started in 2022 over 574 carers have been supported. The project offer is led by specialist mental health workers who provide a varied range of services such as of one to one support carers, a carer education programme to include understanding of mental health services and targeted engagement work with the Councils mental health system partners to stimulate increased carer identification and referral. 

Considerations 

Care Act needs assessments

Waiting times for assessment are regularly monitored at the performance board and by the directorates operational management team (OMT). Reducing waiting times and optimising the experience of adults with care and support needs and carers on waiting lists is seen as a priority for the council. 

As of January 2024 57 per cent of assessments were completed within 28 days with an overall waiting list of 630 people awaiting a needs and or carers assessment. 

The performance board actively monitors the number of Care Act needs assessments started and completed within 60 days. Over the last three years there has been a positive trend in reducing the length of time it takes to complete an assessment. 

Financial assessments

As of January 2024 there were 1,213 financial assessments awaiting some form of action before the assessment could be concluded. Adults who draw on services and carers reported a challenging relationship with the finance team and difficulty in understanding the financial assessment documentation which creates unnecessary confusion and anxiety. In addition, a lack of communication was reported concerning how financial contributions were reached as well as changes in financial contributions. The council may wish to consider a thematic review of current practice and process and a review of financial assessment documentation in coproduction with people who draw services and carers.

Equipment and minor adaptations

People who draw on services and carers reported significant delays in both assessment and delivery of equipment and minor adaptations during the peer challenge especially if they resided in a rural area of the county. In October 2023 the council served a contract default notice to the provider and are currently working with the provider to ensure commissioned timescales are met.

Deprivation of Liberty Safeguards

Outstanding Community and Deprivation of Liberty Safeguards (DoLS) assessments stand at 1,114 as of January 2024. The council, as with the majority of councils nationwide, faces backlogs of unauthorised DoLS applications due to overwhelming demand surpassing available resources. 

Currently there is no legal justification that exists for unauthorised applications and as a consequence the Council, who are the Supervisory Body are susceptible to judicial review. As such it is highly recommended that the backlog of unauthorised DoLS is added to the adult social care and health risk register, accompanied by a series of robust control measures.

Annual reviews of support plans (does not include carers reviews)

As of January 2024 2,407 annual reviews were overdue (1,160 overdue by up to 6mths, 630 overdue by 6mths to one year and 617 overdue by one year). 

The council has a county-wide reviewing team which undertakes reviews for people who have relatively settled packages of care and who would originally have been assessed by a neighbourhood support team. Neighbourhood support teams maintain case responsibility for cases that are more complex or volatile. With regards to Mental Health and Learning Disability Teams these teams maintain case responsibility and undertake reviews as part of this. Performance on annual reviews is a priority for the council given that benchmarking against south east authorities indicates that the councils performance (at the time of the peer challenge) was below the South-East average (performance for April to December 2023 was at the south east median figure of 59.1 per cent). Performance data is reviewed monthly by the adult social care and health departmental management team. 

A review project was established in 2023 regarding those adults who had recently transitioned into adult social care with 60 reviews being completed since June 2023. This has had positive impacts on other teams, reducing their review backlog. 

The peer team identified that gaining a grasp on the backlog of reviews was essential. Firstly, considering the possibility that a portion of these residents may have experienced a reduction in their care and support needs that could potentially result in reduced to no costed support, and secondly, the potential harm to the council's reputation, not only from possible Local Government Ombudsman complaints that would be upheld if found that a review had not been completed but also from the impending Care Quality Commission (CQC) assessment of assurance given the low completion rate. Considering both these areas, the peer team was surprised to see that the backlog of reviews was not documented in the adult social care and health risk register. The peer team proposes that the inclusion of the backlog of reviews into the adult social care risk register be deliberated by the directorate management team (DMT) along with risk mitigation plans on how to rapidly reduce the backlog further.

Management of waiting lists

Although most teams across the adult social care and health directorate have waiting lists the Learning Disability and Older Persons Mental Health Teams have a considerable issue due to high vacancy levels and continued increase in demand. It should be noted that although the Care Act 2014 does not allow for waiting lists, nationally there is not a Local Authority adult social care department that does not have some form of waiting lists due to depleted budgets and rising and continued demand for adult social care. 

The peer team identified that across the adult social care and health directorate there was not a consistent approach in place regarding the management of waiting lists. For example not all teams were making case note recordings where review and monitoring of those on waiting lists had taken place which may result in the perception that monitoring has not been undertaken as there is no case note evidence. In addition, there is no documented management oversight process in the adult social care database LAS of when cases on waiting list have been reviewed by management which could evidence management oversight, assurance and risk mitigation actions.

Neighbourhood Support Teams triage all referrals on the day they are received and priority rate in accordance with perceived risk and level of need and complexity. The assessment waiting list is reviewed fortnightly and any new information contained in the adult social care database, LAS, is used to agree re-prioritisation. This current approach relies on new issues being raised and recorded onto LAS but does not appear to consider those people who may be in greatest need/at risk but no new evidence has been raised. 

Currently all those on waiting lists receive a letter within the first week giving them contact details, in case their situation changes. The peer team questioned the routine use of letters due to sight difficulties or people with high levels of anxiety who may not open mail.

Mental health and learning disability teams manage those on waiting lists differently to the Neighbourhood Support Team as they will call the adult (and or representative/carer) and undertake welfare visits where necessary whilst the adult is awaiting an assessment. Contact with the adult (and or representative/carer) is then routinely recorded within the LAS case management system.

Across the directorate waiting lists are formulated in an excel spreadsheet as currently LAS cannot report on waiting lists. This is not an uncommon situation as a number of the databases used nationally cannot monitor/report on waiting lists. However, due to the use of spreadsheets the peer team were concerned that it may be difficult to ascertain if a person is on more than one waiting list and thereby may be at increased risk.

It is recommended that a standardised approach is implemented across the directorate regarding those adults/carers on waiting lists and how their safety and wellbeing are monitored whilst awaiting an assessment. A standardised approach will ensure a consistent management approach and enhance the overall customer experience. It is recommended that the approach should consider assessment of risk as well as mitigating actions to reduce risk whilst a person awaits assessment, the most appropriate form of contact should be agreed with the adult and or their representative and where necessary welfare checks undertaken. Finally, all contact monitoring made with the adult whilst they are awaiting an assessment should be recorded into LAS to evidence oversight and safe management.

In addition the peer team strongly recommend adding waiting lists to both the adult social care and health risk register and the corporate risk register along with plans on how to reduce the lists and mitigation actions on how the safety and wellbeing of adults will be assured whilst they are awaiting assessment. 

Carers Voice

The council is in the upper quartile of Adult Social Care Outcome Framework (ASCOF) measures for carers being consulted and reporting quality of life and social contact. With regards to carers satisfaction levels with adult social care services 37.6 per cent of carers identified as very or extremely satisfied which is slightly higher than the national average of 36.3 per cent. The council also undertake an internal survey, ‘Listening to You’ which asks carers to rate their experience of assessment and reviews and their overall rating for adult social care and health services.  In the most recent survey 83 per cent of carers felt their experience of assessment and review was positive and 73 per cent reporting positive overall rating for adult social care and health services.

During the peer challenge carers reported not feeling supported especially those that were self-funders. Carers reported ongoing difficulty in navigating care and support pathways and processes and ongoing struggles with managing their finances due to their caring commitments. Several carers voiced the trauma and impact on their mental health in having to give up work as a result of their caring role which they felt was not acknowledged by the council. The majority of carers spoken to felt that carers assessments where a “tick box exercise” which provided little practical advice and or support and in addition a lack of physical and financial support for carers. As part of the councils project work around carers they may wish to run a series of focus groups with carers to gain their views, wants and needs which will support the council in the further development of their carers offer.

Self-funders

Those that self-fund reported limited support in place for self-funders, with scarce information and advice. The council may wish to consider a review in coproduction with self-funders of their current self-funder offer in regards to the quality of the information and advice they are providing to assure they are delivering their Care Act statutory duties effectively for self-funders.

Quality statement 2: Supporting people to live healthier lives

Strengths 

Prevent, reduce and delay

The adult social care and health directorate have a Prevention Strategy in development which will be linked to both the council’s corporate priority of ‘helping people help themselves’ and the Adult Social Care and Health Strategy which promotes a preventative, personalised and strengths based approach to prevent, reduce and or delay the need for long-term care and support. To support the prevention agenda an integrated front-door (Health and Social Care Connect) was established whereby occupational therapy and community healthcare are strategically placed to provide early intervention and non-dependency solutions. 

The council utilise a range of technology enabled care such as lifeline units, gas leak, flood and power cut alerts, robot pets, police approved key safes, home security, interactive screens, whizzan blue boxes used in nursing homes (via in-reach teams), reminders to take medication, eat, drink and a range of other tasks. Currently in excess of 4,500 residents have been supported through some form of technology enabled care to support their independence. 

In addition, there are a range of Public Health preventative services in place, including the Warm Homes Grant, One You East Sussex (an integrated health and wellbeing service) and a investments in Welfare Benefit and Debt Advice services. The council also undertakes annual winter mailing which is sent to all clients and carers providing information on vaccinations, access to financial support and staying warm. 

The council are keen to further develop their prevention offer and widen the range of technology enabled care utilised.  As such work is underway to develop a prevention strategy in partnership with residents, Public Health, the NHS, Primary Care and the voluntary, community and social enterprise sector as well as the private sector. The ambition of the Council is to have this partnership prevention strategy in place by early 2025.

Befriending scheme

As part of the partnership prevention work between adult social care and health and Public Health it was identified there was a need to develop a befriending scheme to tackle chronic loneliness and isolation and improve older adults mental health and well being. The scheme was coproduced with residents who draw on care and support services to ensure the user voice was central to the service design. People who draw on care and support services spoke highly of this service and how it has given them a ‘lifeline’.

Day services 

The council has numerous day services for a wide ranging cohort such as those adults with a learning disability, dementia, Parkinson’s, carers, residents over 50 and 55 without care and support needs but were loneliness and or isolation may be an issue. All these day services are run by independent and voluntary, community and social enterprise providers which provide a wide range of activities. For those adults who are supported by the council these services can be spot purchased by the council of purchased via direct payments. As of April 2023 at least 370 adults with care and support needs were accessing independent sector day opportunities.

East Sussex community support service for adults with a learning disability

The service supports people with a learning disability in their own home or in supported living. The service aims to improve quality of life and to enhance skills so that people can live as independently as possible. The service is rated ‘good’ by the CQC.

Considerations

Information and advice

In 2021/22, the council was in the top quartile for the ASCOF measures on the proportion of adults who draw on services and carers who found it easy to find and access information. In the Councils recent ‘Listening to You’ survey 66 per cent of clients and 77 per cent of carers responded positively to questions about access to information and advice. This is in contrast to conversations had during the peer review with adults who draw on services and carers who reported not knowing where to go for information or who to contact.  Furthermore difficulty in navigating the councils adult social care and health webpages were also raised as well as guidance and information not always being available in the accessible formats required. 

The council may wish to conduct a mystery shopper approach of its current website, whereby residents, people who draw on services and carers navigate the site and provide feedback on the availability and accessibility of information and advice. Healthwatch has supported this methodology in other councils and coordinated the mystery shopper approach in conjunction with the council with beneficial and cost-effective results.

Direct payments

There are 1,551 of adults in receipt of direct of payments who are drawing on the councils adult social care and health support services (this does not include carers) which equates to 29.3 per cent of the total population of adults drawing on services as of January 2024. The council have in place both a direct payment policy and staff practice guidance. Information regarding the councils direct payment offer can be found on their website and is available in a number of different accessible formats if required.

The council has two commissioned voluntary and community sector organisations who provide direct payment support services. Both services provide information and advice regarding the use of direct payments, support in the recruitments of personal assistants, from advertising vacancies to employment law, support with banking and payroll and support with Disclosure and Barring Service (DBS) checks. Adult social care and health directorate staff and managers reported that the current personal assistant process was extremely difficult and convoluted and can take up to six months to secure a personal assistant which is having a significant impact on hospital discharge.   

The council have implemented a direct payments action plan in response to a survey conducted which stated that only 20 per cent of people said they faced no challenges with their direct payments and that direct payments processes could be made less complex. The action plan aims to improve current processes making the use of direct payments and accessing a personal assistant easier and less complicated for people.

With regards to the reviewing of direct payments the Councils policy on reviewing of direct payments (Operational instructions: for all operational staff, Direct payments core guidance, November 2023) states that an initial review will be completed within six weeks of the adult receiving direct payments and thereafter, scheduled reviews will take place annually as part of the annual support plan review.  Given the backlog of reviews the council is not meeting its internal policy guidelines or its statutory duty as outlined in the Care and Support (Direct Payments) Regulations 2014 (section 7.1). The lack of monitoring of direct payments has also been raised in a number of Safeguarding Adults Reviews (SARs) involving families/carers of adults with care and support needs concerning control and coercion and the families disguised compliance with adult social care services. As such, the peer team recommend that the council place the annual review of direct payments onto their adult social care and health risk register along with risk mitigation plans.

Quality statement 3: Equity in experiences and outcomes

Strengths 

Coproduction

The council have a wide and varied range of expert by experience panels and boards that are actively involved in commissioning decisions. For example; ExtraCare where the Design Council methodology was utilised to engage with people who draw on ExtraCare and what the customer journey should like moving forward. 

In 2022 the Council implemented the Citizens Panel to help develop the Adult Social Care strategy which was published in 2023. The group helped agree the six priorities outlined in the strategy, which sets out a plan to enable care, support and independence for adults across East Sussex. The panel now meet four times a year to review how strategy actions are being taken forward and co-develop and feedback on a range of Adult Social Care policies and services.

Equality and inclusion strategy action plan 2023-2024

As a result of the coproduction work with residents and people who draw on adult social care services in developing the Adult Social Care and Health Strategy barriers for people from seldom heard communities who may experience health and social care inequalities were identified. As a result the Council undertook a dedicated piece of work during 2022/23 which resulted in the development of  a report and action plan on seldom-heard people and communities. The plan was agreed corporately with sign off received from the Peoples Scrutiny Committee and is overseen by the Equality, Diversity and Inclusion Scrutiny Review Board. an Adult Social Care and Health Equality and Inclusion Strategy Action Plan for 2023-2024. The action plan is linked directly to the Adult Social Care and Health Equality and Inclusion Strategy 2021/24, which and consisted of five objectives.  Each of the Strategy objective has a subset of actions to promote the voice of those from seldom heard groups by removing barriers, increasing engagement and further training for adult social care and health staff.   

Equality, diversity and inclusion

The council has a range of diverse services to promote equality and inclusion whilst recognising the importance of diversity. For example, the Havens Carers Project (delivered by Care for the Carers) which supports carers in areas of high deprivation, and Alcohol Care Teams which are also designated in areas of high deprivation (Hastings and Eastbourne). 

Equality, diversity and inclusion data and reporting

To improve the current recording and subsequent use of equality, diversity and inclusion (EDI) data the Council are working in partnership with Sussex NHS Foundation Trust on a collaborative project ‘Ensuring Everyone Counts’. The project aims to improve the recording of EDI information across the Council and NHS providers. Currently the Councils performance team reports regularly on gaps in recording EDI data and training sessions are offered to adult social care and health directorate teams about the importance of the collection of EDI data.

Building and enhancing social justice in the workforce

The adult social care and health directorate ‘Building and enhancing social justice in the workforce’ group consists of a range of staff across the adult social care and health directorate. To date the group have recruited a dedicated project manager to lead on reducing violence, harassment and discrimination against staff. The group were successful in their bid to be an Improving Adult Care Together (IMPACT) demonstrator site to work with national experts to reduce violence and discrimination experienced by social care staff.  The group also host the Equalities Allies meetings and support in the development and delivery of equality, diversity and inclusion training. 

Considerations 

Rurality leading to inequitable service provision

Due to pockets of rurality postcode inequalities regarding service delivery/provision were identified as well as increased isolation for those living in such areas due to limited transport. However, to combat this issue the Council have ‘Flexibus’ which can be booked residents to take them to destinations such as the nearest town, bus route or train station, hospital or shops. Flexibus was seen a ‘lifeline’ by those carers and adults who draw services spoken to during the peer review.

Implementation of workforce racial equality standards (WRES)

To further promote the work the council are undertaking in addressing workforce inequalities they may wish to consider implementation of the workforce racial equality standards which are a statutory requirement of NHS organisations.

Quality statement 4: Care provision, integration and continuity   

Strengths 

Provider market

The council have 50 Home Care providers and 300 Care Homes with no registered provider rated as inadequate by the Care Quality Commission (CQC). Supply is generally good, with a joint market oversight panel with the NHS Trust in place. The Council has good relationships with the provider market which was identified as a key strength by the peer team. In 2022/23 the Council used 100 per cent of the Fair Cost of Care grant on fee uplifts, providing a 10 per cent fee uplift across all services. However, with the cost of living crisis significantly impacting the sector as well as post covid impacts, the council is finding it increasingly difficult to maintain ‘published rates’.

Commissioning and joint commissioning

The council has robust and transparent relationships with system partners, providers and key stakeholders. District and Borough Housing departments work with commissioning as one equal and virtual team. Joint Commissioning teams have been in place for many years with the adult social care and health directorate hosting the Adult Social Care and Health Joint Commissioning Team and the Mental Health Joint Commissioning Team. Staff are drawn from the council and the NHS. Jointly commissioned services are available to people whether their support needs are being met by the NHS or by adult social care, which has resulted in a significant decrease of unnecessary hand-offs and silo working. The Joint Mental Health and Integrated Care Board Commissioning team has resulted in a holistic approach to commissioning with a shared understanding and ability to address social determinants of health across the County. The joint commissioning approach has supported effective delivery of section 117 aftercare services (Mental Health Act 1983 (as amended, 2007)) via a partnership procedure and 50/50 joint funding arrangements which has successfully promoted timely discharge from hospital. 

Joint community reablement team

The joint community reablement team was identified as an outstanding partnership provision which is jointly funded and provides a reactive service in terms of supporting a timely journey out of hospital and a robust reablement offer. The service is staffed by a multi-disciplinary team of health and social care professionals working within the new integrated care framework. The service offers in reach to acute hospitals via their in reach team. The team join ward rounds and undertake initial assessment of patients in hospital when required. The team can immediately establish if the person is suitable for joint community reablement discharge, if consent can be obtained which has reduced the length of stay for a person discharged with joint community reablement services by over two days. 

The service also has a number of intermediate care beds and an integrated Therapy Lead. Milton Grange is a thirty bedded unit, with a 10 bedded dementia unit, with a length of stay on average 35 days, and 20 general beds, with an average length of stay of 28 days. 

Recruitment and retention is a challenge for the service and there is focus ‘on growing their own’ staff. The service appears to be actively identifying solutions to their recruitment and retention difficulties such as staff appreciation awards, improved training and professional development programmes.

Market support team

The market support team offers support across all cohorts and is seen as a critical friend to providers. The team are proud of their working relationship with CQC locally. The team undertakes a market oversight panel every two weeks and use this to direct support to providers. The panel is attended by adult social care and health operational teams and providers from regulated services. This approach has resulted in provider improvements in service delivery and CQC ratings. Officers in the team are highly experienced and all come from provider backgrounds. 

Coproduction in commissioning

Many examples were provided of how people who draw on services, carers and residents are regularly involved in the commissioning cycle. One such example was the commissioning of the Mental Health Support Services contract (£3.6 million contract value) whereby wording in the specification was changed to what people who draw on services wanted from the services as well as people who draw on services being involved in the tender process.  Another example is the Involvement Matters Team (IMT) which is facilitated by the adult social care and health directorate and is made up of adults with learning disabilities who draw on adult social care services. Members of the IMT sit on the Learning Disabilities Partnership Board which is co-chaired by a member of the IMT. The board is the overarching reference group for adults with learning disabilities in East Sussex. The IMT are heavily involved in co-production and service development across East Sussex, including creating specific questions and KPIs for tenders and sitting on tender panels, delivering parts of adult social care and health training and production of numerous ‘easy read’ documents.

Considerations 

Young adults transition with complex and challenging needs

The council is acutely aware of service provision gaps in relation to young adults who are transitioning from children’s social care to adult social care who present with complex and challenging needs. Although a relatively small cohort of young adults, the number is increasing and the lack of suitable provision presents a significant issue across the adult social care and health directorate, especially when placements breakdown.

Although the council has well established and positive relationships with a small number of providers who are able to support these individuals in very specialised placements the council is only able to find appropriate accommodation out of county. To address the increasing demand for highly specialist placements the council is working in partnership with system colleagues including the Integrated Care Board (ICB), the NHS Trust and district and borough colleagues. A partnership pan-Sussex strategic approach has been initiated to consider how collectively the health and social care system can respond to this challenge.

Hospital discharge

The overall picture for hospital discharge in Sussex is challenging. The council have a Hospital Discharge Team in place which up until recently were operating under the Discharge to Assess (D2A) model. However at the request of their NHS partners, the team have reverted back to undertaking assessments in acute settings and in the community. System partnership work is underway to implement a Transfer of Care Hub which will run in conjunction with a discharge hub from the hospital.  It is hoped this will provide a single version of the truth. Although the Transfer of Care model was seen as positive there seemed to be limited evidence of a robust strategic framework. 

The council commissions D2A beds for the East Sussex place (c.56 beds) and uses a combination of approved home care providers, block hours and the joint community reablement team to ensure timely discharges. The council have worked closely with providers and colleagues in acute to ensure good occupancy in D2A beds and to reduce the average length of stay (which had increased during the pandemic and over winter 2022) from 60 days in March 2023 to 31 days in October 2023, for block commissioned beds. A D2A partnership panel meeting takes place every two weeks looking at delayed discharges over 21 day cases. With regards to specialist mental health discharges these are led by the council's mental health teams.

Carers and adults who draw on services reported that communication around hospital discharge and returning home was poor, causing unnecessary anxiety to both the adult being discharged and their carer. It was not clear to the peer team if these issues arose due to acute hospital processes or adult social care processes.

Contract monitoring

The council does not have a dedicated contract monitoring function and there are not dedicated contract monitoring dedicated posts within the adult social care and health staffing/operational teams structure. Commissioning officers with support from project managers appear to lead on contract monitoring although this was slightly unclear to the peer team. All regulated provider services have a documented Quality Assurance System in place to monitor the 5 CQC key areas of safe, caring, responsive, effective and well-led. Commissioners and project managers conduct audits, site visits, reports, mock inspections and gather resident/client and other stakeholder feedback. 

The peer team were in agreement that current contract management arrangements may present as a risk to the council. The peer team concluded that a dedicated and structured approach to contract management would provide increased visibility and assurance over the efficacy of council commissioned contracts and the opportunity to monitor and measure the impact and outcomes for people. 

Market position statement

Despite the demographic changes and challenges the Council face these do not appear to be articulated in the current market position statement. It is recommended that the council acknowledge these challenges and expand its scope to look ahead and signal to the provider market what services need to be developed to support emerging and future needs.

Voice of providers

Both Extra Care Services and Home Care providers reported good working relationships with the council.  Council commissioners were seen as being actively interested in contract and quality assurance meetings/visits and that communication was regular. 

This was in contrast to the views of Care Home providers who reported a more challenging relationship. For example the NHS Capacity Tracker not being used by the brokerage team to understand availability or voids resulting in the brokerage team cold calling care homes for bed information which is available to them via the tracker but not being utilised to streamline the process.

Residential nursing care home providers reporting receiving more complex cases which require more resource and funding. It was felt that commissioners do not know the difference between what care can and should be delivered by nursing care homes and what care can and should be delivered in residential care homes. However, residential nursing providers reported that open and frank conversations can be had with commissioners. 

The majority of providers spoken to, homecare and care home providers, reported they would value reinstatement of the provider forums to share learning and allow for networking between local providers[1]. 

Quality statement 5: Partnerships and communities

Strengths 

Learning disability

The council’s Learning Disability Team is a long standing well established team staffed with highly skilled and passionate practitioners and managers.  It was clearly evident that there was a strong team spirt with staff supporting one another where necessary. Numerous case examples where heard which showcased a person centred and strength based approach. The team are co-located with learning disability health colleagues which promotes a seamless pathway and a ‘no wrong front door’ approach.  The team can access a range of bespoke training developed especially for working with adults with a learning disability, for example DoLS training and learning MAKATON. The average caseload in the team is approximately 20 which is in line with national best practice (20-25 cases). The team have developed a caseload tool which RAG rates complexity and ensures cases are allocated appropriately dependent of skill level, knowledge and experience. Staff spoken to were clearly legally literate with an in depth understanding of the Care Act and the Mental Capacity Act. The team are keen to support apprentice social workers and occupational therapist and tailor caseloads to accommodate apprentices university studies as well as providing shadowing by a supervisor.

The team working closely with commissioners and the Involvement Matters Team in the ongoing development of services.  With regards to adults who draw on services there is a range of choice available such as ‘Steps to Work’, a supported employment service that helps people with a learning disability and/or autism into work which include a number of community-based projects such as working in a café and car cleaning service, as well as routes into employment via work placements with local employers.  In relation to the national performance measure of those adults in paid employment the council continue be rated nationally in upper middle quartile.

However, there appeared to be no transitions pathway or guidance available for when people at age 26 or over come into the team. The council may wish to consider development of practice guidance and pathways as part of their Transitions Transformation Programme. 

Integrated care partnership: Sussex health and care assembly 

The Sussex Health and Care Assembly, chaired by the chair of NHS Sussex, is the statutory joint committee between the NHS and local government (NHS Sussex, Brighton and Hove City Council, East Sussex County Council and West Sussex County Council) that comes together to formally agree the strategic direction of the Sussex health and social care system. Its core purpose is to agree the strategic direction and facilitate joint action and commissioning across a broad alliance of organisations to improve the outcomes, equality of access and patient experience of health and care services for all communities across Sussex.  Evidence of maturity in the system was clearly evident with the council seen as a well established system partner. There was considerable evidence of East Sussex seen as a ‘place’ which the council clearly champions. To support this place based approach Integrated Care and Neighbourhood teams provide a localised approach which was seen as a benefit to residents. With regards to political engagement this was seen as good with local Members of Parliament (MPs) briefed on relevant issues. 

Voluntary, community and social enterprise sector (VCSE)

Partnership Plus, hosted by the council, provides a forum for senior officers from the voluntary, community and social enterprise (VCSE) sector and public sector, including the council’s chief executive and director of adult social care and Health. Partnership Plus leads on a number of cross sector activities including a collaborative commissioning programme and a loneliness stewardship group. The council invests in the Three Voluntary Actions in East Sussex; Voluntary Action for Eastbourne, Lewes District and Wealden, Hastings Voluntary Action and Rother Voluntary Action. Partnership Plus was seen as an enabler with various working groups that feed into a shared and unique partnership arrangement such as the Commissioning for Excellence Programme which aims to establish East Sussex as a centre of excellence for VCSE commissioning. 

VCSE providers reported good relationships with the council who have retained funding to the sector and continue to listen and learn from them regarding areas of local need, localised safeguarding trends and interventions required. In addition the council have commissioned the voluntary and community sector to work with seldom heard and marginalised residents/communities. With regards to the council's Adult Social Care and Health Self-Assessment providers praised the council as the voice of the VCSE sector was clearly and transparently represented. 

VCSE sector providers reported a strong working relationship with the council that is genuinely collaborative, open and transparent with a culture of ‘making things happen’. Furthermore the council was seen as a listening and learning organisation with the council’s Director of Adult Social Care and Health seen as ‘persistent’ in a positive way. However, challenges do exist such as housing which is an issue for both residents and the VCSE sector workforce given the high cost of housing across the county. In addition, challenges from health partner demands and pace of change was reported given new structures are being implemented especially in relation to the Integrated Care Board (ICB). 

Mental health social care 

Up until fourteen years ago delivery of mental health social care was delivered via a Section 75 Agreement.  Despite the Section 75 no longer being in place the council’s Older Peoples Mental Health Team and the Mental Health and Substance Misue Team remain collocated with NHS mental health colleagues. Significant evidence of effective collaborative multi-disciplinary working to improve patient outcomes were identified. It was clearly evident that the Councils mental health social care teams were seen as valued partners by the NHS Trust and that each partner was well aware of their roles and responsibilities which has resulted in no duplication of effort and clear lines of accountability and governance. 

With regards to the council’s presence in the integrated care mental health system, the council’s Director of Adult Social Care and Health is clearly visible and chairs the mental health discharge front runner programme. The council are members of the NHS Trust run Complex Care Panel which promotes a social care lens. With regards to moving on from the Care Programme Approach and local Community Mental Health Transformation plans the council was seen to play an integral role and are active partners in the transformation programme. 

Mental health social care practitioners and managers spoken to were extremely knowledgeable, skilled and experienced and their passion and dedication was clear to see. Both teams evidenced innovative and creative practice ensuring adults with mental health and or substance misuse difficulties achieved their desired outcomes. Threshold requirements for assessment are aligned to Care Act, for example where there is an appearance of need. In addition, there was significant evidence of an early intervention and preventative approach aligned to the council’s statutory duty to prevent, reduce and delay the need for long-term services. 

In respect to local population based issues such as suicide in older men there is demonstrable evidence of joint plans with active engagement from the council. An example is the Beachy Head focused work programme regarding suicides (50 in last year) championed by the Director of Public Health working in close collaboration and partnership with the NHS Trust and the Integrated Care Board. 

In respect to challenges, appropriate accommodation on discharge was identified as lacking which is creating unnecessary delays of adults being discharged from hospital. In addition, both mental health social care teams have difficulty regarding recruitment given the high cost of housing in the local area. 

People with lived experience of drawing on mental health services reported that further work is required around discharge and discharge planning to stop the increasing issue of revolving door patients, such as discharge planning commencing on admission to ensure that by discharge robust plans are in place. A lack of community assets which focuses on recovery and wellbeing that can reduce loneliness and isolation was also seen as lacking as well as a lack of early intervention to reduce/prevent the risk of hospitalisation. It was also felt that there was not a consistent mental health community offer across the county e.g. wellbeing centres in some areas but nothing in other areas. The need for support with benefits and keeping ones tenancy, especially if admitted to hospital was also seen as lacking. The council may wish to consider how it utilises housing officers who could provide information, advice and support with tenancies and benefits. This approach has been successful in a number of local authorities across the country. In relation to accommodation issues the council may wish to consider the successful approach developed by the London of Borough Croydon whereby a mental health partnership board was implemented to address housing issues for those residents with a mental health condition that had representation from adult social care, housing and the local NHS Mental Health Trust. 

Approved mental health professional service

The council operates an Approved Mental Health Professional (AMHP) hybrid model consisting of a highly skilled daytime AMHP team resourced by five full time equivalent AMHPs who are supported by a bank of duty AMHP colleagues who work in substantive posts across adult social care and the NHS Trust. The daytime AMHP team is collocated with the NHS Trust Crisis Team which promotes early intervention, prevention and least restrictive options. There are also AMHPs in the council's children’s social care Multi-Agency Safeguarding Hub (MASH) MASH which is certainly a best practice model and again ensures early intervention and prevention and least restrictive options. As with most NHS Mental Health Trusts bed availability is an ongoing issue however there is a robust section 140 joint policy in place which is invoked by AMHPs when necessary. 

Social supervision and forensic social work

Forensic Services are operated by the NHS Trust and delivered under a Section 75 arrangement. The service consists of nurses and four social workers. Care Coordinators act as social supervisors. Forensic social workers were extremely knowledgeable and skilled senior practitioners who evidenced robust risk assessment and management abilities, supported by a wealth of risk management tools.

Considerations

Integrated Care board 

Conflicting accounts regarding the working relationship between the council and the Integrated Care Board (ICB) were heard during the peer challenge. From an ICB perspective they felt there was maturity in the system and that the council were proactive and not at all parochial and were happy to contribute to systemwide discussions and always step in and support (e.g. leading on system Mental Health discharge). In addition they felt that the council sees issues with a longer lens over the whole of Sussex rather than a focus on their own geographical boundaries. With regards to relationships with community providers these were seen as positive with evidence of active collaborative work between health and social care locally. 

Challenges however were identified by the ICB with regards to those young adults transitioning with complex and challenging needs but that early stage discussions were being had with the council and families which were seen as positive and helpful. A further difficulty raised were current planning cycles given they work differently between health and social care. It was acknowledged by the ICB that this must improve given current financial pressures on both organisations. 

With regards to Continuing Health Care (CHC) assessments council practitioners and managers reported a progressively challenging and tense relationships between adult social care and the ICB with an increase in disputes. The council have in place a designated CHC team consisting of highly skilled and experienced social workers and resource officers. Practitioners reported that despite their proficiency in completing CHC checklists the default stance of the ICB is invariably ‘no’ resulting in practitioners routinely seeking legal guidance to assist them in contesting CHC outcomes. 

Section 117 Aftercare (Mental Health Act 1983, as amended, 2007) 

Adult social care and health practitioners and managers reported ongoing challenges in regard to Section 117 Aftercare and the approach taken by the NHS Trust.  Practitioners reported ongoing issues with NHS Trust having limited knowledge of Section 117 resulting in the NHS Trust often inappropriately discharging people from Section 117 without discussion with council and or the person. Although joint assessments and reviews are taking place and recorded in LAS there appeared to be differing Section 117 process and practice for teams across the NHS Trust. The Council in collaboration with NHS Trust may wish to review current practice and process across all teams (council and NHS Trust) to ensure current practice is aligned to Section 117 of the Mental Health Act and the Code of Practice (2015).

Dementia pathways and service provision

Both the NHS Trust, the council and the ICB are aware that the current dementia offer is not robust and further work is required to improve the offer. The integrated joint mental health commissioning team have implemented interim plans and system partners are working towards the development of a long-term provision offer, however this is not yet in place. Council practitioners and managers reported a significant gap in relation to accredited dementia friendly home care resulting in adults with dementia being put unnecessarily into respite from hospital rather than discharged home with a package of support.   

This area relates to safeguarding, safe systems, and continuity of care. 

Quality statement 6: Safe systems, pathways and transitions 

Strengths 

Safeguarding Adults Board

The council has an extremely robust Safeguarding Adults Board (SAB) in place with a highly experienced, knowledgeable and skilled independent chair who is an ex-director of adult social care. The board is rightly proud of their robust partnership safeguarding approaches and interventions across the health and social care system. The board is made up of senior representatives from a range of statutory services (including representation from the East Sussex Children Safeguarding Partnership) who all are dedicated and passionate in ensuring there is an ongoing collaborative partnership approach to safeguarding across the social care and health system. The board have a range of safeguarding dashboards in place to monitor outcomes across statutory partners and both a strategic plan (2021/24) and an annual report (2022/23) are in place with the most recent report (2023/24) in development. 

In addition to undertaking Safeguarding Adults Reviews and ensuring learning is disseminated across partner agencies bespoke thematic review programmes of work are also undertaken, for example, thematic review of transitional safeguarding where both safeguarding adult reviews and children’s serious case reviews were analysed.  This resulted in the development of partnership transitional safeguarding policies and procedures and a pledge to ensure there are no longer any cliff edge cases. To date all statutory agencies have signed up to the pledge. This is indeed an area of best practice that should most certainly be celebrated.

It was evident that there were robust working relationships between the Safer Communities Partnership, the Domestic Abuse Partnership Board, the Safeguarding Adults Board and the Children Safeguarding Partnership which again is area of best practice that should be celebrated.

Currently there is no lived experience representation on the board, however work is actively in progress to address this.  In addition, further work is being undertaken to understand how learning from safeguarding adult reviews is embedded across partner agencies and how effective these processes are. 

Considerations 

Preparing for adulthood and transitions 

The pathway for those young adults preparing for adulthood is disjointed and unclear and leaves the council open to litigation and or reputational damage. Transition assessments including financial assessments are not completed until the young person is aged 17.5 years of age and those aged 14 to 18 years remain with children’s social care. Although the council do seem to be aware of young people who will be transitioning, they are tracking cases via an excel spreadsheet which is not the most appropriate or safest way to track and monitor and cases. Adult social care and health practitioners and managers reported ‘a poor transition process’ regarding those young adults with a learning disability which is often resulting in cases being transitioned to the adult learning disability team at age 25 or 26. In addition, these cases normally have no clear plan in place which causes unnecessary anxieties for families and practitioners. During the peer challenge general practitioners reported ongoing issues regarding a lack of clear and transparent pathways and processes for those young people transitioning into adult social care. 

In regards to the backlog of annual reviews regarding those young adults who have recently transitioned a project was implemented in 2023 to clear the backlog with those who have direct payments being prioritised. However, practitioners reported that the amount of work involved has been underestimated and that progress has been slower than anticipated. Progress is being tracked via a spreadsheet with weekly progress updates. Some Carers assessments have been included in the project since January 2024 but information not captured. 

Good working relationships with health colleagues was reported regarding those young adults with complex needs and challenging behaviour, with weekly meetings held with two transition nurses known locally as Roald Dahl nurses.

The peer team were in agreement that creating a dedicated transitions team and a transitions pathway which is coproduced with young people and their families feels like the next step following the current project to catch up with reviews of 18-24 year olds.

Section 11 (2) (b) Care Act 2014

Practitioners and managers spoken to could not identify the process and/ or procedures in place across adult social care when an adult with care and support needs and/ or their representative refuses safeguarding intervention. This issue has been raised in several recent coroner cases where Councils have received a Regulation 28 Prevention of Future Deaths Notification for not having such processes and procedures in place. As such it is recommended that practice guidance is developed (Kent County Council have an excellent easy read practice guidance document). 

Quality statement 7: Safeguarding

Strengths 

Safeguarding in Adult Social Care and Health Teams

All adult social care and health teams have a link safeguarding worker from the Safeguarding Development Team who provide specialist advice and support. Clear measures are in place regarding the allocation of safeguarding enquiries which is supported by the use of a safeguarding allocating tool ensuring those safeguarding enquiries which are rated as high risk and complex being allocated to a senior social worker. All staff undertaking enquiries have to undertake a two day mandatory safeguarding enquiry course before they are able to complete enquiries.

Considerations 

Safeguarding statutory three stage and management oversight

Although there is a documented safeguarding customer journey in place the triaging of safeguarding concerns is clearly happening twice. Once at the front door by an unqualified senior resource officer from the Health and Social Care Connect Safeguarding team, and secondly by an adult social care and health team practitioner who re-triages the safeguarding concern as part of the duty team process. 

Further concerns were identified in that once the senior resource officer (unqualified role) from the Health and Social Care Connect Safeguarding team has made the decision not to progress a safeguarding concern there is no qualified management sign-off process to ensure this is the correct response and no facility in LAS which could evidence management sign off has been agreed. In addition staff within the Health and Social Care Connect team used pre Care Act language when referring to safeguarding concerns calling them ‘safeguarding alerts’ which is ‘No Secrets’ language.

Provider safeguarding concerns

Different pathways exist for provider safeguarding concerns dependent on the team, some may be triaged by Health and Social Care Connect where as others will be sent directly to the team. It is recommended that a consistent approach to safeguarding pathways is required with a single point of access to ensure that concerns are not ‘lost’ within the system.

Organisational abuse large scale enquiries

With regards to provider organisational large scale safeguarding only a documented customer journey is in existence. Given organisational abuse enquiries may involve six or more different commissioners and a large number of residents/adults who draw services a robust procedure and practice guidance is required. It is recommended that an organisational abuse large scale enquiry procedure and associated practice guidance is implemented (Somerset and Worcestershire County Council have best practice examples).

Person in position of trust

The council lead for person in position of trust referrals received into the council is undertaken by the Local Authority Designated Officer (LADO) for adults. The role of the LADO is a statutory role set out in Working Together to Safeguard Children (2018) (Chapter 2 Paragraph 4) and is governed by the Local Authorities duties under section 11 of the Children Act 20004. This role is specially for children social care and not adult social care. It is recommended that to align with the Care Act 2014 rather than children’s social care statutory guidance the role be change to person in position of trust lead and associated procedures and practice guidance updated. 

Safeguarding audits

The auditing of safeguarding concerns and enquiries was paused in December 2023 and is due to recommence in March 2024. A recent thematic audit of 38 safeguarding concerns was undertaken by the Safeguarding Development Team looking at the increase of safeguarding concerns to safeguarding enquiry. The audit identified that of the 38 cases 37 were deemed to have been accurately triaged.  However, given that Health and Social Care Connect receive in excess of 2000 safeguarding concern referrals a month an audit sample of 38 cannot be seen as representative and an ongoing audit programme that focuses on both the three stage test outcomes and outcomes of enquiries is highly recommended.

Inappropriate safeguarding concerns

Health and Social Care Connect reported high levels of inappropriate safeguarding concerns from police. The peer team recommend that this issue is escalated to the Safeguarding Adults Board where discussions can be had on what constitutes a safeguarding concern and training put in place if necessary.

This relates to capable and compassionate leaders, learning, improvement, and innovation. 

Quality statement 8: Governance, management and sustainability

Strengths 

Assurance and performance boards

A recent Improvement and Assurance Board has been established which works in collaboration with the Performance Board with a focus on CQC assurance. The Performance Board runs monthly from January to May and then bi-monthly from June to December and is chaired by the Director of Adult Social Care and Health. The board has standing agenda items such as national reporting measures, data quality reviewed quarterly, safeguarding performance reviewed monthly and ‘listening to you’ feedback quarterly. 

Risk register 

Each directorate within the council has a risk register that is monitored by the directorate management team. All risk registers across the council are kept within excel spreadsheets, it is unclear how therefore interdependencies can be seen or a holistic overview of risk captured. With regards to the adult social care and health risk register this is monitored quarterly via the performance board. A number of risks highlighted in the risk register do not appear to have been updated in some time and it recommended that each time the register is reviewed the date of review is added with set of notes to show oversight and management of risk. A further recommendation is for the council to consider implementation of a risk register system for the council for example Pentana. 

Annual teams business plans 

All teams have a bespoke annual business plan and risk logs that link to the adult social care strategy and corporate council plan priorities with associated key performance indicators. Business plans are discussed during team meetings and key performance indicators are reported into the performance board.

Workforce sustainability

Adult social care and health have a workforce strategy and programme in place to tackle recruitment and retention issues. For example new roles are being considered to free up specialist/professional capacity as well as ‘you said and we did’ and ‘Staying Put’ questionnaires. A new recruitment campaign has recently been launched ‘I choose East Sussex’ which includes updated branding to promote opportunities through recruitment and advertising materials including videos, social media campaigns and targeted advertising which can be adapted for different roles and locations. In addition the ‘Return to Social Work’ scheme is advertised on the council’s website giving opportunities to register interest and receive flexible support, targeting people who have previously left the profession and may wish to return. Unqualified staff who may wish to become qualified social workers or occupational therapists can also register to ‘Pathways into Social Work’.

Considerations 

Health and Wellbeing board

Mature and established relationships were identified within the Health and Wellbeing board with the ability to have challenging and positive discussions around a myriad of topics. Councillor engagement with board was identified as good. The Director of Public Health annual report is overseen by the board and outcomes of this drive initiatives on the ground. There seemed to be a consensus from the board that time to reflect and stocktake on its purpose was required. The peer team agreed that a focus on a whole life prevention strategy in the face of demographic challenges the best use of local resources may be good a starting point  

Performance data

The council's performance team provide monthly reports in Tableau, however a number of teams are also utilising excel spreadsheets meaning there is not one single version of the truth. Currently only 160 managers have access to Tableau and discussions are ongoing with managers and teams about what they want in terms of data. With regards to collating outcomes focused data e.g. outcomes that matter to an adult as part of their ongoing support planning an Imosphere upgrade to the adult social care database LAS will provide the necessary outcome reporting required.  There are a large number of dashboards in place which focus on activity, performance, safeguarding and equality with performance team staff attending monthly operations team meetings to review and share trend analysis. 

Adult social care and health strategy 

Numerous practitioners and middle managers were asked about the adult social care and health strategy and to explain the associated key principles and priorities and how they could evidence these in everyday practice. However no practitioners or managers could articulate a response and clearly had not read the strategy. It is recommended that further work is undertaken with the adult social care and health workforce to ensure they are clear on the key priorities of directorate.  

Quality assurance framework 

The quality assurance framework has recently been refreshed with the council's social work standards updated.  The adult social care and health audit programme consists of two audits a year being completed on each staff member. However, to date only 225 out of 580 have been completed.  Further work is required to embed the auditing programme across the directorate which the principal social worker is leading on with support from the senior leadership team.  Until a robust auditing process is established the council cannot assure themselves fully that practice and process is consistently aligned to Care Act and relevant legislation and national best practice guidance. 

Quality statement 9: Learning, improvement and innovation

Strengths 

Supervision

The supervision policy has recently been updated and linked to the quality assurance framework. Staff are expected to have monthly supervision which is monitored by a monthly report. Currently audits of supervision are not in place to determine the quality of supervision. It is highly recommended that audits of supervision is undertaken as part of the audit programme. 

Culture

All staff spoken to were dedicated and passionate about improving outcomes for adults with care and support needs and seem to enjoy/like working for the council. 

Corporately there is an A-Z to wellbeing offer which staff reported as good. This was evidenced in the recent Local Government Association Social Work Health Check Survey with 86 per cent of council employed social workers stating there was a good wellbeing offer in place. Practitioners and managers are expected to be office based for set days to ensure the sense of team can develop. Good case load numbers, an average of 22 were reported with allocation practice guidance in place to support managers in allocating cases to correct practitioner skill mix. 

Principal social worker and principal occupational therapist

The principal social worker (PSW) is actively involved in the Safeguarding Adults Board and is an active member of Safeguarding Adults Review and Training and Development sub-groups. The PSW has recently developed an implemented adult social care and health practice standards which have been well received by both practitioners and managers across the directorate. Throughout the peer challenge the peer team heard how the PSW was seen as ‘dynamic’ and extremely well thought of by both practitioners and managers and also by members of the Citizens Panel. 

The principal occupational therapist demonstrated a good grasp on practice across the directorate and is working on plans to ‘grow their own’ occupational therapists. It was evident that the PSW and principal occupational therapist have a good working relationship and share learning. 

Assessed and supported year in employment offer 

The assessed and supported year in employment (ASYE) was found to be comprehensive. All ASYEs spoken described a positive support offer whereby caseloads are protected as well as having good access to assessors and supervisors all who are registered Social Workers. 

Considerations 

Reported Inequity in Pay

A number of staff reported inequity in adult and children social care social workers pay once they complete their assessed and supported year in employment (ASYE) with children’s social workers receiving an additional pay incentive of 10 per cent).

Twelve casefile audits were undertaken as part of the peer challenge. The main findings showed that in 87 per cent of cases there was significant evidence of strengths-based practice, and in 90 per cent of cases evidence of robust recording demonstrating professional curiosity, accountability and ownership. In 80 per cent of cases there was evidence of management oversight, and 85 per cent of robust risk assessment and management. In over 90 per cent of cases interventions and responses were timely.

• Appoint an adult social care lead.
• Political briefings.
• Secure corporate support and buy-in.
• Maximise the council’s adult social care business intelligence capacity to inform the self-assessment.
• Get health partners and integrated services leadership on board.
• Compare and learn from children’s inspections.
• Gather insights from partners and providers.
• Be clear on approaches to co-production and responding to diverse needs.
• Encourage organisational self-awareness.

• Councils need an authentic narrative for their adult social care service driven by data and personal experience.
• The narrative needs to be shared with those with a lived experience, carers, frontline staff, team leaders, middle managers, senior staff, corporate centre, politicians, partners in health, third sector and elsewhere.
• Ideally this story is told consistently and is supported by data and personal experience - do not hide poor services.
• This will probably take the form of:
• What are staff proud to deliver, and what outcomes can they point to?
• What needs to improve?
• What are the plans to improve services?
• In the preparation phases, consider putting it on all team agendas asking staff what they do well, what is not so good and to comment on the plans to improve. Collate the information from this process and add to the self-assessment. Ensure the self-assessment is a living document that is regularly updated.
• Immediately prior to CQC arriving, ask staff what they are going to tell the regulator. How is their experience rooted in observable data and adds to the overall departmental narrative? These stories drive the understanding of yourselves and others. 
• The regulator is interested in outcomes and impact from activity. The self-assessment needs to reflect this as do other documents.
• The conversation with the regulator is not a chat. For those interviewed it should be a description of what they do and the impact they have had. Case examples written in the authentic voice of those with a lived experience bring this alive.

We appreciate the senior political and managerial leadership will want to reflect on these findings and suggestions to determine how the organisation wishes to take things forward. 

Whilst it is not mandatory for the council to publish their report, we encourage councils to do so in the interests of transparency and supporting improvement in the wider sector. If the council does decide to publish their report, the date at which the council chooses to do so is entirely at their discretion and would usually be at the culmination of an internal governance process.

As part of the peer challenge process, there is an offer of further activity to support this. The LGA is well placed to provide additional support, advice, and guidance on a number of the areas for development and improvement and we would be happy to discuss this. 

William Brooks in the LGA Principal Adviser for the South East covering East Sussex and is the main contact between your authority and the Local Government Association. His contact details are:

Email: william.brooks@local.gov.uk