Preparation for Assurance: Peer Challenge Report, Liverpool City Council

Liverpool City Council (LCC) 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 deputy chief executive and corporate director of adult care and health (DASS). The DASS was seeking an independent perspective on how prepared adult social services are for a Care Quality Commission (CQC) inspection and how well LCC is delivering adult social care services for its residents. 

This adult social care peer challenge took place within the context of the Department for Levelling Up, Housing and Communities (DLUHC) appointed Commissioners at LCC. On 10th June 2021 the then Secretary of State for Housing, Communities and Local Government, Rt Hon Robert Jenrick MP, appointed four commissioners for Liverpool City Council. These appointments were made following the completion of a Best Value inspection by Max Caller CBE. The Best Value report was published on 24th March 2021 and gave evidence that the council had failed in numerous ways to comply with its Best Value Duty (Part 1 of the Local Government Act 1999). 

The Commissioners' role is to support the council's improvement as per the directions set out by the Secretary of State, and report directly to the Secretary of State on progress made within the council. The commissioners are due to be in place until 9th June 2024 and will provide the Secretary of State with regular progress reports. Three reports have been completed to date. 

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. 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: 

• Andrew Cozens CBE, Independent social care and health policy and improvement specialist 
• Councillor Helen Holland, Cabinet Member for Adult Social Care, Bristol City Council 
• Melissa Wise, Interim Executive Director, Adult Social Care & Health, Reading Borough Council 
• Alison Ansell, Director of Adult Social Care for Mid Essex, Essex County Council 
• Sheila Wood, Head of Service and Principal Social Worker, Cheshire East Council 
• Marcus Coulson, Peer Challenge Manager, Local Government Association 

The team was in Liverpool for four days between 27^th–30^th June 2023. In arriving at their findings, the peer team held

• Interviews and discussions with councillors, officers, partners and carers 
• Held meetings with managers, practitioners, team leaders and frontline staff 
• Read a range of documents provided by LCC, including a self-assessment, and completed a case file audit of seven cases. Specifically, the peer team’s work was focused on the Care Quality Commission (CQC) framework four assurance themes for the up-coming adult social care assurance process. They are: 
   

The peer team was given access to at least 108 documents including a self-assessment. Throughout the peer challenge the team had more than 53 meetings with at least one hundred and eighty different people. The peer challenge team spent over 252 hours with LCC the equivalent of 36 working days. 

Initial feedback was presented to the council on the last day of the peer challenge and 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.  

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

Liverpool has a sense of place and community that was evident to the peer team when speaking to staff, those who engaged in adult social care services, and everyone associated with it. The sense of great community spirit and assets the team felt is something that can and should be harnessed for improving engagement, inclusion, and support. This helps people feel supported with someone to turn to other than formal services. 

The consistent message the peer team heard from speaking to those in adult social care and related professions such as in the NHS and VCS was that the staff are resilient. There has been much public criticism heaped upon the wider council in recent years, but the staff in adult social care simply continue to get on with their work in spite of this. They speak about the need for senior staff stability and clear direction in addition to needing improved person-centred practice and processes through the range of teams and services. Staff have the right value base and are proud to work for Liverpool City Council and wish to deliver good services to local people. There is a clear commitment from everyone with whom peer team spoke to putting the person at the centre of care notably by the specialist teams. 

For adult social care, and the council as a whole, there is a strong platform with public health to build a whole population approach to wellbeing to help prevent, reduce, and delay demand. There is a clear understanding of the profile of health inequalities, as shown in the investment in social prescribing and a strong platform of community engagement, which was reinforced during the pandemic. 

New practice standards can help clarify what the council means by strengths-based practice. The extension of these standards and other practice related documents are essential to delivering the ambition and vision for adult social care into day-to-day practice. This should be further reinforced by reflection, supervision, and an enhanced approach to audits. 

The peer review team heard about good access to advocacy and examples of its contribution to better services and outcomes, including, and unusually separately, for carers. 

There is good engagement with NHS staff on interface issues including discharge arrangements, continuing health care, mental health services, and transition from children’s services. All are aware that the challenge is to consistently translate these into successful outcomes. The input from the council that is sustaining these however, is significant and could reduce as collaboration continues. 

For Consideration 

The adult social care web presence at the council is deficit-based, with its focus primarily on needs and services. The council should consider rebalancing the content with an additional focus on measures that residents can take for themselves together with advice or guidance. The Living Well directory is similarly focused. It needs reorienting to wellbeing, recovery and to have a more strengths-based support focus. 

The council recognises that it needs to build up its wellbeing and prevention offer including defining how partners are contributing to this. An aspect of this is that a new target operating model has been developed which places more emphasis on prevention and early intervention, which will be implemented from October 2023. 

There is a need to overhaul the adult social care front door, separating it from Children’s and Homelessness services. The senior staff are well aware of this and there is a plan in place to deliver it. This will be crucial for improving the customer experience and in raising the profile of adult social care. 

Staff understand the need to transform services and there is an opportunity for management to empower staff to contribute their ideas on service redesign. There is also a need for staff to develop approaches to working better together across teams. The peer team found evidence of too many hand-offs, occasional disputes and, as a result, the risk of discontinuity of care. 

The assessment process is convoluted and time-consuming for all involved. Both staff and service users the team spoke to were clear that a ‘quick win’ would be to produce simple guidance on assessment. This would help everyone better understand what the process is for, how to make it work for users and carers, and how to record it. 

The council is encouraged to consider developing an adult social care intranet to provide information and detail about processes. This would help to deliver important internal communications, hold cross-department resources and requests and would help to bring all teams together whilst ensuring key resources are readily available to all. It could also describe the specific adult social care processes staff need to use. 

Colleagues across the service are aware of the need to reduce the number and type of waiting lists across the department. Effort should continue to reduce waiting lists and backlogs for assessments and reviews and to track progress. There should be a consistent approach to managing risks from the waiting lists through the use of a risk assessment tool. This is especially important for those requiring occupational therapy and/or being supported in neighbourhood teams. The peer team saw evidence that there is a 40-50 week wait to have a 'standard' assessment by an occupational therapy assistant and 57 weeks on average for a more 'complex' assessment by an OT. As this progresses the council should develop a clear narrative outlining that it has robust timeframes and milestones and is clear and can be easily understood by the regulator and the service user. This will be a key area for CQC inspections. 

The council needs to develop its understanding of inequities in relation to access and take-up of services and the related outcomes. The Liverpool City Council plan has tackling inequalities as a core purpose and ambition for the council. We heard that the adult social care department is seeking to make better use of intelligence from a wide range of data sources to better understand how to tackle inequalities and respond to inequity of access to services and outcomes from them. An increased and consistent focus on equality, diversity and inclusion across the services would support this. 

This relates to markets (including commissioning), workforce equality, integration and partnership working. 

Strengths  

The adult social care service has some strong and effective providers in the market. There are several provider forums which cover the care home market, supported living and homelessness. The council uses these forums both to seek feedback and to communicate the strategic direction of the council. 

The peer team heard that partners in the private and voluntary sector are ready and willing to work with the council and have ideas on how to make sustained improvements. Such as, i) a better use of voids, ii) more efficient rostering and iii) more outcomes focussed contracts and flexibility for innovation. There were some suggestions by providers of a gap between 'strategic and operational discussions between providers and LCC' along with a lack of connectivity with operational staff. When asked, there appeared to be no demand modelling in place and some providers did not have demand to meet voids so were seeking out of area placements. LCC could address each of these aspects by working in a more partnership based way with these providers. 

Investment in domiciliary care is showing positive results in terms of stability, availability, and quality. This is evidenced by the fact that there are now very few people currently waiting for a care package which represents good progress with few hand backs. 

The adult social care service works well with partners to respond effectively to service concerns or failures when they become evident. This is evidenced by how the council works with CQC and the NHS, in particular, to respond to issues identified by inspection, contract compliance visits, or alerts from providers themselves. There is a shared commitment to ensure minimum disruption to the adults and the carers using the service and making the necessary improvements wherever possible. 

Carers in Liverpool have access to a range of services, including assessment, peer support and advocacy. Local Solutions is one such provider and offers assessments and a range of other supportive services to carers, who value it very highly as the see it as very important in their lives. ‘Mytime’ is a particularly well regarded innovation where unpaid carers who could benefit from a break from their demanding roles are connected with businesses and organisations who donate complimentary leisure, cultural and educational activities. This is a good initiative and can be found here: MyTime for Carers | Giving Carers The Break They Deserve (mytime4carers.co.uk) 

The mental health and domiciliary care providers are very positive about relationships with the council’s social care commissioners and value them highly in comparison with other neighbouring authorities. 

LCC provides three community intermediate care reablement hubs (Crown, Lime and Sedgemoor) which provide short term support for up to six weeks following discharge from hospital. The hubs also provide step up beds for admission avoidance. Over 50 per cent of people are discharged home with 29 days on average. These are highly regarded by service users and carers. They were recently recognised by the Emergency Care Improvement Support Team (ECIST) as best practice for social care discharge, reablement and their implementation of the SAFER principles. They have further potential that has not yet been fully realised, especially for adults with a Learning disability and/or Autism. These services are not yet working to full capacity and would benefit from clarity on their service model, their key contribution as part of the wider market and future vision and direction to ensure accessibility is maximised. 

The Sedgemoor Dementia Support Hub accommodates people who require respite care and short-term reablement care and is highly regarded by carers who described the service as ‘a lifeline’. It is well led by staff who have a clear view on how it can be developed and improved and could be further freed up to do so.  

For consideration 

The peer team recommend that a more strategic approach to commissioning is necessary, which is something that the council acknowledges. Steps are being taken to appoint a permanent senior member of staff to drive the change required. This is essential and urgent so that the council can better understand the needs that should be addressed and the resources that will do it (including housing). The aim will be to improve outcomes and secure better value. 

The council recognises that there is work to be done on market shaping to ensure that the market understands the council’s ambition and can adjust and develop services in response. This has worked well in the domiciliary care sector and needs extending to residential, nursing home, supported living and dementia care, where there are issues of sufficiency and quality of supply. 

The quality of services in the market is of concern and LCC recognise in their self-assessment that they are an outlier in care home quality, the percentage of homes with ‘good ratings have shown a declining trajectory’ and that ‘improving quality in care homes is a key priority’. The peer team recommend a strategic partnership focus on raising quality standards and adopting a preventative approach to quality to complement the tactical support offer. For example, a regularly updated market position statement would help identify the need for growing new services (such as extra care housing) and filling evident gaps in provision now and in the medium term (such as nursing care and dementia support). This would also indicate future plans for promoting the independence, care, and support for younger adults. 

The point above was reinforced by managers and frontline staff who told the peer team about gaps in the market that need addressing. The most urgent is access to nursing homes, dementia care and respite. 

Healthwatch is the independent consumer champion for both health and social care and they told the peer team that sometimes residents feel dismissed and frustrated in their contact with the council through the adult social care front door. The peer team think there is scope for strengthening the customer journey narrative for all user groups, including carers. This is now known to be a key aspect of the CQC approach to understanding the lived experience. The peer 

team recommend that the council conducts work around the customer journey across a range of user groups to further the understanding of the issues and to develop an appropriate response, then compare the findings to what the council knows about itself. This should be done at pace. 

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

Strengths  

There is a Liverpool Adult Safeguarding Board (LSAB) that was established in July 2021, solely focused on activity in the City (previously there was a SAB across four of the Liverpool City region local authorities). This has renewed the focus and commitment of partners locally to help ensure that safeguarding is recognised as everyone’s business. Further engagement from key stakeholders and a commitment to improvement will support this continued development. 

The board is well managed and together with a new chair (Duncan DooleyRobinson, appointed in January 2023) and with renewed partnership relationships steps have been taken to strengthen safeguarding processes. The peer team recognise the value of the investment in a new safeguarding assurance team and whilst the SAB is in its infancy and the new chair is settling into the role. 

The commitment to complete the outstanding Safeguarding Adults Reviews and Domestic Homicide reviews and learn lessons from them is important and welcome and there is a good understanding of the need to address consistency of practice. The principal social worker (PSW) should take the lead role in disseminating learning from Safeguarding Adult Reviews to managers and practitioners in accordance with national guidance (Role and Responsibilities of Adult PSW’s – DHSC 5 July 2019). 

The council knows where there are quality and safety concerns in the wider market, as outlined in the previous section of this report. 

The appointment of a Continuing Health Care (CHC) Lead is a positive asset as it provides a focal point for consistency of approach, clarity about processes, resolution of disputes and engagement with partners.  

For consideration  

The peer team (and the sector as a whole) anticipate a focus by CQC inspections on waiting lists for assessments. In the self-assessment for this work the council recognises this risk where it states, “Like many local authorities, Liverpool has waiting lists for assessments, reviews, and safeguarding. Tackling these and managing the risks that they present is our key priority.” The peer team agree with this analysis and intent and recommend that the council should continue with its efforts to reduce and remove backlogs and waiting lists. 

The council should consider developing a process for managers to monitor and risk assess on a consistent basis the number of people waiting for assessments or reviews. This will ensure that the Council is aware of any increase in urgency from deterioration in the circumstances of those waiting for assessments. 

The council should consider the use of fixed term contract, independent workers or agency provision of occupational therapists (OT) to clear the OT and OT Assistant backlogs. The Disabled Facilities Grant is forecast to be fully spent this year and has been overspent in the last two years with additional funds added, so there is a recognition of the importance of this work. This extra capacity will help the council break the cycle of delay. 

Similarly, using fixed-term contract Best Interest Assessors or commissioning a trusted provider could help reduce the long waiting times for Deprivation of Liberty Safeguards (DoLS) assessments. 

The peer team found some confusion about the Outcome Review meetings. These were introduced due to the high levels of some cost decisions as well as high cost of packages and the council is well aware that this would take some time to embed with staff. Therefore it would help to share the terms of reference with the staff and allow them to attend the meetings. This will increase staff understanding of the purpose and processes involved and thereby develop their professional understanding and practice. 

The peer team suggest an analysis of the decision-making processes from end to end to consider the length of time taken and the impact on staff and the people waiting for care and support. 

The work of LSAB and sub-groups needs to ensure that the principles of Making Safeguarding Personal (MSP) are embedded. This would promote “...a way of 

working that should be seen across all practice areas, not limited to safeguarding, where practice is person-centred, outcomes focused, and strengths based.” (ref: MSP Toolkit Handbook p.5). 

Whilst it is welcome there are no holding trays for safeguarding enquiries it is important to ensure they are not inappropriately closed. We found an instance of this in the case audit. This is a key role for supervision and reflective practice discussions. 

The education of partners is still required on what is a safeguarding referral, rather than a general expression of concern or a way of escalating a response to a referral. This is a familiar issue in most councils and can be addressed by working with key partners such as the ambulance service and the police. 

We think the council should consider how to address the inequality of funding contributions to the LSAB from partners, including from the Police and the 

Integrated Care Board. If safeguarding is everyone’s business, then financial contributions should reflect this as they reflect the investment in the whole endeavour. 

LSAB should take steps to ensure full engagement and participation across statutory partners. The seniority of, and regularity of attendance, from some partners was reported to us as a concern. 

The peer team considered seven cases in the audit. 

Strengths 

The move to strengths-based assessments is work in progress and it is evident that a robust training programme is planned using a well-regarded external facilitator. The strongest evidence of strengths-based recording was seen from the Integrated Discharge Assessment Team workers and mental health workers. 

There were examples of effective portal referrals, resulting in a timely response for people seeking support. Recording was noted to be timely, proportionate, and appropriate. 

There was evidence of comprehensive and timely recording in the majority of case files. However there were also examples of recording that was not proportionate in that some sections had been copied forward and completed when not required. This was confirmed by the PSW who was present during the case file audit and consulted on Liverpool processes. Not copying forward is an area that she is already addressing with practitioners and their managers. 

For consideration 

There was evidence of effective short-term interventions but there was a lack of longer-term planning. There is a need to look beyond the immediate crisis to help prevent, reduce and delay the need for longer term care and support. 

More outcomes need to be person centred and expressed in the person’s words. It is suggested that the recording policy requires review. There were multiple examples of assessments being carried forward without being updated in Liquid Logic. Within the review there is also an opportunity to reinforce the need for proportionality and to revise assessment documentation. 

The need for culturally appropriate support and professional curiosity was highlighted in a case audit that involved an older person who could not communicate in English and was reliant on her family to communicate while she was in care home. Advances in linguistic technology such as Google Translate may be an appropriate consideration here. 

There was variable evidence of mental capacity assessments and Best Interest Decisions, some assessments were not current. 

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

Strengths  

From speaking with the individual’s involved the peer team judge that the adult social care department is well led politically and professionally with a clear sense of direction and passion. Furthermore, the transformation imperative is understood politically and corporately and supported by the DLUHC Commissioners. 

NB: Since the peer challenge team were onsite the council's cabinet member for adult social care and health has left the authority. As the council manages the transition to a new cabinet member there is the need to ensure clear briefing on the adult social care transformation agenda, improvement plans and management of different risks in the present and for the future. 

The Health and Wellbeing Board and the Select Committee have member led agendas that contribute to service and policy development and the department is well supported by its business partners. 

There was evidence that the budget was well constructed, and savings targets robustly challenged for their achievability. We heard about the process recently followed from the department, the finance business partner and councillors. This has boosted transparency and accountability. The Adult Social Care department has a budget of £246.7m for 2022/23 and has been asked to deliver savings of £13.6m in 2023/24, £19.2m in 2024/25 and £25.1m in 2025/26. In conversations with the DASS and finance leads there was the view that these are achievable through a focus on the adult social care transformation agenda and a clear determination to improve.  

Power BI is described by Microsoft as “an interactive data visualization software product developed by Microsoft with a primary focus on business intelligence. It is a collection of software services, apps, and connectors that work together to turn unrelated sources of data into coherent, visually immersive, and interactive insights”. The peer team saw it as a great tool to animate performance management and were impressed by its functionality and how data and live records were interacting to give real-time information to managers and partners. This looks like a very useful tool for the adult social care service to understand its activity and drive performance across the department. 

The NHS partners the peer team spoke with told us they recognise the scale of the task required at, and with, LCC and how they can contribute. This awareness and belief in a shared endeavour bodes well for the future, whilst not underestimating the challenges ahead.  

For consideration  

The peer team welcome the commitment to delegate budget responsibilities in the organisation as there appear to be unnecessary delays in the current processes. The peer team found a lack of clarity about who decided what and in what timeframe. Further delegation should bring greater clarity and simpler accountability lines. To that end the service intends for budget alignment through the planned structural changes likely taking place at the end of the year. 

There is a lot to build on in relation to performance management. The adult social care senior team have plans to ensure that the department’s dashboard reflects all the council’s Care Act responsibilities in a simple, graphic form. There will be similar dashboards at all levels showing activity, responsiveness and cost, which will be a game-changer in the council’s adult social care transformation and improvement journey. 

From what the peer team read, heard, and saw prior to being in Liverpool there was little evidence of co-production. This was reflected in those whom the peer team had the opportunity to meet whilst onsite and in what the peer team in from plans and policies. This needs investment in as well as building into the transformation process and business as usual. 

The peer ream would like to reinforce the view that staff are keen to contribute their thoughts on service redesign and it is important they are activity involved so that plans and progress is transparent. The staff the peer team had the pleasure of meeting were typically positive, thoughtful, and aware of the challenges they face. They were also personally invested in the proposed solutions and a central asset that has a clear desire to deliver better outcomes for the people of Liverpool. The peer team recognise that the leadership of the service are well aware of this and there have been significant engagement events since January 2023 with staff throughout adult care to give further direction and clarity to the priorities and actions of the service. 

There is scope to consider how feedback from service users, carers and partners can be systematically used to improve services. This can be through co-production, consultation, inviting feedback and analysing complaints and commendations. 

The peer team suggest that the Better Care Fund can be used as a vehicle for modernisation and prevention. It is largely an aggregation of previous funding agreements and allocations, with little headroom for challenge and innovation. 

The department has the intention to raise the profile of the PSW role across the organisation which will ensure that their insights are influential with the aim of raising the quality of frontline service delivery. 

The forthcoming workforce strategy needs to be properly embraced. The peer ream heard a previous version had a low profile and little impact. There are major challenges in recruiting, sustaining, and developing the workforce across the whole sector in the City and this needs senior engagement alongside the NHS’s strategy. 

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 - don’t 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’s 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. 

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. Claire Hogan, LGA Principal Adviser is the main contact between your authority and the Local Government Association. Her contact details are email: [email protected], telephone: 07766 250347. The LGA Care and Health Improvement Adviser for the North West is Hazel Summers, who can be contacted via email: [email protected] or telephone: 07827 083838. 

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.  

For more information about the Adult Social Care Preparation for Assurance Peer Challenge at Liverpool City Council please contact:  

Marcus Coulson
Senior Advisor – Adults Peer Challenge Programme 

Local Government Association 

Email: [email protected]

Tel: 07766 252 853 

For more information on the programme of adults peer challenges and the work of the Local Government Association please see our website: Adult social care peer challenges | Local Government Association