Central Bedfordshire Council adult social care preparation for assurance peer challenge report

Central Bedfordshire Council (CBC) requested ADASS Eastern Branch to approach the Local Government Association undertake an Adult Social Care Preparation for Assurance Peer Challenge at the Council and with partners. The work in CBC was led by Julie Ogley, Director of Adult Social Care & Health (DASS), Central Bedfordshire Council. She was seeking an external view on the readiness of the adult social care directorate for the arrival of the Care Quality Commission’s Assurance inspections and a view on how the Council is able to deliver value for money, quality, effectiveness, and the most personal outcome focused offer for local people.

The peer team made a series of findings and recommendations. Other comments and recommendations are included in the body of the report.

1. The Adult Social Care and Health Service in CBC demonstrates timeliness of response for assessment of need and identification of support to people who use services. 
2. It is evident that staff in CBC are proud, passionate, and responsive team players, putting services in place for people, and ensuring a person-centred approach. 
3. A peer audit process is in place in CBC, managers up to director level are involved in monthly reflective, audit and assurance activity, ensuring quality in practice. 
4. Providers report a long-standing history of good working relationships with ASC, and describe CBC staff as responsive. Mentoring is undertaken with providers, to raise standards, and this is welcomed by them. 
5. The First Response Team is working well. Staff are focused on prioritisation and setting up prevention services before people are transferred to long term teams. This prevents, reduces, and delays the need for care support.
6. Transitions for young people entering adult social care is working well and was seen to be person centred, resulting in good outcomes for people. There are good relationships between the Adults’ and Children’s staff teams, and the strong links between them, is a notable strength. 
7. The Leader and the Cabinet Member are strong and experienced with a good awareness of the communities in CBC, and of the challenges and issues for the Social Care and Health agenda. 
8. The “One Council” approach provides a strong message by the council’s chief executive to CBC’s leadership team, which focuses the council on the most pressing issues, and enables resources and priorities to be aligned to them.
9. The Director of Adult Care, Health and Housing is very well regarded by and welcomed as a knowledgeable and experienced partner and leader driving forward the ambition for preventative, outcome focused services at system forums, and within the council. 
10. The council should consider how work on Equality Diversity and Inclusion (EDI) is widely understood within the system, and how individuals are able to articulate their role in delivering EDI and that the narrative on outcomes for people as a result of the work on this area, is well embedded.
11.  The council should consider how it can bring the voice of the lived experience to the fore, this will improve strategy development and outcomes for people.
12. The council may wish to reflect upon how they could expand the provision of Direct Payments and ensure that these strike the right balance between choice and control for recipients and assurance.
13. Consider how the council can minimise risk levels as a result of the number of workarounds due to multiple systems currently in place, by ensuring there is one accessible system accessed by MS Teams and linked to the performance management system.
14. Consider how the Council can drive improvement in the quality of care provision at the pace required, ensuring a robust system-wide quality assurance framework.
15. The council should consider what needs to be done to place the unique needs of Central Bedfordshire Council (CBC) on the Integrated Care Board (ICB) agenda to drive focus and improve outcomes for people at pace.
16. Consider how to put in place practice recording that correlates well to strength-based/ systemic practice and Making Safeguarding Personal (MSP), which is recorded and reflected as evidence in case files.
17. There is a need to consider how you are going to meet the increased demand for mental health provision in adults and children. 
18. CBC need to align its strategic plans, strengthen the narrative, drive forward at pace and ensure the engagement of all partners at all times linking to the vision for Adult Social Care (ASC).

Background

1. Central Bedfordshire Council (CBC) requested that the Local Government Association undertake an Adult Social Care Preparation for Assurance Peer Challenge at the Council and with partners. The work was commissioned by ADASS Eastern Branch as part of their preparation for future Care Quality Commission Assurance inspections and to gain a view on how councils can deliver value for money, quality, effectiveness, and the most personal outcome focused offer for local people.

2. A peer challenge is designed to help an authority and its partners assess current achievements, areas for development and capacity to change. The peer challenge is not an inspection. Instead, it offers a supportive approach, undertaken by friends – albeit ‘critical friends’ with no surprises. All information was collected on a non-attributable basis in order to promote an open and honest dialogue and feedback form the team of peers is given in good faith.

3. Prior to the onsite peer challenge work Central Bedfordshire Council Adult Social Care Directorate team completed a self-assessment about the work of the service. In advance of the peer challenge work, members of the team conducted a day of detailed case file audits with a small number of cases and allocated a day where they met with people with lived experience and carers.

The peer challenge team arrived at their feedback after triangulating what they read, heard and saw whilst onsite with a view as to saying what needed to be said whilst being mindful of the multiple audiences for the work in the partnership.

The members of the peer challenge team were:

• Graeme Betts - Strategic Director Adult Social Care, Birmingham City Council
• Colin Noble – Member Peer. Suffolk County Council
• Nicola Mickleburgh - Interim Inspection Preparation Manager, Adults and Communities, Southend-on-Sea City Borough Council
• Simon Froud, Adult Social Care Director (North), Essex County Council
• Nick Faint, ADASS Associate (East of England)
• Jane Myers Deputy Director of Operations, Rochdale MBC
• Ian Redfern, Principal Social Worker (PSW) Warwickshire County Council
• Venita Kanwar, Peer Challenge Manager, LGA Associate

4. The team engaged virtually between 23rd and 25th November 2022. The programme included activities designed to enable members of the team to meet and talk to a range of internal and external stakeholders. These activities included:

• interviews and discussions with councillors, officers, and partners
• meetings with managers, practitioners, frontline staff
• reading documents provided by the Council, including a self-assessment and
• a range of other material, consideration of different data and reflecting upon
• the case file audit.

5. The framework the peer team used was that of the Care Quality Commission and their proposed four Domains of Assurance they will be using for the upcoming adult social care inspection regime. They are:

Care Quality Commission Adult Social Care Assurance four Domains

Working with People

• Assessing needs
• Supporting people to live healthier lives Providing Support
• Care provision, integration and continuity
• Partnerships and communities
• Workforce equality, diversity and inclusion Ensuring Safety
• Safe systems, pathways and transitions
• Safeguarding Leadership
• Governance
• Learning, improvement and innovation
• Capable, compassionate and inclusive leaders.

6. The peer challenge team would like to thank councillors, staff, those people and carers with a lived experience and partners for their open and constructive responses during the challenge process. All information was collected on a nonattributable basis. The team was made very welcome and would in particular like to thank Julie Ogley, Director of Adult Care, Health and Housing, Robert Winkfield, Head of Service Adult Social Care Assurance, Alison Palmer, Market Sustainability Officer and Kate Perry, Trainee Manager (NGDP) at Adult Social Care at Central Bedfordshire Council (CBC), for their invaluable assistance for the support to the peer team, both prior to and whilst onsite, in planning and undertaking this peer challenge which was very well planned and delivered.

7. Prior to being on-site peer team members looked at 10 case files in detail from across the areas of adult social care. The onsite visit also involved the opportunity for face-to-face interviews, in addition to the virtual interviews mentioned in paragraph 4. These were held with a group of working age adults and a group of carers.

8. The peer team read around 100 documents including a self-assessment / position statement. Throughout the peer challenge the team had more than thirty-six meetings with at least ninety different people from adult social care, health, third sector and other partners. The peer challenge team have spent over 194 hours with CBC and its documentation, the equivalent of 28 working days.

9. Our feedback to the Council on the last day of the challenge gave an overview of the key messages. This report builds on the initial findings and gives a detailed account of the peer challenge.

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

Strengths

• Timeliness of response is quick, no queues
• Auditing of case files is comprehensive
• D2A, and work on collaboration is very positive (at operational level)
• Innovations such as MDT working are great, but should be rolled out at pace
• Robust approaches to practice and managing risk through RAG rating and scrutiny of caseloads and funding
• Reflective discussions, presentations elements of strength-based approach with a golden thread through ASC
• Bring lived experience to the fore for example working well in transitions

10. The peer team found that a genuine strength for CBC was the work that the council does to ensure timeliness of response for assessment of need and identification of support. Of note was hearing from front line practitioners about their passion and pride in being responsive, and their ability to work as a team to put services in place and to ensure a person-centred approach. We heard “the service is always person centred and looking at the client's whole picture especially their strengths - we get this information by partnership working with all involved with our customers.” The council’s self-assessment indicated the following and this was fully triangulated by the peer team by senior managers, front line practitioners and partners. “Despite the level of demand, the number of people waiting for a Care Act assessment has improved, falling from 51 in May to eight people outstanding in September 2022”. The peer team also noted that CBC were proud of their reablement service, currently rated good by the Care Quality Commission (CQC), works effectively to keep people independent at home. The most recent East of England Regional data has indicated that for CBC, the number of permanent admissions into residential and nursing care for working age and older adults was the lowest in the region.

11. Staff described how proud they were of working for CBC and they described their managers as accessible and very supportive. They felt able to approach all levels of management and described how their managers proactively took an interest in reaching out to them. Many had chosen to work for CBC throughout their career and others that had experience of working elsewhere described CBC as being the best place they had worked. “It’s where I belong” a “great place to work”.

12. Auditing of case files is comprehensive across Children’s and Adults’ Services, and in Adults Services there is a well-developed case auditing framework for content of assessments, reviews or practice documents and the sharing of learning from them. We heard from practitioners, “We regularly have case audits of our assessments, support plans and safeguarding documents to ensure that we are incorporating person centred and strength-based approach in our practice” and “we use an audit tool, one per quarter is standard - but we do more to ensure consistency and outcomes being evident. It’s important, and we need to get this right”. There is also a peer audit process in place where managers up to director level are involved in monthly reflective, audit and assurance activity. Ensuring quality in case files is a priority for the council and seen by staff as a welcome approach.

13. CBC work with seven out of area hospitals and the work being done with hospitals on Discharge to Assess (D2A) follows best practice guidance. There is close collaborative planning by staff at an operational level using discharge planning notifications, daily meetings and identification of the support needs of people that ensure people are discharged from hospital safely.

14. CBC is developing and beginning to provide innovative multi-disciplinary services that begin to address the challenges of not having a local hospital in the area. Grove View Integrated Health and Care Hub in Dunstable, has been described as one of the first of its kind to have opened in Central Bedfordshire and it is scheduled for completion in Spring 2023. Grove View will serve as a ‘one stop shop’ where people can access care and services seven days a week. The Hub delivers co-ordinated services provided by mental health, community and social care workers with the aim of delivering improved outcomes and customer experience. Staff who have been involved in the development of the Hub spoke with great passion about the difference it would make to people. The peer team thought the approach was a great example of multidisciplinary working and could be a very good foundation demonstrating effective and collaborative work with partners and people who access care and support which can put the Council in a good place in preparedness for CQC Enhanced Assurance. The peer team urges the Council and partners to move at pace with the ambition to roll Hubs out to a further four localities.

15. The council have a robust approach to managing risk and practice through RAG rating and scrutiny of caseloads and funding. There are tracker processes in place to oversee demand pressure and triage through RAG rating. Waits for assessments are risk managed and have senior management oversight. There are funding level agreements and sign offs in place for team mangers and senior staff to manage budgets effectively and to bring funding decisions closer to the person. In addition to this, a recent tool, Power BI is used by managers to track performance and budget decisions to ensure proportionality. The peer team heard of the use of a quality framework which has three stages to support
care providers. The framework has quality alerts, which are reported in a central database with a monthly review.

16. CBC have reflective discussions, presentations and elements of strength-based approach with a golden thread through ASC which provides ASC and the Director of Adult Social Services (DASS) with assurance and understanding of the frontline work which is positive. The approach brings staff teams together when they know their work is being reviewed, validated and seen as important to the organisation.

17. There are pockets of good practice to understand the lived experience of people in CBC and this could be built upon further and brought to the fore. The peer team heard about the co-production of the Carers Strategy working with carers groups and partners to ensure a person-centred approach for carers. Councillors spoke passionately of the importance of hearing from and listening to their communities, having worked extensively with the Special Needs Action Panel (SNAP), a group based in Central Bedfordshire for parents who have children with special educational needs and disabilities (SEND) and also with Gypsy and Traveller groups. Transitions representatives spoke of working closely with SNAP where Transitions officers attend meetings to discuss what is working well and not so well and the peer team heard that young people have been involved in developing a document for individuals going through transition called “Your Journey”. This is the local offer for young people which was coproduced with young people parent and carers.

For Consideration

• EDI needs to be embedded in the local authority and across the care and health system
• Strengthen and show evidence of people with a lived experience telling a story of good outcomes
• Practice recording did not correlate well to strength-based practice and MSP
• The rate of Direct Payments (DPs) is low, and this could limit people’s choice and control over their support
• Staff described processes and systems being a barrier for example DPs and technology
• Workarounds of the systems to enable performance management, demand and capacity
• Funding authorisations processes do not correlate well to supporting personal budgets and creative ways for people to support plan, to meet eligible needs as there is an emphasis on purchase of services

18. The peer team felt that EDI did not feel comprehensive or robust in CBC or the wider care and health system and needs to be addressed and embedded. While operational staff could speak about how they take difference and diversity into account in their strengths-based approaches, this was not the case at all tiers across the system, the peer team felt that people were not clear about EDI in its widest sense not just in terms of race. Two peer team members met with one small group of people who have lived experience and it was good to hear stories of good outcomes relating to support provided by a Transitions Social Worker who communicated well with people and helped them to resolve issues such as setting goals for independent living. This was evidently important to people, and they valued the help received. It was unfortunate to have not heard more stories such as these from across the spectrum of adult social care services. The CQC Enhanced Assurance is likely to concentrate their activity on lived experience, and therefore building the evidence of results the work CBC and partners do with people should be afforded some priority.

18. The peer team found a difference between how staff and managers described working in a strength-based way and what was recorded in case files. Although the sample size was small (ten case files), the impression gained from the audit was that recording focused on what people were unable to do and did not identify personalised outcomes. Outcomes were often expressed as services, rather than what these services were helping people achieve. Some of the language used was quite ‘medical’ in nature with reference to people “suffering from” conditions, being “bedbound” and needing “QDS” meaning four calls a day. Managers described how strength-based practice had been championed just prior to the pandemic and recognised that this might be an area to focus on again. The introduction of a new recording system will provide an opportunity to design forms that support strength-based recording. There were good examples of person centred and strength-based work in one of the cases audited and in the transitions services which provides CBC the opportunity to build on local good practice.

19. Choice and control is likely to be a focus in the CQC Enhanced Assurance and CBC has a low rate of DPs. This is recognised by managers who were clearly motivated to try and change the position. Managers described how this remained “a stubborn problem” despite efforts made in the past. The introduction of payment cards was seen as positive but when talking to staff, the peer team found that there may be other system and process improvements that could make a difference. Staff described the process of arranging Direct Payments as “complicated” and “bureaucratic” for them, and for people being offered them. They also referenced difficulties in some areas identifying support that could be bought with a DP. CBC may want to consider how the focus on service provision in assessments might also be a barrier to DPs being considered. A strong focus on outcomes – what the person wants to achieve – can help in identifying alternatives to commissioned services. CBC has good peer networks and may be able to make use of how others have addressed this issue.

20. The peer team heard from senior staff about the priority they have given to implementing and improving the technology offer to people who might benefit from its use. Front line practitioners and operational staff clearly understood the benefits of technology and there seems to be a good technology offer available. They did however speak about the issues they were experiencing in prescribing technological solutions for people and how the process for ordering it might be made easier. Practitioners said, “we are not experts, it's difficult to identify the tech and the training is not enough to equip us with the expertise”.

There was acknowledgement however, that as a result of the difficulties they had that a person experienced in the use of technology was now providing weekly online support. This was to help navigate the completion of forms for the ordering of items. The peer team were told that ordering everyday items such as pendants was easy, but more complex items were problematic. We were told “There is much to improve”.

21. The peer team were told that there were a number of workarounds of the systems that CBC in place. If this is the case, then it will add to an increasing risk level of issues that are slipping going unnoticed. CBC should take some time to reflect upon and review how it brings together RAG rated risks currently in place so that front line staff and team managers have access and oversight, and are able to manage demand and capacity, so they can alongside the performance team, be able to report effectively.

22. CBC needs to consider how to ensure evidence is captured on the case management system to show it is person centred and strength based as currently the system does not reflect the practice.

23. Further work is required on co-production and bringing people and providers of services with a lived experience to feedback to all staff on how to improve service delivery. The peer team heard that ASC are learning from complaints, and this is a good foundation for improvement. 

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

Strengths

• Provider and voluntary sector feedback was very positive
• Utilising and building the PAMMS process
• Operational relationships and alignment across teams is strong (internally and with partners)
• Positive working relationships across Council functions, collaborating for positive outcomes for residents e.g., housing developments and housing options
• Awareness of the challenges facing the care and health system and building on team strengths

24. Providers reported a long-standing history of good working relationships with ASC with some providers citing having a relationship with the Council for as long as 18 years. Some of the positive feedback heard included examples such as communication from the safeguarding team that comes back in 24 hours, social workers are very good and responsive, and always “deal with the issue”. The peer team were told that the DASS attends provider meetings and they specifically liked that they “refer to us by name as if they know us personally and know the work we do”. There appears to be a great deal of trust, the peer team heard providers say, “it’s not a blame game, we feel confident talking to contracts team without judgement or punished if things go wrong….during the pandemic the Council stepped up, you cannot fault them”.

25. Care providers advised that mentoring work and trial visits by staff have been undertaken with CBC to raise standards and have been helpful. Before the pandemic, there were incidences when CQC and CBC were requesting differing responses from providers, based on either a CQC inspection of service provision, or information obtained by the council from the Provider Assessment and Market Management Solutions system (PAMMS). Providers were unclear in these situations as to what their response should be. Since then, CQC have worked with the Council to raise the standard of quality of care provision and thereby raise CQC ratings. Support to providers is offered for as long as is required to improve provision and turn around services. Since the pandemic there has been an increase in concerns raised, therefore
working with providers to support them to obtain improved CQC ratings has increased. The peer team recommend that CBC should deliver more support for providers rating “Good” to get them to “Outstanding”. In order for CBC to do this PAMMS reports could be shaped so that they are designed to help providers achieve a “Good” CQC rating. Providers are open to discussions with CQC and CBC about how the PAMMS report could be reframed and perhaps this is an area that could be further explored.

26. Voluntary sector groups reported good working relationships with the council and officers, they informed the peer team that the change to grant funding for some and a move away from a procurement process had been helpful and provided them with more flexibility. The voluntary sector felt that there was good collaboration between themselves and the Council, for example all of the groups the peer team met with reported that they had good links with the commissioning team, and that relationships and interactions with them were good. Voluntary sector colleagues said that they were working together with the council to change things for the benefit of communities. They cited as an example the development of the carers strategy which was seen as good example of coproduction.

27. Operational relationships and alignment across teams is strong between staff and managers. Examples were given to the peer team of how teams cooperate and support each other with a shared aim of getting the best for people. Positive projects and outcomes clearly evidence this.

28. It was mentioned to the peer team, that work is underway with colleagues to understand the housing offer and the new independent care charge which has been recently introduced. Work has been undertaken with Social Workers and the Contracts Team, Housing, Planning and the Commissioning partner in order to source homes through Homes England. A number of housing projects have been developed in Central Bedfordshire which have had a positive effect on residents’ lives, enabling independent living. One of these projects, the Meeting the Accommodation Needs of Older People (MANOP) project was developed based on a research-based assessment of the housing needs of Central Bedfordshire and produced through co-production with people, and more are planned. This work has demonstrated clear communication and planning with internal colleagues including social workers, external partners and stakeholders to ensure the projects deliver the right outcomes. CBC are aligning housing developments and housing options and
strategy with the changing demographic of the area.

29. There is awareness of the challenges facing the care and health system which is building on team strengths - There are positive relationships with Central Bedfordshire Council and Primary Care colleagues. The “Working Together” project for example demonstrates how collaborative working can support a specific locality and can act as a foundation to build on further and improved joint working.

For consideration

• Opportunity to review the commissioning function to deliver better outcomes for example, data, new managers and development of strategies
• The ICB is in its early days, still showing some historical perceptions; there is a need now to focus on driving forward and improving outcomes
• There is a need to consider how you are going to meet the increased demand for mental health provision in adults and children
• Harness the voluntary sector, they could do more on innovation and coproduction with commissioners
• Quality across care providers needs to improve with the support of the PAMMS process and additional resources (Quality Assurance Officers)
• Consider auditing your published strategies to make sure they are reviewed and up to date

30. The council should take the opportunity to review the commissioning function to deliver better outcomes; this should include for example, data, new managers and development of strategies. The peer review team suggests the commissioning function link with the performance team and public health in order to develop and underpin the commissioning strategies and instigate a Market Shaping strategy. CBC managers have found it difficult to attract, recruit and retain commissioners because of their demographics. It was recognised that personnel in the commissioning team are in flux. While this may be disruptive, it is a great opportunity for the team and department to embed principles such as lived experience driving commissioning. The Market Position Statement was noted to be out of date (2020) and will need refreshing with the Investment Prospectus. CBC should be innovative using co production in commissioning and consider the demographics of the population when the focus groups are being organised. Consideration should be given as to whether investments made are in the right areas.

31. Senior managers from across the Council have indicated that the Integrated Care Board is in the process of developing a method of working collaboratively given the system and some participants are relatively new. The peer team were told that there are some good processes for working being considered which have emerged from pilots. The peer team feel that work now needs to be put in place to focus on the ICB priority areas, at pace, to drive focus and improve outcomes for people along with devolving responsibility at Place level. It was mentioned to the peer team that the DASS is driving this with partners and working with the new Transformation Director for the ICB.

32. The peer team heard about the significant increase in the number of people supported who have mental health problems in Central Bedfordshire. Figures presented by CBC have indicated a 208 per cent increase since 2017 (48 cases in 2017 and 142 Cases in 2022). Given the increased demand for this client group, the peer team did not hear how the Council and partners were planning ahead for this in commissioning plans or commissioning strategy.

33. The peer team recommend that CBC seek to better harness the voluntary sector as they want to do more on innovation and co-production with commissioners. The voluntary sector cited an example of where new commissioning had been undertaken however, there had not been engagement with the sector to explore if existing provision could have
adapted and supported the desired outcomes.

34. Quality across care providers needs to improve with the support of the PAMMS process and additional resources (Quality Assurance Officers). One of the areas the CQC Enhanced Assurance visit might focus on is the quality of providers and their ratings, which in CBC, could be improved. The use of PAMMS should be utilised and focus with consistency aligned to CQC

35. The peer team feel that by using PAMMS, supporting tools and software, and working alongside the Contracts Team, intelligence can be obtained on how to further improve quality of care provision.

36. The peer team heard from Council officers that some of your published strategies were out of date for example the Joint Strategic Needs Assessment is dated 2017. While the peer team were aware that work is going ahead to update some outdated strategies in the background, this will not be apparent when CQC start their Assurance work by looking at the CBC website. In terms of first impressions, it could be worth putting some resources into ensuring public facing documents are up to date and are in line with best practice and easily available and accessible.

Strengths 

• Transitions demonstrates good outcomes for young people 
• Discharges performing well for example use of a tracking app, focused on a person
• Robust triage for safeguarding 
• Prioritise casework to ensure a timely response for example the development of a First Response Team as an outcome from the pandemic 
• There is engagement and reflective practice by senior management to demonstrate assurance 
• The tri borough EDT service provides safe support for people out of hours based on excellent working relationships across the system

37. Transitions for young people entering adult social care is working well and was viewed by the peer team to be person centred, resulting in good outcomes for people.  There was evidence of good relationships between the Adults’ and Children’s staff teams. They meet every 4-5 weeks to discuss early help and people leaving care, which provides sufficient planning time to get services and support into place in a timely way.  Staff recognise the needs of the young person and identifies the right transition process in these meetings. These meetings are demonstrating an open and inclusive approach and showcases strong links between Children's and Adults’ workers. Given that this is an area of practice where authorities can often struggle this is a notable area of strength.

38. Good practice in Transitions highlighted to the peer team was the provision of training flats with the support of housing service. In terms of the offer this was innovation in provision. When there is instability in Children's Services i.e., young people need to move to another setting, there are discussions about what happens post 18. The Adults team will help to identify post 18 accommodation or placements to minimise the changes, which in turn improves outcomes for young people.

39. The peer team heard that discharge from hospital was performing well, with the council discharge team of eighteen staff having changed ways of working to improve discharge from hospital. Social Workers work in teams across two Acute Hospitals and also work across seven out of area hospitals. The Discharge to Assess (D2A) service is supported by East London Foundation Trust (ELFT) into bedded or domiciliary care or reablement services. There is close working between teams for discharge planning and notifications.  Support needs not requiring Care Act assessments are carried out in hospital. There are daily staff meetings to keep an overview and to resolve any difficulties. The hospital in conjunction with partners have developed an innovative app to manage the patient journey which gives the person a better outcome and keeps them and their family updated about discharge. In addition, the Trust has a “Shrewd System” in place which helps with flow out of hospital. There are positive relationships across the systems which are working innovatively together. Newly commissioned services help with flow out of hospital for people with complex needs, and for assessing people in their own homes with involvement from the voluntary sector. Red Cross and Age UK support home first principles and ensure that the right low-level support and help is in place to facilitate a safe discharge, and avoidance of readmission to hospital.

40. In any care and health system, there is always a risk of senior managers and front-line staff not being joined up. The Peer Team heard some examples of this and suggest that the ICB leadership consider ensuring there is a greater join up.

41. A new First Response Team developed during the pandemic changed the social care operating model. The First Response Team is working well, with staff focused on prioritisation and prevention services being put in place before people are transferred to long term teams. This prevents, reduces, and delays the need for care support. There are also tracker processes in place to oversee demand pressure and triage through RAG rating waits for assessments, this ensures risks are managed and has senior management oversight. This system helps service managers to prioritise work and risks as part of demand management.  

42. Managers are engaged in reflective practice; this ensures that management are aware of concerns and issues for frontline practitioners which can be swiftly discussed and addressed and also ensures that learning is shared. The peer team heard that the engagement of managers was welcomed by operational staff and their involvement gave practitioners confidence that the work they were doing was valued and demonstrated safe practice.  

43. The peer team heard of the positive work and positive working relationships that CBC Emergency Duty Team (EDT) have with partners across three local authority areas. The EDT carry out contingency planning, which looks at what is in place for a person when in crisis. They describe good communication from daytime staff with a focus on making sure people are safe and supported. In addition, Adult Mental Health Practitioners (AMPHs) are well resourced with no issues noted around recruitment. AMPH’s showed an awareness of equality and diversity and spoke of working with people from different cultural backgrounds from all three Local Authorities, and specifically in Luton which has a higher number of people from different black and minority ethnic communities.  

For consideration 

• Health collaboration into transition for young people with mental health problems could be improved 
• CBC has a low conversion rate of safeguarding concerns to s42 enquiries compared to other authorities. There is a rationale for this, and it would be sensible to consider the evidence you have to support that rationale 
• There is an opportunity in your new case recording system to clearly demonstrate strength-based practice and an outcomes focus  

44. Health support for young people with mental health problems moving into adult services was described as an area that could be improved. There appear to be differences in the offer for young people compared to adults, creating uncertainty around transitions. Social care staff were involved but did not have consistent and clear relationships with health colleagues which was in contrast to other areas such as in learning disability services.

45. CBC has a low conversion rate for concerns to s42 enquiries. The rationale given for this was that having dedicated safeguarding professionals responding to concerns allows robust triaging and for work to be safely completed as care and support assessments, where other authorities might complete this work at the enquiry stage. CBC has good assurance in place for cases that progress to enquiry however it might be helpful to review cases that do not progress to enquiry in order to provide evidence that the approach is working. Currently it was the peer team’s understanding that these cases would only be looked at if they were selected as part of the audit process of assessment for care and support. If they were selected they might not be looked at through a safeguarding lens. Doing a specific piece of work would make sure the rationale is well evidenced for CQC.

46. CBC is introducing a new case recording system to take over from SWIFT the current system which has been used for many years. Staff across the council have spoken about the current system being “clunky” which makes it difficult to input information or understand processes.  As ASC begin to design and implement the new system, the peer team would recommend the Directorate seize the opportunity in your new system to clearly demonstrate strength-based practice and outcomes focus and will provide practitioners with a focus on a strength based and outcomes focused approach for every person they come into contact with.   
 

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

Strengths 

• The Leader and the Cabinet Member are strong and experienced with a good awareness of the communities in CBC 
• The CX is engaged with the ICB and is shaping the agenda. 
• CX has a one council approach 
• The DASS is highly regarded by partners and providers. She is an anchor for CBC and the wider system  
• Partners spoke of positive relationships with the council 
• The leadership are open to new ideas and there are forums at which staff can speak openly
• Wellbeing of staff has been mentioned as a focus 
• High morale amongst staff, a passion to be working with people and describing CBC as a “great place to work” 
• Training opportunities for care providers and staff 

47. The Leader and the Cabinet Member are strong and experienced with a good awareness of the communities in CBC.  The Leader has a strong focus on the financial strength of the council and a good command of the overall budget and strategy. The Cabinet Member has been in place since the formation of the council in 2009 and has a deep understanding of the ageing population and the pressures it brings. Both had a good understanding of the work which was being undertaken by ASC staff and the positive outcomes felt by those with lived experience. It was clear that both the Leader and Cabinet Member have good relationships with their residents and staff. The Cabinet Member is very hands on, with good knowledge of projects being undertaken, and is involved in reviewing any changes needed to them. Both recognised the challenges that CBC and ASC will be facing, along with the affect this would have on CBC.

48. Councillors the peer team spoke with told us that they recognise the seriousness of the adult social care agenda, and in recognition of this they are open to critique to develop decision making.  Councillors felt that they work together across the council with transparency and reflected that the personalities involved enabled good dialogue to take place and this was reflected in all areas of the work of members, but particularly in overview and scrutiny (O&S). Councillors spoke of the level of trust between O&S and Executive members and the strong working relationship that they have. It was with interest that the peer team heard that policy development and budget discussions form part of the work of O&S, this may move the agenda on such items at pace.   

49. The Chief Executive of CBC is engaged in the ICB, and we heard from system partners that he represented the council as an equal and valued partner, this demonstrates clear leadership.  The Chief Executive is vocal about shaping the agenda so that it represents the priorities for CBC and the other local authorities more broadly. For example, the prevention and public health agenda and keeping people out of hospital.   

50. The peer team felt the Chief Executive’s “One Council” approach was a strong message to CBC’s leadership team, which focused the council on the most pressing issues, and enabled resources and priorities to be aligned to them. The peer team suggest that the Corporate strategies are strengthened to incorporate the ASC vision and the links with the 2050 vision. 

51. The senior management team is highly regarded by staff and partners, and specifically the DASS was very well regarded and welcomed as a knowledgeable and experienced partner and leader driving forward the ambition for preventative, outcome focused services at system forums. At different levels of leadership, we heard health counterparts speak of the willingness and openness of CBC senior managers and staff and their responsive and collaborative approach was highly regarded.  There is no doubt that the DASS, who is leaving her post, will be a loss to CBC, she has been described as “an anchor” due to her many years of service and the experience she brings as a result of that. 

52. The leadership are open to new ideas and there are forums at which staff can speak openly. Staff forums were cited as being enthusiastic about working at CBC, with lots of initiatives available to them, including training opportunities, and recognition through award ceremonies. 

53. Senior management were praiseworthy of their staff and took into consideration staff wellbeing providing support through supervision and team meetings. Staff described being very well supported and that managers at all levels were approachable and visible. CBC have undertaken work around the cost of living and staff wellbeing. Support is offered to staff experiencing mental health and wellbeing problems in collaboration with a mental health provider. CBC offer benefits to staff through a third party, which includes managing finance and living, and they have an employee assistance programme offering support for addictions such as gambling. The council also have a number of forums on offer as well as the “Lunch with the Director” offer for staff to meet with different directors which includes the DASS. 

54. Front line practitioners could not speak more highly of their managers. The peer team heard from many sources about the support, openness, and willingness of managers to make time for staff concerns.  The peer team heard the following from staff, “Managers are all really approachable. We feel really comfortable to approach other managers too not just our own. Managers come to you directly, there’s no skirting around the situation”.  One person said of her support in CBC, “I started as an unqualified admin in 2003 and was supported to go through college where I did a social work degree. I never needed to look further afield.  I’m now heading towards retirement and being supported in that! It is a good place to work. A real open door policy. There’s an ethos to grow your own in our teams. ASYE projects do get brought on and grow. Supervision is very good and is regular. Our management of case loads is very good”. The peer team heard from several individuals of the opportunities they were given to expand their experience both through training and also through direct involvement in varied work activities. They remarked that CBC felt to be a unique place where work was “never the same day in day out”, and there was a great sense of pride to be working for CBC. 

55. Middle managers were equally passionate about their staff who they said were willing to embark on new initiatives, for example the new Hub is an innovation that staff were excited about.   

56. As part of the CBC quality framework, the Contract Team organise additional training and support to care providers if required to support the quality of service they deliver. CBC demonstrate that they gather information from providers directly as well as obtaining information from care provider forums. Newsletters share training opportunities and are made widely available.  Care provider forums access training and a bespoke training offer is also available for providers. 

For consideration 

• CBC needs to align its strategic plans, strengthen the narrative, drive forward at pace and ensure the engagement of all partners at all times linking to the vision for ASC 
• Consider the working arrangements to work at pace to bring forward improved outcomes for citizens
• Ensure the work that you are doing on EDI is understood and having an impact across all partners 

57. Across the system the peer team were struck by the ask from the wider members of the system.  For example, partners like Milton Keynes Council had a clear deal and ask of the system, and there were similar messages about Luton Borough Council. Central Bedfordshire’s needs should also be clearly articulated within the broader ICB partnership and these need to link to the vision for ASC.   

58. An issue that stakeholders raised with the peer team, was that there was a considerable amount of effort and energy going into the ICB, but this was not proportionate to the amount of progress you would hope to see for that investment of time and energy.  Getting the needs of CBC clearly articulated along with ensuring the arrangements are in place to deliver them at pace requires further consideration. 

59. The peer team did not hear very much about the work being done on Equality, Diversity and Inclusion (EDI) from across the system. Leaders recognised this was an area for development. The peer team felt it would be helpful for CBC and partners to begin to drive the work in this area and to make sure it is understood and is having impact across the system and making a difference to people’s outcomes.  It is the peer team’s belief the focus of the CQC Enhanced Assurance will be about people, their lived experience and the potential for them to access relevant and appropriate services that meet their needs and provides them with choices. There was some good work cited of engaging and listening to the Gypsy and Traveller community in the area, but the team would have liked to have heard more about other groups with protected characteristics and how their needs were being taken into account, and how they were being involved in co-production activity.  The peer team felt that more needed to be done to understand the EDI experience in CBC to ensure it is widely understood within the system, that individuals are able to articulate their role in delivering EDI and that the narrative on outcomes for people as a result of the work on this area, is well embedded.

We appreciate the senior political and managerial leadership will want to reflect on these findings and suggestions in order 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. Rachel Litherland, LGA Principal Adviser is the main contact between your authority and the Local Government Association. Her contact details are:

Email: [email protected]
Tel: 07795 076834

There is also Claire Bruin, Care and Health Improvement Adviser who can be contacted at:

Email: [email protected] 
Tel: 07584 272635

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 Central Bedfordshire Council please contact:

Venita Kanwar
LGA Associate
Email: [email protected]
Tel: 07865 999 508

Marcus Coulson
Senior Regional Advisor
Local Government Association
Email: [email protected]
Tel: 07766 252 853

For more information on the peer challenges and the work of the Local Government Association please see our website: Council improvement and peer support.