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Preparation for assurance peer challenge report, Cornwall Council

Final report - October 2023


Background 

Cornwall Council 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 Ali Bulman, Strategic Director Care and Wellbeing and statutory director of Adult Social Services (DASS) who was seeking an independent perspective on how prepared adult social services are for a Care Quality Commission (CQC) assessment with a particular focus on safeguarding and the role of the safeguarding adult board.

The purpose of a peer challenge is 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 preparation for an Assurance Peer Challenge teams typically spend three days onsite in addition to undertaking case file audits, lived experience interviews and a review of data. This process should be seen as a snapshot of the client department’s work rather than being totally comprehensive.

All information collected is non-attributable 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:

  • Glen Garrod, Executive Director Adult Care and Community Well-being, Lincolnshire County Council
  • Cllr. Colin Noble, former leader Suffolk County Council and Local Government Association Peer 
  • Moira Wood, Adults Principal Social Worker, Gloucestershire, and co-chair of the South West Principal Social Worker network.
  • Tom Chettle, Head of Service, Buckinghamshire Council
  • Jenny Lamprell, Head of Strategic Commissioning, Wokingham Borough Council.
  • Sarah Farragher, Peer Challenge Manager, Local Government Association

The team were on-site at Cornwall Council for three days from the 10th to the 12th of October 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, frontline staff, and people with lived experience.
  • Read a range of documents provided by Cornwall Council including a self-assessment and completed twelve case file audits. 

Specifically, the peer team’s work focused on the Care Quality Commission (CQC) framework four assurance themes for the up-coming adult social care assurance process. 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 300 documents including a self-assessment. Throughout the peer challenge the team had more than 37 meetings with at least 100 different people. This included lived experience interviews with seven people and attendance at a co-production meeting including about a dozen people with lived experience. The peer challenge team spent over 200 hours with Cornwall Council the equivalent of 30 working days. Invariably this is still a snapshot of Cornwall Council.

The peer challenge team would like to thank councillors, staff, people with a lived experience, carers, partners, and providers for their open and constructive responses during the challenge process. All information collected on a non-attributable basis. The team was made very welcome and would like to thank Emma Trethewey, Tamsin Dower, and their team, for their invaluable assistance and for the support to the peer team, both prior to and whilst onsite, in planning and undertaking this peer challenge.

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. 

Key messages

There are observations and suggestions within the main section of the report linked to each of the CQC themes and quality statements, most of the areas for consideration identified where already identified within the self assessment or discussed with the council as part of the Peer Challenge. The following are the peer team’s key messages to the council:

Message one: Corporate and political alignment to Adult Social Care

Cornwall Council Adult Social Care has historically been significantly financially challenged. The Council has addressed a significant structural deficit in the budget which has resulted in £45m additional net recurrent investment in adult social care. This has reset the adult social care budget position and should provide significant opportunities to improve outcomes for people.

The strong and consistent message across the leadership of the council regarding this scale of investment is impressive both politically and corporately and is a significant strength for the council.

Message two: Adult Social Care Leadership and External Relationships

The adult social care senior leadership team is relatively new, with the DASS having been in place for just over a year.  The team are energised, engaged, and ambitious. The DASS has significant personal credibility with staff, partners, and people with lived experience and there is a confidence that she will deliver improvements.

External relationships are also improving, and the peer team heard positive stories from several partners and people with lived experience. These relationships along with positive internal partnerships provide the team with significant opportunities in preparation not just for adult social care assurance but for Integrated Care System (ICS) assurance.

The role of the Principal Social Worker (PSW) is a key position for CQC assessment. The peer team heard that due to organisational policies the DASS does not manage the PSW. It is essential that the Principal Social Worker is central to development and promotion of practice and that the DASS is fully sighted on this work. The peer team have highlighted that there are some examples of good practice, but strengths-based approaches and co-production are not yet fully embedded. These are key development areas in practice that the PSW should be driving. The council may wish to consider a review of the current PSW role and status to ensure that this is delivering the interface between strategy and practice effectively.

Message three: Embedding the approach.

The peer team were very impressed with the overall corporate approach, ownership, and direction of adult social care. The council appears to be in an early stage of this journey. Some of these strategic messages are not yet embedded in the system and there does appear to be a gap between this aspiration and the delivery of improved outcomes for people. The peer team heard examples of front-line staff and people with lived experience who are still struggling with the practicalities of accessing the range of support needed to enable people to live healthy, and independent lives and ensuring consistent and good quality support.

The position was similar with providers who expressed that they have  not been consistently engaged with market shaping and confident about relationships and engagement with the council. There is evidence of improving relationships with the ICS, but further work needed to support integration and improve outcomes for people in Cornwall. 

The council is undertaking a major piece of reshaping and resetting work with a focus on the long-term strategic changes that will deliver transformation rather than just the quick wins. The council may want to consider how the self-assessment articulates the operationalisation of this strategy to ensure this approach is visible through to front line staff, people with lived experience and partners. Similarly, there are opportunities to highlight where there have been positive outcomes that have already been delivered.

Message four: Ensuring Safety 

The council have significant waiting lists across a number of areas and actively track and manage these through a power BI dashboard that is circulated weekly and discussed at management team. As this is an online system the waiting lists did not form part of the evidence pack and were provided after the on-site visit. The latest dashboard (December 2023) suggests that around 750 people are awaiting needs assessments with around 50 per cent of these waiting more than twenty weeks. Carers waiting lists were not visible on the dashboard however the council reports that this is provided on a weekly basis by the carers organisation and there is an improvement plan in place.  There are references to improved waiting times for assessments and reviews within the self-assessment however the Council may wish to consider strengthening its narrative in relation to actions being taken to manage immediate safety and decrease waiting lists with specific reference to the revised CQC data request.

There is an increase in volume in safeguarding referrals and a significant inconsistency between the strategic and operational views of how safeguarding was operating. The council may wish to review safeguarding processes to ensure that these are operating optimally.

Given the challenges within safeguarding the Safeguarding Adults Board may wish to refresh its priorities to focus more clearly on prevention in line with the corporate work that is happening, embedding the lessons learned from Safeguarding Adults Reviews (SAR’s) and outcomes for people through Making Safeguarding Personal (MSP).

Theme 1: Working with people

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

Strengths 

  • Staff in the independence and well-being service are actively utilising equipment, reablement and community support options to support well-being and prevent, reduce, and delay the needs for more intensive support. 
  • People who access direct payments report that these are supporting them to exercise control over their lives and live a good life and the service is starting to embrace a co-production approach and involve people with lived experience in the areas of personalisation and commissioning.

Considerations 

  • The council appear to be in the very early stages of resetting a strengths- based/personalisation approach and may want to consider how this is embedded so it becomes “how we do things around here” and using the existing good practice to tell the story.
  • There is significant work happening on market shaping responsibilities but there is further work to develop these into a coherent narrative that is understood by local providers. The Market Position Statement is a key vehicle for this narrative.

Case file audit findings

The peer team considered twelve cases in the audit. Each case was presented by an allocated worker. The council had previously audited all the cases reviewed.

Strengths 

  • There were some good examples of strengths-based practice, within the case audits and workers going the extra mile to support outcomes for individuals.
  • There was a triangulation of the outcomes of the case audits with lived experience interviews for one of these cases, with a consistent reporting of positive outcomes.

Considerations 

  • The case audits highlighted significant challenges with the way that safeguarding is recorded and how outcomes and activity can be tracked effectively.
  • The Cornwall Council internal case file audit appeared to be well received by staff, however it is heavily focused on process rather than outcomes for people with lived experience.

Examples of learning from the case audits has been included within the relevant quality statements.

Quality statement one: Assessing needs

Assessments

The case file audits, both those internally completed by the council and those undertaken by the peer team, suggested a mixed picture of assessments. Cornwall is following a discharge to assess process from the acute hospitals, consequently social workers are commissioning packages of care based on recommendations from the integrated transfer of care hub (ITOC) prior to assessment. There is a risk that these services may be overprescribed and result in more people entering long term residential and nursing care sooner than necessary. This is something that the council may want to consider as part of the ITOC development. 

The case file audits highlighted some good examples of strengths-based assessments with interventions tailored to individual outcomes and a commitment by the workers to provide support in way that worked for the person.  Invariably there were also some cases with room for improvement and the council’s internal audit process was identifying improvements on an individual basis such as language in assessments that could be more strengths rather than deficit based.

Consideration of mental capacity within assessment and support planning was varied. The peer team witnessed some excellent examples of mental capacity being considered and maximised using innovative strategies, however there were also examples of previous mental capacity assessments being relied on to support new decisions, and mental capacity being applied narrowly to single decisions without consideration of the wider context.    

Carers Support

Cornwall Council have made a significant commitment to improving carers support. There is a vibrant community and voluntary sector however there are challenges with increasing demand and complexity, and parity of esteem with statutory services. The peer team talked to people with lived experience who were providing carers support services who reported that there is a historic lack of faith in the council to support carers. This narrative is changing and the DASS appears to have credibility in her approach to change this. 

In advance of the on-site visit one member of the peer team attended a co-production meeting. This was clearly a relatively new forum but was well attended, chaired by the DASS, and had a clear focus on developing a co-production approach. 

There was some mixed messaging during the review about carers assessment and how these were managed with some interviewees thinking these were an outsourced function. Through the case audits it was identified that people are being referred to carers services that do not have capacity to provide support and therefore people are waiting longer for support.

Due to the geography within Cornwall carers are more exposed to deprivation and inequality particularly in relation to access to transport. There is a carers improvement plan in place to address many of the issues identified in relation to carers. 

Information, advice, and guidance

Feedback from people with lived experience is that information, advice, and guidance is not easily available. One member of the peer team tested out the on-line offer at a weekend which resulted in a referral through to the single point of access.  The peer member received a follow up phone call on the next working day showing a proactive approach however this demonstrated a gap in opportunities for people to self-serve which if addressed could potentially reduce volume of demand. The peer team noted that the Council has an ambition to improve its digital offer for adult social care, currently this is one area where there is not yet a baseline improvement measure within the self-assessment. The council may want to consider accelerating this offer. The LGA has a digital support offer that may be of interest.

Staff in the independence and well-being service are actively utilising equipment, reablement and community support options to support well-being and prevent, reduce, and delay the needs for more intensive support. Feedback from front line staff is that often there is potential to further improve these offers but that these are hampered by availability of appropriate community support and a prioritisation of reablement to support hospital discharge.

Direct Payments and Personalisation

The number of people in receipt of direct payments in Cornwall is around 21 per cent against a regional average of circa 26 per cent and a national average of nearly 27 per cent. This is lower than would be expected and is an area of significant focus for the council. To support this individual service funds are just being re-introduced and there are several direct payment champions across the service. 

People who access direct payments report that these are supporting them to exercise control over their lives and live a good life, however there are some barriers within the policy that restrict how direct payments are used in the spirit of the Care Act. Examples include a fixed rate payment for personal assistants, which is significantly lower than market rate and an exclusion of transport costs from the direct payment. Operationally the council are moving towards more flexibility within personal budgets with a planned redraft of the policy to rectify these anomalies.

Direct payments were a key feature of discussion at the co-production forum chaired by the DASS and people with lived experiences were able to provide feedback on how implementation could be improved, this was a positive discussion for the peer team to hear. The peer team heard from both officers and people with lived experience of the oversight and administration of direct payments. This includes a proportionate response to monitoring usage and a proactive reviewing system. 

Quality statement two: Supporting people to live healthier lives

The council has structured itself around four priority themes. A brilliant place to be a child and grow up, a thriving and sustainable Cornwall, vibrant, safe, and supportive communities, and an empowering and enterprising council. Consequently, departments work thematically across both service and corporate functions. 

A commitment to the well-being principle can be seen clearly in this corporate approach. The vibrant, safe, and supportive communities theme sets out ambitious current performance and stretch targets across a number of well-being measures including: a reduction in violent crime and domestic abuse, successful completion of drug and alcohol treatment programmes, obesity, self-reported well-being and safety and satisfaction with their local area. Discussions with corporate colleagues outside of the adult social care teams demonstrate a commitment to delivering on this outcome and detailed some of the plans that are in place to deliver this. The peer team heard positive examples such as community, voluntary sector and commissioning employing people with lived experience to help develop and shape the work. Within adult social care staff talked about clear enablement goals such as supporting people to develop the skills to use public transport.

This is a relatively new approach and feedback from people with lived experience and front-line staff still refer to historic approaches. The council may want to consider how it changes the messaging on the front line to enable the impact of its vision to be fully realised.

Quality statement three: Equity and outcomes

Cornwall has an aging population and has a challenge of an increase in people over the age of 65 combined with a reduction in working age adults. There are significant health inequalities within Cornwall and social deprivation is apparent in a difference in average life expectancy for men of seven years and women just over five years depending on which area people live in. The latest data suggests that 21 per cent of the population are disabled, compared to a national average of 17.8 per cent. There are three main areas of health concern: hip fractures, dementia, and diabetes. 

There is a recognition that a significant proportion of council staff are not providing personal equality data, the implications for practice of this is that it could be an indicator of a potential lack of awareness of understanding other people’s equality considerations. One example of how this might influence practice could be seen in a case review. A daughter acted as interpreter for her mother and the worker did not seek to source an independent interpreter.

Following a LGA led peer challenge focused on equality, diversity, and inclusion the council is taking proactive action to implement the recommendations. There is now an Equcouncil and the NHS to address gaps in data.

Through the review the peer team heard several examples of how the Council is actively working to address inequalities in outcomes. There is now a homeless advisor in the hospital, and this is in response to the challenges faced in discharging people who are homeless. Advocacy appears to be well used and was referenced throughout the review, although there have been some capacity gaps identified within this provision.

The care market is a particular area of challenge for ensuring equity, and this is covered further in the providing support theme. This is particularly an issue for rural areas as travel time is significantly elongated reducing the availability of care. Despite these challenges staff talked positively about aligning the right support to the right person at the right time.

Transition to adults 

Transitions services in Cornwall are led by adults’ services; there is reportedly close working between the transition workers and children’s disability teams. Planning generally starts at sixteen but monthly meetings between the services discuss children from the age of fourteen. Transition can continue up until the age of 25. Cornwall does not operate a single transition service; children are allocated to transition workers with their locality team and front-line staff advised that not all teams have dedicated transition workers. The council advised that there is resource in each area for transition worker however there have been recruitment challenges in some areas which are being addressed and capacity increased. Individual reports of transition experience from people with lived experience were positive about the quality of the transition support received from the social worker and the outcome achieved. 

One of the gaps in transition is related to children who are placed outside of Cornwall and often these requests can come into adult services at a much later date. There are challenges meeting needs of some of the young people in transition due to the different service offerings between the two services. Differences in the local offers means that there is significant variance in mental health services (CAMHS), education and community support options and opportunities depending on where they live.

There are some good examples of co-production with young people through initiatives such as “activate” that work with people up to the age of 25 years.  

Theme 2: Providing support

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

Strengths 

  • There is evidence of coordinated long term strategic planning within adult social care, corporately, and with partners. During the review peer team members had the opportunity to see the presentation of a 25-year housing and support strategy presented to scrutiny. The council is aware of and honest about the challenges and the areas in which development of strategies and plans are still needed. There is clearly the drive and the competency to deliver improvements and the relationships in place to manage this.

Considerations 

  • The delivery of outcomes against plans has not yet come into fruition, consequently the impact of the work that is going on is not yet being recognised by staff and communities. The council may want to consider how it communicates and tracks delivery of these ambitions with front line staff, people with lived experience and wider stakeholders. 

Quality statement four: Care provision integration and continuity 

The council appears to have robust strategic commissioning arrangements in place. Commissioning priorities are subject to a project management approach which includes co-design work with: people with lived experience, providers of care, legal, finance, commercial procurement and commissioning and operational colleagues. Most people are supported within Cornwall rather than in out of county placements.

Commissioning staff feedback was that the council is aware of gaps within market provision; support for carers, dementia and nursing capacity, self-funder support, autism, young people with a history of trauma, learning disability and complex needs support options and support for people with multiple complexities and vulnerabilities.  A number of these areas are already included within the strategies and plans the council is developing for closing the gap and meeting future demand however there is further work to do to address the entirety of these challenges and secure consistency in provision.

The peer team saw little evidence of an articulation of the council’s preventative offer for adult social care. It appears underdeveloped and under resourced and does not cover the primary, secondary, and tertiary levels despite a strong corporate approach and some positive practice, for example innovative approaches to digital and building on the existing positive risk-taking framework. A joint population health strategy and combined prevention approach to support people to remain healthy and well will support the sustainability of adult social care in the long term and this involves doing things differently. 

Quality assurance and continuity of care

Regulated care in Cornwall is good according to LG inform date  with 80.7 per cent of homes rated good or outstanding by CQC, compared to an average of 78.5per cent nationally.  There are concerns about the quality of accommodation in care homes. Quality assurance is collaboratively managed with the NHS and there is a proactive approach to partnership working to address quality and safety concerns. 

There have been several large provider failures and there is proactive response to this. The council set up an arms-length relationship with Corserv in response to three provider failures. This has helped to ensure continuity of care and created an opportunity for dividend return to the council. 

There is a targeted contract management process based on a serious and critical weighting algorithm (SCOT analysis) and a contract management toolkit in place to ensure open and supportive dialogue with providers.

The peer team did hear some examples in which commissioning and operational activity could be more joined up. The case audits highlighted several individual circumstances in which the interface between safeguarding, complex case management, and contract management could have been improved and this is covered further in the safety theme.

Addressing workforce challenges 

The biggest reported issue for provision of support in Cornwall is availability of care provision. The council confirmed that the rates paid to providers are “close” to the rates identified through the fair cost of care exercise and there is a commitment to foundation living wage foundation rates. However, because Cornwall has a lower wage seasonal economy providers struggle to compete with other sectors and subsequent retention of care staff is significantly challenged. 

The council has adopted “Proud to Care” a dedicated social care recruitment website to support recruitment to social care posts. To date over 100 posts have been advertised, however this is in the context of thousands of vacancies. There is a Proud to Care team of eight people to support this initiative demonstrating the commitment to making this work. Further work is required to measure the impact that Proud to Care is having on filling vacancies.

The council are engaging with schools and colleges to raise the profile of health and social care and introduced embedded training in local college courses. 

The council has commissioned an external workforce strategy this is due to be presented to the departmental leadership team in December 2023.

Housing

The council has bought together the joint commissioning opportunities (led by the strategic directors of housing and social care) for  housing and adult social care, this is positive as housing sits in a separate directorate to adults and is evidence of the strong corporate approach the council is taking to the challenges it faces. General issues with housing availability include a need for affordable homes which impacts on workforce challenges for adult social care and housing challenges for people with care and support needs.

Strategic housing needs are understood and quantified. Modelling has suggested that there will need to be thirty-one thousand specialist homes needed by 2052 with around three thousand additional extra care beds and eight hundred additional residential beds. The council has established strategic relationships with housing partners including arrangements in which partners are owned by the council. This is clearly a long-term strategy.

Quality statement five: Partnerships and community

There is a move to area-based working and community hubs, based on guided conversations, using personalised support and personal budgets to avoid handoffs and promote collaboration. This is not just focused on adult social care services and includes a range of other services such as community drug partnerships. Building a concept of “know your area” and using local data to lead local conversations is starting to become embedded. The operation of these services is managed by area directors and there does appear to be a difference in the quality of the offer based on locality. The council may want to consider the impact of this variation on citizens.

Partnership working on primary prevention is based on a concept of “eyes in the community.” This brings together the fire service, paramedics police and community support officers with referrals into adult social care as necessary. The principle is that the most trusted service work with the person in the first instance to encourage engagement around issues such as hoarding.

There are plans in place as part of the Integrated Care System development to build on these locally based provisions to increase the range of health support that can be delivered at home to reduce unnecessary hospital admissions.

There is an opportunity to significantly strengthen the voluntary sector offer within Cornwall. Twenty-four libraries are now delivered in partnership with town and parish councils and local community groups. There is a vibrant and willing voluntary sector, however the peer team heard reports that the supporting infrastructure was under-commissioned and every part of this is under pressure, several services such as befriending have not returned to face-to-face delivery post-covid. The local carers organisations are highly valued by the people that access these.

There is some positive evidence of joint approaches between the NHS and the Council to use voluntary sector to support the delivery of outcomes that address key issues, for example support for mental health and board level voluntary sector representation for the integrated care system. 

Hospital discharge

Cornwall has developed integrated transfer of care hubs (ITOC) in line with national best practice guidance and continues to operate a discharge to assess model following the end of nationally identified funding. The overall approach to hospital discharge appears to have improved significantly over the last twelve months.

Front line staff report that the implementation of the ITOC’s has improved discharge process and timeliness although there are some disconnects between the social work offer and the hub role and this was particularly evident within the case audits.

Hospital discharge remains a challenging area of work.  Current figures indicated that 2.7 per cent of people are going into residential care straight from hospital which is higher than the 1per cent best practice recommendation although this is an improving picture. Some of the discharge pathways need some work including issues that are part of the wider ICS such as a specification for homefirst and a review of the use of community hospital bed provision. For the Council specifically there are issues with people arranging their own care (self-funders), and compliance with deprivation of liberty safeguards (DoLs). A joint intermediate care strategy aims to improve these pathways as well as supporting people to remain at home and reduce care needs. A newly established homeless pathway provides support for up to twelve weeks and has significantly improved this offer. 

Theme 3: Ensuring safety

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

Strengths 

  • The Safeguarding Adult Board (SAB) is appropriately represented by all senior partners. There is a strategic alignment with community safety and safeguarding children boards and the board is funded by all statutory partners.

Considerations 

  • A review of safeguarding gave a very mixed picture and there was a marked difference between the views of different people within the system. This is detailed in the narrative of the report and the council may wish to consider an end-to-end process review of the safeguarding offer.
  • Similarly, the peer team were not assured that the Safeguarding Adult Board (SAB) is focusing on those areas that would be of greatest benefit for Cornwall, for example prioritising resources on a covid-enquiry that appears to mirror the national enquiry rather than addressing the issues that are presenting locally. The DASS has requested an audit of learning from Safeguarding Adult Reviews (SARS).
  • The peer team reviewed a high-level table of waiting list data however there was insufficient detail to enable the team to be assured that these risks were being robustly managed. This is something that CQC will focus on, and you may want to consider how you demonstrate control and grip over these high-risk areas.
  • The peer team did not get the opportunity to look in detail at some other areas of safe pathways and transitions, such as mental health, section 117 and deprivation of liberty safeguards and the council may want to assure itself in relation to these areas. 

Quality statement six: Safe systems, pathways, and transitions 

The corporate approach to outcome delivery is impressive and will support and improve safe systems, pathways, and transitions. There was evidence of trying to build a mentality of safeguarding being everybody’s business with initiatives such as training Parish Councils in safeguarding.

There has also been a significant effort to bring together the work of the Safer Cornwall Partnership (SCP), the Safeguarding Adults Board (SAB) and the Safeguarding Childrens Board (SCB).  The SAB chair is a member of the SCP, and all three chairs meet informally on a regular basis.

The quality of regulated care residential and nursing within Cornwall is generally good with 80.7 per cent of care homes rated good or outstanding which is slightly above the national average of 78.5 per cent. There are four care homes that are inadequate, and they are subject to a quality improvement plan. The ratings of domiciliary care providers are also above average with 75.2 per cent of domiciliary providers rated good or outstanding, compared to a national average of 61.5 per cent. 

Waiting lists and unmet needs

The service has records of waiting lists for DoLs, Occupational Therapy, Carers Assessments, Care Act Assessments, and financial assessments.

Through the case reviews and discussion with managers the peer team gained some insights into how work was being prioritised. Access workers, who are non-registered professionals are making triage decisions on urgency but due to volume this is outside of waiting times. Access workers work alongside registered social workers and occupational therapists and are supervised by managers who are professionally qualified. 

Discussion with front line teams and managers indicated that staff were aware that there was unmet need due to a shortage of care capacity, a position that was reflected through conversations with people with lived experience.  The peer team where unable to ascertain whether there was a robust process for managing and reviewing unmet needs although there is a dashboard in place. Certainly, at operational level there did not seem to be a consistent approach in place across the localities and the council may want to assure themselves around their understanding of waiting lists, the approach to risk management and the narrative around how this is described.

The self-assessment reports that people awaiting assessment in the last year have reduced by 41 per cent and people awaiting reviews has reduced by 46 per cent. The council has a target of eradicating waits of more than 28 days by spring 2024.

The financial assessment team did demonstrate a grip on their backlog position, the target for assessment is 21 days and the team reported 100 people are outside of this timescale. The team described a new on-line tool that went live in August. This will enable people to undertake more self-assessments and will speed up the time taken for financial assessments. There are good working relationships between the financial assessment officers and the locality teams to problem solve when getting information is tricky.

There is no formal waiting list for safeguarding however there were multiple reports of unrecorded waits, for example information reported via the portal at the weekend not picked up until Monday, cases being allocated to people on annual leave and inconsistency and lack of clarity about whether an initial safeguarding enquiry should be screened within 48 hours or five days. These issues are discussed further within the safeguarding section of this report.

Housing and homelessness 

There is a recognition that access to housing is a significant challenge in Cornwall.  This has been exacerbated by a change in behaviours in the private rental market, following the pandemic, and in response to the cost of living. Housing issues and homelessness was a consistent theme with front line staff and featured in multiple conversations with the peer team.

Strategically the council are aware of this issue and have put together a robust 25 year supported housing strategy which was considered at scrutiny whilst the peer team where on site, this is discussed within the providing support theme.

Front line staff were also concerned about the high support needs of people experiencing homelessness and the availability of services that had the skills and the capacity to be able to provide a response.

Quality statement seven: Safeguarding 

In advance of the peer review the DASS requested a specific focus on safeguarding and the role of the safeguarding adult’s board.   

As part of the case audits the team observed some excellent and detailed strengths-based practice with relation to safeguarding, however the team also noted that the process and timelines on Mosaic appeared overly complex with multiple and overlapping organisational and individual safeguarding episodes. 

The volume of reported safeguarding issues is rising, and this is not sustainable within the current operating model. Discussions with managers and staff indicated a mixed picture of safeguarding and in some cases, diametrically opposing narratives were given in different meetings suggesting a disconnect between the strategic and operational view of how safeguarding is operating.

Conversion rates and feedback suggests that things are being viewed as safeguarding which do not meet the threshold and that the processes are overly complex. The Council may want to consider an end-to-end review of process to ensure that safeguarding is being managed based on the six key principles of safeguarding.

Safeguarding processes

The conversion rate from triage to further section 42 enquiry is low (14per cent) and out of kilter with other areas. This is likely to be an over reporting of inappropriate safeguarding concerns creating significant pressure on the existing systems. This position increases the risk of being able to provide a proportionate and personalised safeguarding response to people who may require a response, as well as labelling people as in a safeguarding process unnecessarily which could cause unnecessary distress.

All potential safeguarding work is triaged by a dedicated team.  The standards for this triage are 48 hours for urgent work and five days for non-urgent work. There are no recorded waits outside of these timescales reported by the service although there was some confusion amongst staff about whether these timescales are adhered to.

The triage function does not undertake any face-to-face visits. It is designed to be a fact-finding service, however due to the volume of referrals it is more frequently becoming a “proportional response” that provides desktop screening exercise only. In some instances, managers are undertaking triage to manage the pressures. The peer team were presented with an example of one locality that was piloting an on the day face to face response to duty and safeguarding which raised the question about how immediate safety checks are managed routinely within the rest of the system.

Triage deals with police and ambulance referrals, as has often been the case in other areas. These are high volume,  often low-level  concerns that are unlikely to  meet the three-point test for safeguarding and the council may wish to consider alternative ways of managing this work, for example as part of the front door response or even earlier through the innovative community safety work that is being developed. The team also heard reports of an increase in domestic abuse referrals.

There was an inconsistency of views around the effectiveness of triage, front line staff in other teams reported work being “handed off” with examples that suggested a cultural position of triage being responsible for safeguarding rather than this being a shared position.

There were reports of a “mini” Multi-Agency Safeguarding Hub (MASH) being in operation. The “mini” MASH includes partners from drugs and alcohol services, domestic abuse services, mental health, children and families directorate, the acute trust, and police. There was also reportedly good links with children's safeguarding functions providing further evidence of the corporate alignment and comments about the MASH being a forum through which advice and guidance could be sought, and multi-agency discussions held for high risk or more complex safeguarding concerns. There were also comments about poor governance and attendance by managers rather than practitioners. Safeguarding triage was not routinely undertaken through the MASH function.

Staff involved in safeguarding work reported good access to legal advice and case law advice. However more generally legal advice was seen as being very risk adverse which may be contributing to some of the challenges.

The safeguarding process on the digital case management system was difficult to follow. In the case audits the team saw one example of multiple safeguarding processes in place some of which were being managed as organisation concerns others as individual concerns. This was escalated by the peer team. The managers reviewed the case and were assured that this was being well managed, and the persons outcomes were being met however the transparency and governance of the recording systems and process may benefit from a review to better evidence how these interventions are impacting on the person.

This observation was reinforced by feedback from other staff who reported that the system was “clunky”, the work was process rather than person centred and driven by timescales. There were suggestions for improving this, for example a picklist on Mosaic rather than a triage referral and better line of sight for commissioners. 

Staff reported that the timescales for section 42 enquiries were often elongated with individuals not being contacted until a social worker had been allocated. 

Quality assurance and governance of safeguarding processes

Whilst there was some concern around the management of safeguarding triage, practitioners in the locality team reported good management support for safeguarding enquires.  Similarly, there was positive feedback about joint working with experienced social workers supporting newly qualified (ASYE) colleagues and co-working cases with allocated adult social care practitioners to maintain relationships.

Partnership working was reportedly positive across the system with an offer of wider support for partners in safeguarding enquires. Risk Managers are allocated to oversee the externalised enquires and quality assure the work meeting regularly with partners.  There is a high-risk panel in place and weekly drop-in sessions with Risk Managers for practitioners.

In response to the over reporting of concerns a threshold document has been developed and a quality assurance document for providers to separate out quality concerns and safeguarding issues is in place.  These processes do not seem to be widely socialised or used.

There was a strong focus on sharing learning; examples included the Safeguarding Adult Board Newsletter, Practice Assurance Group, bespoke learning events such as the safeguarding conferences and domestic homicide reviews, and a newly introduced auditing process, shared in supervision and themes in team meetings.

Access to advocacy appeared to be a challenge with a reported wait of between four and six weeks for allocation of advocacy for safeguarding.  The Council are paying identified relevant person representatives (RPR’s) for people who are subject to a deprivation of liberty safeguards (DOLS) to act as an advocate.

Staff reported that safeguarding training is now delivered exclusively online and there is no opportunity for in person training. 

Making Safeguarding Personal (MSP)

The peer team heard mixed reports about the progress towards making safeguarding personal.  The safeguarding adult board and senior managers within safeguarding were positive about the progress that was being made however this view was not necessarily the case across the wider team.

Leaders within the safeguarding service indicated that making safeguarding personal was an improving picture with 69per cent of people having outcomes recorded in 2023 compared to 58 per cent in 2022. Other practitioners described this as a tick box exercise stating it was difficult to get the right level of feedback and identify outcomes.

There were examples of providing proportionate responses through care management.

The Safeguarding Adults Board (SAB)

The Independent Chair of the SAB has been in post since 2017. The board is funded by all statutory partners and is attended by people with an appropriate level of seniority to effect change within their organisations.

There is starting to be good alignment between SAB, the Community Safety Partnership (CSP) and the Safeguarding Children Board (SCB) with the chairs meeting regularly. The independent chair of the SAB is a member of the CSP.

There are close links between safeguarding adult board and the interim head of safeguarding. The SAB has asked for an audit of MSP which is positive to note given the inconsistencies of views from people the peer team talked to during the review. 

The peer team were less assured that the board is focusing on those areas that would be of greatest benefit for Cornwall, for example prioritising resources on a covid-19 enquiry that appears to mirror the national enquiry rather than addressing the issues that are presenting locally.

The board noted a previous intention to develop a prevention strategy which has not come to fruition in part due to the pandemic. However, there is good synergy between a potential safeguarding prevention strategy and the Council priority outcome of vibrant, safe, and supportive communities suggesting that this may be any area which could easily be developed and enable more effective management of safeguarding demand.

The mixed picture of operational safeguarding challenges would suggest that there is a role for the board in assuring itself that safeguarding is operating effectively in line with the principles of safeguarding and setting out the position for what good looks like locally through improved conversion rates and embedding safeguarding more generally.

There was a good analysis of lessons learned from Safeguarding Adult Reviews (SAR’s), but the peer team were unable to track the actions, activity and implementation of changes that had been made in response to these findings.

Theme 4: Leadership

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

Strengths 

The council has a strong leader, chief executive and DASS, evidenced by the commitment to adult social care priorities and grasp on the detail through corporate planning. The council’s leadership team from director to team manager level has a mix of both service and corporate responsibilities to ensure ownership. There is a need to embed this through distributed leadership to front line delivery.

There is a commitment to co-production which will inevitably mean a handing over of power to people with lived experience and front-line staff. This needs to be balanced around the requirements of the council to ensure equity of services across the system. 

Considerations 

The ability of the service to think system wide is hampered by fractured historical relationship and an imbalance between emergency response and strategic planning.

The internal council reset is happening in parallel to a reset within the wider ICS. Early progress is being made in relation to the development of integrated discharge arrangements, intermediate care priorities and the strengthening of place-based localities. However, there is a disconnect on the alignment of the “Cornwall pound” with disagreements on key areas such as continuing health care and section 117 and a caution around fully embracing joint commissioning.

Quality statement eight: Governance management and sustainability

The leadership of adult social care is well-led by a strong leader, chief executive and DASS. The DASS had good personal credibility across the board and the peer team heard comments from frontline staff, partners, and people with lived experience to this effect. Comments from people with lived experience included:

“It’s a pleasure working with Ali”. 

 and 

Alison is very good”.

There is exemplary corporate support for adult social care through the One Council approach. Council priorities are outcome focused and thematic rather than service specific and all senior officers have a proportion of their time focused on corporate priorities as well as service delivery. The success of this approach was evident when talking to council officers outside of adult social care who demonstrated a commitment and understanding of adult social care issues.   

This commitment has been reinforced through a significant budget realignment to enable adult social care to meet its statutory functions with an additional £45m of investment into the service to address a previous structural deficit of between £30million and £40million. This additional investment has been delivered by the removal of 400 council posts.

Overview and scrutiny is well-established. There is a clear action plan and a link with cabinet member for health and social care services. Democratic services officers have regular catch ups with directors. Relationships are good but still enable challenge in the system and scrutiny is well attended by partners. There is further development needed with the relationships with Devon NHS hospitals as although there is now regular attendance at meetings often requested reports and updates are not followed through.

Relationships with the NHS

Relationships with the NHS appear to be improving, NHS colleagues prioritised attending all scheduled peer review meetings despite the system being in OPEL 4. There is an absolute shared commitment across the NHS and social care around the development of community support, a shared intermediate care vision and strategy and support for people with multiple vulnerabilities. Cornwall are following national best practice recommendations through the delivery of transfer of care hubs and discharge to assess. All these priorities require significant development to improve outcomes for citizens, but this shared and consistent view should support a step change in delivery across these areas.

There were several areas in which relationships around a number of areas of the joint funding of placements where there is a lack of local policy challenging relationships around the key areas of joint commissioning, section 117, and continuing health care funding. 

Mental health social care services have recently been disaggregated with mental health social work returning to the council. These need embedded into social care services and the benefits of a wider corporate alignment.

There is a shared desire to move away from emergency planning to a sustainable and strategic approach however this is extremely challenging and the system defaults to multiple continuous escalation responses which is likely a symptom of some of the relationship maturity within the system.

Quality statement nine: Learning, improvement, and innovation

The One Council approach has created a shared corporate focus on adult social care, there are key performance targets and trajectories against all outcomes and some innovative and exciting plans in place for Cornwall.

The commitment to improving co-production with people who use services including sharing outlined commissioning strategies and ways of working was positive to note, albeit at an early stage. The overarching sense from the peer review was that once these plans come to fruition this will have a significant impact on outcomes experienced by people, however many of these plans are still in development or early stages of delivery. 

The council has recently had a corporate Equality and Diversity peer review. This review notes positive leadership and the outcomes have been used to inform an equalities action plan which has had a specific focus on equality and diversity for staff. The recommendations included a review of the strategic HR function and options to support attendance and employee forums.

One example is equality, diversity, and inclusion of staff data, whilst there are some gaps in this data there is a generally a good understanding of this, but it is not yet being used to inform workforce planning. This has been reported as a priority for Cornwall. Due to the geography staff generally both live and work in Cornwall; there is limited turn-over of professional staff. This is positive in terms of organisational memory, understanding of the system and stability but does potentially reduce the opportunities for learning and innovation that come from a more diverse workforce offer.  This also creates challenges in setting a new narrative as people will naturally refer to how things have worked historically.

There are already some excellent examples of initiatives that the council may wish to promote more strongly such as staff conferences, use of people with lived experience as part of the safeguarding conference and the voluntary sector initiative for mental health. There are areas in which the council could better evidence how learning is translated into practice, for example reporting how the lessons learned from SAR’s is being fed through into practice. 

Strengths-based practice 

Through the review the team saw some good evidence of strengths-based practice but there is further work required to embed this across fieldwork. There is a programme of training being delivered some of which was taking place whilst the peer team were undertaking case file audits. Staff were able to give some good examples of practice, and examples could be seen within the case file audits.

Barriers to practicing in a strengths-based way appeared to be largely structural, for example linked to recording systems, organisational arrangements, and policy decisions. There were also variations at place level in relation to the approach adopted. One example was the way that social workers case manage work for people who have  complex and dynamic needs. There is a gap in services for people who are homeless and have multiple vulnerabilities, consequently the social workers are providing significant amounts of support to people. Social work as an intervention is not a recorded category on the case management system and therefore social workers often find they are unable to justify this time with people. Other examples covered earlier in this report include the direct payments policy and the issues discussed in the MSP section.

Top tips for assurance preparation - for consideration

  • 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

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, 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 therapy! For those interviewed it should be a description of what they do and the impact they have had in people’s lives. Case examples written in the authentic voice of those with a lived experience bring this alive.

Immediate next steps

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 council’s 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 several 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. Contact details are: 

Email: [email protected]
Telephone: 07899965730

Jan Thurgood is the main contact for the LGA Care and Health Improvement Adviser for the South West Region. Contact details are: 

Email: [email protected]
Telephone: 07545219587

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. 

Contact details

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

Sarah Farragher
Peer Challenge Review Manager, Local Government Association

Email[email protected]
Tel: 07531541208

For general information about Adult Social Care Preparation for Assurance Peer Challenges 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