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Bristol City Council adult social care preparation for assurance peer challenge report

Final report: December 2023


Background

Bristol City Council (BCC) asked the Local Government Association to undertake an Adult Social Care Preparation for Assurance Peer Challenge at the Council and with partners. The work was commissioned by the Executive Director: Adults and Communities (DASS) at BCC. He was seeking an external view from a team of peers about the experience of people receiving support from Adult Social Care and comment on the Council’s preparations for Care Quality Commission (CQC) up-coming assessments. 

A peer challenge is designed to help 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 the LGA Preparation for Assurance Peer Challenge team spent three days onsite conducting the challenge, this process should be seen as a snapshot of the Adult Social Care department’s work rather than being wholly comprehensive. 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: 

  • Jane Robinson, Corporate Director, Adult and Health Services, Durham County Council 
  • Councillor Denise Scott-McDonald, Cabinet Member for Health and Adults' Social Care, Royal Borough of Greenwich 
  • Rachael Roberts, Deputy Director, Adult Social Care, Portsmouth City Council 
  • Jon Goodwin, Assistant Director and Quality Assurance Lead 
  • Russell Jones, Assistant Director, Children and Adults Joint Commissioning, London Borough of Southwark and South East London Integrated Care Board 
  • Christopher Blackham, Deputy Head of Service, Adult Social Care, Livewell Southwest, Plymouth 
  • Alun Davies, Expert by Experience 
  • Marcus Coulson, Peer Challenge Manager, Local Government Association 

The team were in Bristol for three days between Tuesday 12 to Thursday 14 December 2023. In arriving at their findings, the peer team: 

  • Held interviews and discussions with those with a lived experience and carers, councillors, managers, practitioners, team leaders and front-facing staff and partners. 
  • Read a range of documents provided by BCC including a self-assessment and completed a case file audit of six cases. 

Specifically, the peer team’s work was focused on the Care Quality Commission (CQC) framework of four assessment themes for their up-coming Adult Social Care assurance inspections.  They are: 

Care Quality Commission Assurance themes

Theme 1: Working with people.

This theme covers: 

Theme 2: Providing support.

This theme covers: 

  • Assessing needs
  • Planning and reviewing care
  • Arrangements for direct payments and charging
  • Supporting people to live healthier lives
  • Prevention
  • Wellbeing
  • Information and advice
  • Understanding and removing inequalities in care and support
  • People’s experiences and outcomes from care.
  • Market shaping
  • Commissioning
  • Workforce capacity and capability
  • Integration
  • Partnership working.

 

Theme 3: How the local authority ensures safety within the system.

This theme covers:

Theme 4: Leadership

This theme covers:

  • Section 42 safeguarding enquiries
  • Reviews
  • Safe systems
  • Continuity of care.

 

  • Strategic planning
  • Learning
  • Improvement
  • Innovation
  • Governance
  • Management
  • Sustainability.

The peer team were given access to at least 142 documents including a self-assessment. Throughout the peer challenge the team had more than 38 meetings with at least 154 different people. The peer challenge team spent over 250 hours with BCC’s Adult Social Care department the equivalent of 35 working days.

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

Key messages

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: Waiting lists

In the self-assessment for this work the Council states, “The number of people waiting for a service is too high and the length of time people are waiting is often too long. Apart from the impact on people waiting, the pressure caused by waiting lists leads to reactive decision making. We are working to reduce waiting times, and whilst implementing our plans we are making sure our risk mitigation and the management of waiting lists is robust, and that corporately and politically there is a good understanding of risk and impact”.  

The peer team agrees with this and recommends that the department addresses waiting lists. This includes the number and type of waiting lists for assessments and reviews that exist across Adult Social Care. This should include situations where, following initial screening by triage, cases have been handed off to long term teams where there may be additional delays.

The team recommends that the service increases its awareness of the number of hand-offs that occur and the risks contained therein. It was unclear to the peer team if there are safe transitions for those with lived expertise and carers in the systems involved. The service should develop its understanding and awareness of risks in these systems. The Adult Social Care and corporate risk registers should be updated in the light of this information and understanding. Mitigations should be put in place. A coherent narrative then should be created as to how those presenting to Adult Social Care with a variety of needs are assessed and adequately supported to manage the risks they present. 

Message 2: Pathways, processes and hand-offs

The peer team heard that whilst the Transfer of Care Hub operated to clear and well-defined discharge pathways which were generally effective, other service user journeys were less so, particularly between the front door and locality teams. Issues highlighted included a need for clearer team parameters and boundaries that would reduce the number of internal transfers and team 'push-back’ and enable a greater opportunity for issues to be dealt with and concluded. A revised system would avoid the need for handoffs which then result in the resident needing to repeat their story. 

Message 3: Safeguarding – timeliness, processes, and risk

The peer team heard from front-facing managers that contacts relating to safeguarding were high with approximately fifty new contacts per day. The themes being presented were carer breakdown, mental health crisis and self-neglect. When the peer team was onsite, Council data indicated that there are three hundred safeguarding assessment cases on the waiting list. The peer team heard concerns raised by staff and managers that enquiries under Section 42 of the Care Act (2014) (known as ‘section 42s') sent to locality teams were then further delayed adding to risk for residents. In addition to this there was little or no oversight of these delayed cases, adding to the risk. This is a significant challenge and the peer team recommend it is addressed in a timely fashion.  

Message 4: Front-facing staff

The peer team had the privilege of meeting a variety of front-facing staff, team leaders and their managers. It was evident that the experience of front-facing staff is mixed. Those in the three locality teams reported that they were under great pressure to ‘do the day job’ as well as complete overdue assessments and manage the daily ‘duty team’ work. They described a variety of coping mechanisms they use to hold their own boundaries and manage the stressful environment they find themselves in. 

Those in the specialist teams who are not subject to daily demand pressures reported feeling under less pressure by comparison (although the peer team does not wish to minimise the demand pressures they themselves are managing). This is reflected in the self-assessment for this work that says the service has a detailed understanding of workforce pressures and that, “…our teams tell us it feels like they are often ‘firefighting’. This leads to a ‘crisis management’ and ‘urgent response’ culture and concerns over waiting times and getting things done. This is exacerbated by a risk averse culture. 

Our staff are very skilled at managing crises but often at the expense of proactive and preventative work that is better for people, more cost effective and more satisfying for practitioners. We are focused on changing this cyclical pattern”. With this in mind the peer team recommends that the service should address the experiences of staff in line with the issue of demand pressures, and thereby reduce the perceived high levels of sickness absence staff reported to the peer team due to work related stress. 

Message 5: Development of Adult MASH

A decision regarding the development of an Adult MASH is required. The Keeping Adults Safe Group has a focus on safeguarding adults and leads on the statutory functions as set out in the Care Act (2014). This partnership group has been tasked with taking forward the work on developing an Adult Multi Agency Safeguarding Hub (MASH). There was a hope that this would have been in place within 2022. As we approach 2024 it should be a priority for the partnership to reach a decision on the resourcing for this in the next three months. This uncertainty is delaying action to improve the way safeguarding activity is managed and monitored. 

Message 6: Adult social care self-assessment 

The Adult Social Care self-assessment and the related narrative outlines a large volume of work to deliver systemic transformational change and thereby address funding gaps in the near- and long-term future whilst developing a sustainable model of social care that builds upon community assets and improves outcomes. The pace of planned change is significant. However, the focus of senior staff does not reflect the current position of the service. The service should create a narrative rooted in the lived expertise of staff and of partners that describes the ‘here and now’ and what is urgent and important and should be addressed, today. 

It is important for the Council to have an Adult Social Care service that is efficient and delivering savings targets required by the Council as a whole to balance the budget.  However, there is also the need to prevent, reduce and delay demand at the front door and manage staff experience and their related morale as well. In the present financial climate in local government this is not an easy task, but it is a necessary one. 

Message 7: Golden thread?  

The peer team would like to challenge the service and ask, “Is there a golden thread through the service?”.  It was not possible for the peer team to see one at this point. The strategic narrative does not match aspects of the operational description in the self-assessment and the experience of those with lived expertise, carers and staff. This would be evident in the future through a clear focus on these issues in the service’s priorities and that the corporate risk register has been updated. 

Message 8: Data - a work in progress that can be developed

A new Power BI system has been developed by the Adult Social Care data team enabling improved access to commissioning information and purchased services.  It will help the service to accurately report on the number of people waiting for assessment and review and the timeliness of work. To achieve this the data system will need further socialising with front-facing managers to ensure staff feel confident in exploring their team's performance as the data team felt that professional curiosity needs to be developed. As a positive, Human Resources (HR) management information enables managers and those in the HR department to understand trends and enables them to act on them. 

Message 9: BCC Cabinet Member

The peer team heard from the BCC Cabinet Member and her desire for good services to be delivered by the Adult Social Care department. There was also a clear commitment from the Adult Social Care Executive Directorate Management Team to drive improvement in the service. 

Message 10: Positive relationships with partners

There are positive relationships with partners created by the Executive Director and his team leading to statements from partners and other stakeholders that they see a definite desire to improve services.  As evidenced by the positive relationships with locality partners and the Learning Disability and Autism Commissioning Team and in the number of, and outcomes from academic partnerships. 

Message 11: Adult Social Care staff

The peer challenge team had the privilege of meeting a wide variety of staff in the Adult Social Care directorate who work to support local people. The peer team observed a strong sense of committed, dedicated, kind and collegiate staff across all service teams. Whilst the staff described many challenges in the system, they remained committed to making a real difference for residents. One such example were the staff in the Assessed and Supported Year in Employment (ASYE) team amongst many that were met. 

Message 12: CQC Provider ratings

The peer team felt it was a strength that there have been positive changes in the local Adult Social Care provider market in Bristol with 97% of providers assessed by the Care Quality Commission (CQC) with good or outstanding ratings.  

Message 13: Positive partnerships and good support

An example of both positive partnership relationships and good support to local people delivered by front-facing staff referenced above is the recent success of the Transfer of Care Hub at Southmead Hospital (North Bristol NHS foundation Trust) where there has been a 30% reduction in people being navigated to leave hospital on Pathway 3 in the last two months. This is a positive achievement. 

Message 14: Cared for in Bristol

There are a growing proportion of people, 87%, whose care is supported in Bristol rather than being placed outside the Council’s boundary and further away from relatives and friends. 

Message 15: The Changing Futures Programme 

The Changing Futures Programme (Changing Futures Bristol) is well regarded by the people accessing the service because it is enabling access to personal and professional support networks in the city.  The ‘My Team Around Me’ model was referenced as particularly good.  The peer team heard about some impressive examples of the Council thinking creatively about how to meet needs. 

Message 16: VCSE and the ‘Make It Work’ Programme.  

The Voluntary, Community and Social Enterprise (VCSE) Sector in Bristol value the ’Make It Work’ Programme (Make It Work — Black South West Network), which was designed to support more Black and Minority Ethnic (BME) organisations to access the BCC framework, and thus provide services. As a result, six new organisations joined the framework. The Black South West Network (BSWN) felt that key to this success was the approach that BCC took. They valued the open and transparent approach and the emphasis that was placed on co-production. 

Message 17: Adult Social Care Commissioning Team

The newly formed Adult Social Care Commissioning Team has clear sight of necessary improvements, is collaborative with diverse experience that adds value and has a strong desire to improve the service. 

Message 18: Recognition of the journey of co-production

The service demonstrates a clear commitment to begin the journey of co-production with people who have lived expertise. There is a recognition that the experiences of those with lived expertise does not reflect this at the moment and so there is a clearly stated organisational desire to change this through Adult Social Care practice. 

Lived expertise feedback

Prior to the peer team being onsite five individuals were asked by a member of the team about their experience of their Adult Social Care services. Amongst other things, they were asked if they felt safe, if they knew who to contact, and of their opinions about what the Council did well and where it could improve in the delivery of services. 

As well as this, whilst onsite, members of the peer team met a group of carers and undertook a further interview of a person with lived expertise. Furthermore, a person with lived expertise joined the peer team.  The lived expertise peer has a long-standing involvement with BCC and Adult Social Care, representing the views of those with lived expertise to the Council, and therefore was able to comment. 

The following feedback has been collated to show where this sample of people felt there were strengths and where there could be considerations for improvement. 

Strengths

  • The people with whom the peer team spoke to said they knew who to contact about their service and that they felt safe. 
  • Carers reported that they value the Carers Centre but felt there was a disconnect from the support they received from the Council. 
  • The Council is resourcing the work it is undertaking to establish co-production and has recognised the work that needs to be done to allow the voices of people with lived expertise to be fairly and properly heard, alongside the voices of professionals. 
  • Under the direction of the Executive Director for Adults and Communities (DASS) and Cabinet Member, the Council has established an Equalities Forum to listen to equalities stakeholders. This has been welcomed. 

Considerations 

  • There is a belief, whether justified or not, amongst some disabled people that the Council is interpreting the Care Act from a cost-saving perspective rather than from a ‘rights and needs’ position. 
  • The council's work to develop a Fair and Affordable Care Policy caused some controversy amongst disability rights groups. In responding to this controversy, the council has sought to engage with disabled people, and responded positively to the Disability Equality Commission (DEC) in its attempts to mitigate concerns. The draft policy has since been withdrawn. The council has requested that the chair of the DEC in an independent capacity sets up a group involving all stakeholders to explore how the needs of disabled people can be met within existing legal and financial constraints in a fair and equitable way.
  • Those with whom the peer team spoke said the front door did not work, as wait times were very long and it was very difficult to speak to someone who could address their concerns. 
  • Some of those with whom the peer team spoke, including some carers, felt that the council did not do co-production.
  • Some of those with whom the peer team spoke, including some carers, expressed concern that the Learning Disabilities Partnership Board was not currently meeting.
  • The Council has been slow to deliver against the recommendations of the Bubb Report  Review of Bristol’s policies and actions for people with learning disabilities and autism). This has left some Carers feeling disillusioned and disappointed, and that the Council does not listen to them. 

Co-production

  • Adult Social Care is in the early stages of developing a co-production/co-design policy and process. 
  • There are some pockets of good practice. Historically, the department had a good record of co-design and engagement. Unfortunately, much of this has been lost due to the impact of austerity, changes in adult care staff and a weakening of the Disabled people’s movement in the city.
  • Because of this weakening of engagement, there is an element of scepticism among some Disabled people about the department's commitment to develop and deliver co-production and co-design. 
  • At the same time, there are Disabled people who are willing to work with and assist the department in its work. The council has several people with lived expertise involved in the co-design group that is co-designing the new co-production / co-design policy and practice. 
  • Whilst the Equalities group set up by the Cabinet Member and DASS is not co-production or co-design in its purest form, it is still a regular vehicle for communication and engagement that has not previously existed, and many members welcome it.

Case audit file findings

The peer team considered six cases in the audit. 

Strengths

  1. In the cases considered person-centred principles were evidenced when describing needs. Documentation of person’s needs were written with clarity and sensitivity, clearly capturing care and support needs. 
  2. There was evidence of a strengths-based focus and moving away from a deficit approach wherever possible. 
  3. The key principles of the Mental Capacity Act (2005) were identified within assessments and ‘best interest’ decision-making recordings were made. The descriptions in cases considered were decision specific and evidence based with a consideration for the least restrictive option. 
  4. There was clear evidence of staff consulting with informal carers to gain their perspective and a triangulation of information was obtained.
  5. Eligibility and decision-making is clearly documented in the cases. 

Considerations

  1. The service could consider making better use of staff summarising identified risks during needs assessments. 
  2. There was limited evidence of what alternative options could have been used to meet the person’s care and support needs. 
  3. Some of the person’s goals and outcomes were not always in-depth.
  4. The recorded outcomes were often generic and not individual to the person. 
  5. In the one case that described a safeguarding enquiry the outcome and closure summary was not recorded. 

Theme 1: Working with people

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

Delays and waiting times should be addressed

There are substantial delays for Care Act Assessments which stood at 626 on the first day of the peer team’s onsite work (12/12/23). There was an average waiting time of 174 days across all teams. Locality teams had average waits of 215 days. The longest wait recorded on the system was 2,708 days which is 7.4 years. The peer team are unclear as to whether this is a data cleansing issue, or a person has been waiting this period of time. The team could not see the evidence of this, nor a clear narrative to explain the data.  The peer team noted that the Swift Response Team currently has 29 care assessments on a waiting list with an average wait of 122 days. The longest being 756 days. Again, it was unclear to the peer team if this was an actual delay or a data cleansing issue. 

The peer team heard anecdotal evidence of a reviews backlog, but did not see the data, but getting a grip of this will be similarly important, as anecdotal reports suggest reviews are driven by a similarly crisis-led model. 

The Occupational Therapy (OT) waiting lists 

The Occupational Therapy (OT) waiting lists impacting on the service’s overall Prevention Model providing equipment before care was of 1,127 people. These people are waiting for an OT assessment and the majority (983) are waiting for smaller aids and adaptations going back to February 2023. These individuals have all had some level of immediate support from the OT service at the front door to mitigate risks but their wellbeing will be affected by the length of wait.  In the view of the peer team it is going to be difficult for the service to prevent, reduce or delay through its intended Prevention Model. This increases risk and costs money. 

There are substantial waiting times to create accessible homes from the Disabled Facilities Grant to receive major adaptations, causing pressures on the care and support system. 

The service recognises the need to address the issues described above. It was unclear to the peer team what the scale of outstanding reviews was, the strategy to address it, and the risks involved. However, the service has committed to, “…undertake work on reducing waiting lists and waiting times, (and) manage our waiting lists to ensure a consistent approach across operational teams, capture best practice…”. (p.10 self-assessment). 

Define endings within current pathways

It was clear from the discussions with the peer team that 'endings' within the current pathways were not clearly defined, and as a result some people continued to have social work support up to twelve months following their discharge from hospital. The current operating model holds support to people discharged from hospital until their situation at home is settled.  The peer team felt this was adding to the overall caseload for the service and risked reducing the quality of the service. The peer team recommend a further examination of this approach and keep intervention pathways to a maximum of six weeks in line with other 'home first' best practice principles. 

Team Clarity of Role and Function

The volume of crisis intervention work that front-facing staff must address on a daily basis has a negative impact on the progression of allocated work within teams. There is an inconsistent interpretation and application of the current operating model.  Staff are not clear about their service boundaries and pathways and end up being unclear about what to do. It is unclear to staff how often they need to communicate to people needing support, resulting in a duplication of information-gathering and inconsistent and numerous hand-offs.  As a result, the journey of the person is confusing for staff and residents alike.  

Front Door – (Prevent, Reduce, Delay)

The demand on the Adult Social Care front door is very high. The service recounts 60-70 contacts per day. A large proportion of these are signposted advice and information. However, there is a missed opportunity to enable residents to self-serve and find their own solutions due to the limited information made available to them both over the phone and via the website.  This is not an empowering nor strengths-based approach. 

The peer team saw and heard evidence of multiple hand-offs at the front door.  When a person rings the service, they are put through to Care Direct call handling, then the Swift Response Team and then to local duty teams. 

Front Door

The peer team also recommends that the Adult Social Care Directorate Management Team considers how to get greater professional expertise at the front door and a model of identified time-based resolution. Other front-door teams reduce their 'hand-offs' by increasing the expertise of staff, including Occupational Therapy as well as safeguarding and mental health expertise at the front door. In addition to this, setting clearer time-based interventions, such as up to five days support and resolution, can make a considerable difference in reducing work that would otherwise be transferred to locality teams. The peer team would also highlight how 'named worker' models can support those people with considerable complexity and frequent contact to the service. 

Wellbeing and preventative information

There is also a lack of wellbeing and preventative information at the front door.  Care Direct staff are missing the opportunity to support residents in one intervention. As a result, staff have found their own workarounds to fill the gap of a lack of local community information. One enterprising staff member has created a Word document referred to as the “Useful Stuff” document that lists the details of these opportunities over ninety-four pages. Other colleagues use this and find it helpful. 

The peer team recommends collaborating with stakeholders from the VCSE sector and people with lived expertise, to explore developing on-line wellbeing information, advice and guidance. There are excellent local examples of these models that have been developed in nearby local authorities (for example the BaNES - Live Well and Wellbeing Hub Welcome to the Community Wellbeing Hub | Bath and North East Somerset) who would share their journey of development.

Carers Centre and assessing carers needs

There were positive experiences by carers who accessed the carer support centre, gaining advice and information and signposting to services, which they very much appreciated. 

As with other people seeking to access services, carers reported long waiting times to accessing an assessment.  They also shared experiences of multiple hand offs when trying to access services and that they were often unclear who they needed to speak to.  It was described to the peer team that the reviewing of carers’ needs was driven by crisis and not in a planned way. 

Reviewing the Carers Offer and Pathway

As a result of the above findings the overall carers offer and pathway would benefit from a comprehensive review. This involves evaluating the effectiveness of existing services, identifying gaps, and implementing measures to enhance support for carers. A refreshed and responsive Carers offer contributes to the overall well-being of both service users and those who provide care, aligning with the principles of person-centred care. 

Workforce

The peer team had the privilege of meeting a variety of front-facing staff, team leaders and managers. The team observed a strong sense of committed, dedicated, kind and collegiate staff across all service teams. Whist the staff described many challenges in the system, they remained committed to making a real difference for residents. This is a significant strength for the Adult Social Care service and can be built upon. 

Transfer of Care Hub: Home First - Promotion of independence

The Home First principle of achieving independence for those leaving hospital is evidenced by a 30% reduction in people being navigated to leave hospital on Pathway 3 in the last two months. The new team felt they were effective with patients coming in, through and out of the hospital and that they were achieving good outcomes. This is a significant achievement. 

Communication and knowledge sharing

There was excellent communication and knowledge sharing across the new integrated team at Southmead Hospital (part of the North Bristol NHS Foundation Trust), however, non-BCC team members shared their frustration at having a ‘read only’ access to the Liquidlogic Adults System (LAS) as they were outside of the Council. This is despite being members of the integrated team. The peer team felt this was a missed opportunity that could be addressed to further integrated working. 

Theme 2: Providing support

This relates to market shaping, commissioning, workforce capacity and capability, integration and partnership working. 

Commissioning Staff Knowledge

During discussions with commissioning staff, it was evident that officers possess a good understanding of their markets and the communities they serve. The Council uses a range of evidence (PowerBI, POPPI, PANSI, LGA, etc.) to have a good insight into local needs and officers recognise that Bristol is one city with many communities, each with different assets and needs.  This local knowledge is a valuable asset and the peer team expect it will be leveraged to enhance service delivery. 

Adult Social Care Single Commissioning Framework

With its single framework, the Council has set a strategic intention to secure a range of quality provision for local people. The Council should be mindful of the risks to transition to the new framework (business continuity, relationships, etc.) and there would be benefit in clarifying areas of ambiguity for the market. 

Co-production Practice and Commissioning Consistency

There are some positive examples of co-production practice in commissioning, for example the use of lay assessors in quality assurance. The Council should seek to build on these to ensure co-production is embedded consistently throughout the commissioning cycle. Engaging service users, their families, and community stakeholders in decision-making processes should enhance service design and delivery. This collaborative approach fosters a sense of ownership and ensures that services are more aligned with the diverse needs of the community. 

Promising Initiatives in Learning Disability and Autism Teams

The Council recognises gaps in the local market, particularly in regard to working age adults with enduring needs, e.g. Learning Disabilities, Autism, and enduring mental ill-health, and is making good progress in taking creative steps to address these via the Learning Disability and Autism Team and to reshape the wider market via the Market Analysis Team. Since their launch in June/July 2023 both the Learning Disability and Autism and the Market Analysis Teams have made promising starts. The Council and the Integrated Care Board (ICB) should explore avenues to embed and expand these arrangements, potentially serving as a model for other service areas. This proactive approach aligns with the broader goal of fostering innovation and improving service outcomes. 

Strong Partnerships in Operations, Commissioning, and CQC

Partnerships in operations, commissioning, and collaboration with the Care Quality Commission (CQC) are well-established and fruitful. The peer team heard examples of the weekly meetings between commissioning, contracts and operations to help troubleshoot issues and regular meetings to discuss individual cases which help build two-way relationships and understanding.  Another outcome are the positive changes in CQC provider ratings in regulated provision sustained over a five year period described elsewhere in this report. This foundation serves as a solid base for effective service provision. The Council is encouraged to maintain and nurture these partnerships, ensuring continuous communication and shared strategic goals. 

Strengthening ICB Strategic Partnerships

The Integrated Care Board (ICB) has promising strategic partnerships that could be further developed to strengthen broader NHS collaborations. One such example is in articulating opportunities to build on the early work being done in relation to Learning Disability and Autism. Exploring avenues for enhanced communication and coordination will contribute to a more integrated and seamless healthcare system, benefiting both service users and the broader community. 

Clarity and Engagement in Provider Partnerships

Strategic provider partnerships are broadly positive, with the Council advised to maintain transparency and engage partners effectively. Clearly defined decision-making processes and involving partners in the decision-making journey are crucial to sustaining and strengthening these partnerships. This approach fosters a collaborative atmosphere and ensures that partners feel valued in the overall service delivery process. 

Strengthening the Narrative on Internal Partnerships

Adult Social Care strategic partnerships within the Council are generally moving in the right direction. There are some good examples such as the work with the property programme on supported accommodation and the work with housing. There is an opportunity to strengthen the narrative on these internal partnerships for the service’s revision of the self-assessment. Clearly communicating the value and impact of internal collaborations enhances accountability and promotes a culture of continuous improvement. 

Coordinated Care and Support for Residents

Although strategic partnerships are generally moving in the right direction, current operational joint working means that residents do not always benefit from seamless and coordinated care and support. This has been described elsewhere in this report, however other example areas would be that stakeholders recognised room for improvement in work with the Avon & Wiltshire Partnership Mental Health Trust (AWP), the Community Learning Disability Team and the development of the carers pathway. 

Contract management

The Council should be mindful of and take steps to mitigate risks of splitting contract management from quality assurance. 

Theme 3: Ensuring safety

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

Safeguarding assessment waiting times

The peer team noted from the performance report, that there were sixty-one safeguarding referrals awaiting triage.  They also noted there were 487 cases that were awaiting allocation. The peer team are not confident on the safety of residents with this significant level of delay. 

Strategic oversight of operational safeguarding

There is a need for more strategic oversight of operational safeguarding work to address the most immediate risks of the waiting lists linked to safeguarding work.  The majority of safeguarding related work appears to flow to the locality teams. This is in addition to other complex work they are doing, such as social circumstances reports, tribunal reports, and social supervision work.  The volume of safeguarding work, hand-offs across teams, and staff resources means it is challenging to safely manage the risk.  This adds additional pressure to those teams who may not have the capacity, necessary skills and knowledge to undertake this more specialist work. 

Front-facing staff sickness absence rates

Front-facing staff from safeguarding and other areas reported that due to the pressure to address waiting lists, the hand offs between teams, coupled with managing duty and complex work leaves some teams feeling over worked and overloaded. However, this is not reflected in the current sickness data.  The service is aware of the “near-constant focus on emergency response and crisis management” (p.14, self-assessment), and the need to address the issues experienced by staff to ensure that risks are escalated and that plans are put in place to reduce waiting times and reduce pressure on staff. 

A decision regarding the development of an Adult MASH is required

The Keeping Adults Safe subgroup of the Keeping Bristol Safe Partnership (KBSP) has a focus on safeguarding adults and leads on the statutory functions as set out in the Care Act (2014).  This partnership group has been tasked with taking forward the work on developing an Adult Multi Agency Safeguarding Hub (MASH).  There was a hope that this would have been in place within 2022.  As we approach 2024 it should be a priority for the partnership to reach a decision on the resourcing for this in the next three months.  This uncertainty is delaying the action needed to improve the way safeguarding activity is managed and monitored. 

Keeping Bristol Safe Partnership

The Keeping Bristol Safe Partnership has developed a set of strategic priorities which is positive and there is a newly appointed chair of the partnership who is an experienced leader. She is committed to improving governance and assurance processes across the partnership so that risks can be escalated and addressed.  The partnership would benefit from developing an outcome-focused action plan to demonstrate how the impact of the work of the partnership will be measured.  There are limited resources attached to the partnership which will require partners to contribute their time and expertise to ensure progress is made in line with the strategy.  The partnership would benefit from considering how the voice of people with lived expertise is captured and informs the work that the partnership does. 

Safeguarding Adults Reviews

The newly appointed chair of the partnership is intent on strengthening the governance around Safeguarding Adults Reviews (SARs).  Monitoring of progress on action plans needs to improve, and outstanding actions relating to previous SARs need to be signed off.  The partnership is aware that it would benefit from a clear process for monitoring progress, evidencing outcomes and a process for signing off action plans. This could be in the form of a closure report that is then formally signed off.  Further work could then be focused on the sharing of learning to ensure that systems and practices can change.

Changing Futures Programme

The Changing Futures Programme is championing a different way of working to manage risk and safeguard people with multiple and complex needs. The My Team Around Me — Changing Futures Bristol is well regarded and achieving some positive outcomes for people. 

Theme 4: Leadership

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

Adult Social Care budget pressures

The Adult Social Care budget is £200m with a savings requirement of £9m, the majority of which is in the 2024/25 financial year.  A recent Use of Resources assessment suggests that Bristol is a comparatively high spender on care which might indicate there are potential savings to be realised. However, this figure comes with a number of caveats and is further complicated by the need to address the urgent waiting lists issues which would need to be factored in as a significant cost pressure in the near future. 

Political observations

There has been some good work in developing strategic partnerships and building on the work that was started during the Covid pandemic.  For example, the One City initiative is well-regarded and should be strengthened. 

Political direction

The Adult Social Care Cabinet Member has a good grasp of the achievements and some of the challenges facing the Adult Social Care service and is respected within the VCSE sector, providing strong leadership and clarity to the voluntary sector from the Council.  There has also been positive work through a community development approach. 

Equalities Issues

The Adult Social Care Cabinet Member has taken the lead in promoting equalities issues through support for the Black South West Network and setting up the Adult Social Care Equalities Forum. 

The future

As the Council looks forward to the near-term future, politicians should continue to fight for what works well, when working with the local community groups and voluntary sector and continue their community development approach. 

Vision, Strategy and Culture

There is recognition that work needs to be done on the vision for Adult Social Care, and there are plans to begin a process of co-producing this in January 2024.  In doing so it will be important to create a ‘golden thread’ to give clarity to staff and stakeholders on the links between strategic priorities and front line practice.  The peer team suggest that the vision will need to include a focus on a reduction in waiting lists, assessments and reviews whilst also seeking to reduce pressure on Adult Social Care staff. 

Inclusive leadership

Developing and strengthening the relationship between senior leadership and front-facing staff will be important for BCC. This can be achieved, in part, though work on the vision, a revision of the service’s self-assessment and creating greater clarity of the service’s priorities to include those of a lived expertise, staff and partners. It was clear to the peer team that there is variation in staff experience across the service but less clear as to how well this was understood by Adult Social Care senior management.  There are some actions planned by the DASS to facilitate this and improve the visibility of senior management.  For example through question and answer sessions with the DASS, Director of Adult Services and front-facing staff.  Regular communications are also being planned by the Director who is developing a strategy with internal communications colleagues.  It is hoped investment in building these relationships will engender trust and create opportunities for staff ideas and innovation to be aired. 

Reduce stress related absences

Listening to the workforce will be important in understanding factors which contribute to work related stress.  Due to time constraints the peer team did not have sufficient time to enable a view to be formed on BCC’s approach to staff well-being, however it would be an area the team would encourage BCC to review. 

The evolving role of the Principal Social Worker

As CQC rolls out its assessments, the increasing focus on the evolving role of the Principal Social Worker (PSW) is becoming more apparent.  CQC is explicitly asking to speak with the post holder in onsite work.  The expectations of the role are changing and as a result, Councils are moving towards a PSW role that holds a senior position providing strategic direction to the quality of operational activity for Adult Social Care. This means they monitor, provide guidance and clarity at a senior level of the lived expertise, that of carers and the related activity of front-facing Adult Social Care staff.  This role will be an important feature of the Council’s internal processes to assure itself that local people are receiving good support.  The service should ensure that it uses the understanding of practice and the management of the associated risk that the Bristol PSW brings to the role which would then be reflected in the priorities of the service and its plans for mitigation of risk. 

Governance, management and sustainability

The ambition of the Council and the Adult Social Care service is clear and demonstrated through the Transformation Programme which is supported by Peopletoo.  The analysis and recommendations from the Peopletoo diagnostic (August 2023) were recognised as accurate by the peer team. It is recognised that this creates an extensive and challenging work programme.  Whilst engaged in this the peer team suggest BCC reflects on the balance between transformation, statutory functions, and CQC preparedness and consider this in the context of refreshing priorities within capacity constraints. 

Partnerships and Communities

BCC has well established and valued partnerships, with many seeing the value of the Health and Wellbeing Board (HWB) which was viewed as constructive and inclusive with good examples of VCSE engagement.  There is an opportunity to build further on cross-council and partnership working, for example a recent development session between the HWB and the Economy and Skills Partnership was seen as positive and a model for future work.  Whilst senior staff within Adult Social Care outlined positive work with housing, this was not seen by the team during the time in Bristol, suggesting there is an opportunity to strengthen this and consider opportunities for joint working between health, housing and social care. 

Learning, Improvement and Innovation

BCC is ambitious in terms of its plans for co-production which are at an early stage. It is however evident that there is some significant history and scepticism in relation to this amongst some people with lived expertise which will have to be recognised and navigated to ensure the ambition can be delivered. 

There is an opportunity to encourage staff to generate ideas for innovation and to build trust through engagement plans. This is coupled with the plans for data that staff can have confidence in and that drives the priorities of the business. The Power Bi tool will be an important part of this journey. 

Take-away summary

Waiting lists

Address the waiting lists across Adult Social Care.  Include an understanding where there may be hidden waiting lists of people who have been triaged in the system, handed off to another team and are still waiting for an assessment. 

Grip on risks

Seek to get a grip on the different risks inherent in the waiting lists. This must include the significant safeguarding risks of long wait times after triage. Senior staff should prioritise this activity to create a narrative with staff and those of lived expertise that is authentically rooted in their experience of what the service is doing to deal with the situation. 

Workforce pressures

Address the pressures the workforce is faced with from high demand, waiting lists pressures and duty work. Invest in your prevention work to reduce pressure on staff and develop a coherent and robust staff wellbeing approach to support those under pressure. 

Pathways

Work to develop clarity of the pathway processes for those entering the Adult Social Care system and how they progress through it.  This would, in part seek to reduce the number of hand offs and reduce waiting times.  To achieve this there needs to be clarity on the roles of each team and an escalation process so that any dispute over case ownership is clear. Being clear on how safeguarding concerns will be triaged and managed would also help. 

Self-assessment

Refresh the self-assessment to reflect the views of those with a lived expertise, staff and partners that is rooted in their knowledge and understanding is the present situation. Create a better balance in the assessment between the present situation and what is being done to address it and plans for the future. 

Multi-Agency Safeguarding Hub (MASH)

Negotiate a system decision around the creation of a Multi-Agency Safeguarding Hub (MASH). This will better enable all agencies to work towards mitigating the risks of anyone slipping through the safeguarding net. The service should decide how it will deliver its safeguarding duties as set out in Section 42 of the Care Act (2014). The service would benefit from one central referral point, where referrals can be triaged and a decision taken regarding action needed, (i.e. move to a Section 42 enquiry, a Care Act Assessment or No Further Action).  Then there should be a decision made of who does the work.  If this is within scope of the work commissioned to design the new operating model that would be helpful, but if not, this needs to be a priority. 

Implications of CQC assurance 

Raising political awareness regarding the implications of CQC assurance for the Adult Social Care service and the Council as a whole.  Work with politicians to raise political awareness regarding the implications of CQC assurance for Adult Social Care and the Council as a whole. 

Transformation and statutory responsibilities

Rebalance the focus between transformation and statutory responsibilities. Through the above steps it should be possible to rebalance the focus between transformation and statutory responsibilities. 

Communications

The service may want to consider a communications strategy to support BCC’s developing understanding of CQC assessments. It will be important when BCC moves to a committee system that Adult Social Care is given the time from the relevant committee to discuss the issues involved. This is where short and medium term priorities will be important as well as the ability to articulate and discuss progress towards them. Other relevant issues would be a risk register that is realistic and clarity about what can be achieved within existing resources as well as what will, and what will not change, without investment. 

Prioritisation

In the present Adult Social Care narrative there is a lot of focus on the future. However there are urgent and important issues in the short and medium term that need to be prioritised and addressed.  This would then enable the service to be able to recognise and speak about the most pressing issues with those of a lived expertise, staff and to the regulator when they arrive.  

On behalf of the Adult Social Care Preparation for Assurance Peer Challenge team for Bristol City Council, December 2023. 

Marcus Coulson

Senior Advisor – Adults Peer Challenge Programme

Local Government Association

Email: [email protected]

Tel: 07766 252 853

For more information on the Adult Social Care Preparation for Assurance Peer Challenges please see our website: Adult Social Care peer challenges | Local Government Association

Immediate next steps and contact details

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

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. 

Paul Clarke is the main contact between your authority and the Local Government Association. 

Email: [email protected]

Telephone: 07899 965730

Web: Home | Local Government Association

Steve Peddie is the LGA Care and Health Improvement Adviser the for the South West and your main contact to the LGA Partners in Care and Health Programme.  

In the meantime, we are keen to continue the relationship we have formed with the Council throughout the peer challenge. We will endeavour to provide signposting to examples of practice and further information and guidance about the issues we have raised in this report to help inform ongoing consideration. 

Appendices

Top tips for assurance preparation

  • appoint an Adult Social Care assurance lead
  • create political briefings that engage members in the present and future challenges
  • 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.

Lessons learned from other peer challenges

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, front-facing 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 are proud of delivering, the impact they have had and the evidence they can point to. Case examples written in the authentic voice of those with a lived experience bring this alive.