Bournemouth, Christchurch and Poole Council adult social care preparation for assurance peer challenge report

1. Bournemouth, Christchurch and Poole (BCP) Council asked the Local Government Association (LGA) to undertake an Adult Social Care (ASC) preparation for assurance peer challenge at the Council and with its partners. The work was commissioned by the Director of Adult Social Services (DASS) at BCP Council. She was seeking a view on how prepared the council’s Adult Social Care Services are for the new Care Quality Commission (CQC) regulatory process and how well the council is delivering services for people. 

2. A peer challenge is designed to help councils and their 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 during the process on a “non-attributable” basis to promote an open and honest dialogue. Feedback from the peer team is given in good faith. 

3.The peer challenge team arrived at their feedback by triangulating what they read, heard, and saw before and during the site visit to BCP Council. Members of the peer challenge team were: 

• Beverley Compton, Executive Director for Adult Services and Health, East Riding of Yorkshire Council
• Councillor Stewart Golton, Leader of the Liberal Democrat Group, Leeds City Council
• Vernon Nosal, Director of Operations, Wellbeing and Housing, Adult Social Care, Southampton City Council
• Bill Nicol, Assistant Director, Derby and Derbyshire Integrated Care Board
• Wioletta Lewandowska, Principal Social Worker, City of London Corporation
• Claire White, Lead Practice Improvement and Development Manager, Surrey County Council
• Marcus Coulson, Peer Challenge Manager, Local Government Association

4. The team were based at the BCP Council Civic Centre building for three days between 6 – 8 June 2023. The programme included activities 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, and 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 Care Quality Commission (CQC) framework for inspection was used by the peer team in making the assessment of the council’s preparedness. The four themes of assurance for the adult social care inspection regime are:

1: Working with people 

• Assessing needs 
• Supporting people to live healthier lives 
• Equity in experience and outcomes   

2: Providing support 

• Care provision, integration and continuity 
• Partnerships and communities 

3: Ensuring safety 

• Safe systems, pathways and transitions 
• Safeguarding     

 4: Leadership 

• Governance, management and sustainability
• Learning, improvement and innovation

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. The team was made very welcome and would in particular like to thank the DASS and her team for their invaluable assistance for the support to the peer team, both prior to and whilst on site, in planning and undertaking this peer challenge which was very well planned and delivered. 

7. Before being on-site, peer team members were given access to the council’s self-assessment against the four assurance domains. Documents were provided to familiarise the team with the local context and challenges at BCP Council. Prior to the onsite work peer team members looked at twelve adult social care case files in detail. The onsite visit involved face-to-face interviews with individuals and groups. These were held with care providers, front line practitioners, working age adults and a group of carers. 

8. The peer team read over eighty-seven documents including the self-assessment. Had more than thirty-eight meetings with 152 different people from adult social care, health, voluntary and community sector organisations, service providers and statutory partners. The peer challenge team spent over two hundred hours working on the peer challenge, equivalent to twenty-eight working days.

9. On the final day on site, the team gave an overview of the key messages. This report builds on those initial findings and hopefully offers some insights to the council to strengthen its improvement efforts.

10. In advance of this peer challenge and as preparation for the impending CQC assurance process the adult social care service completed a clear, well structured, and thoughtful self-assessment for this peer challenge. It outlined where the service has strengths and where there are areas for improvement. It also comments upon the plans for improvement, which suggests a good deal of self-awareness. 

11. The staff are a key asset for the service. The staff the peer team met with were positive, motivated and hard-working as they are focused on delivering good services for local people in a changing and complex environment. The recent history of this new council is still being felt by staff as a new identity and culture is created. This process is regarded as one of the fastest and most complex local government reorganisations in recent memory and has been managed well. We felt that teams are acting together as one organisation now, serving the combined populations of the original councils that were in place. 

12. The council as a whole is managing a significant level of risk with its recent financial history and immediate future challenges. More specifically within adult social care, backlogs of work have occurred predominantly due to the impact of the pandemic and resultant staff shortages, as well as increased and changing needs for services. Managing backlogs of assessments, deprivation of liberty safeguard cases and outstanding care reviews may lead to an increased risk of legal challenge, and to a perception by the regulator that the council is not fulfilling its statutory duties under the Care Act 2014. Furthermore, delays also present risks to the people the council are trying to support, in that needs may further deteriorate, reducing quality of life, impacting on wellbeing and leading to cost pressures and changed patterns of demand.  The council faces future financial challenges and has little in reserve to manage these in the near future. There is also a new political administration since May 2023 local elections and newly formed strategic health organisations. 

13. Within this context therefore the service needs to be able to demonstrate a clear awareness of the present and future risks and robust plans to show how the service is going to confidently manage delivery in this environment. It is imperative that the council shows how the council is systematically managing those people who are awaiting assessments, reviews or care delivery.

14. For the assurance process, there is a strong expectation of councils to demonstrate co-production in everything it does to support local people. We felt that the work that is being done in BCP Council was stronger in practice than how it has been described in the council’s self-assessment. When speaking with staff we have found lots of good practice than is really shown in the self-assessment.  The council could strengthen the narrative around co-production, how it is achieved, with whom and what outcomes it is leading to. A further development might be to consider how the council describe the changes that have been made as a result of co-production.

15. The staff’s enthusiasm and commitment to change and improvement at BCP Council was very evident in every meeting. For the council’s inspection preparations it would be good to separate out what has been done from what the council is about to do. The council might want to consider using something like a “maturity matrix” to emphasise the stage at which each element of the improvement plans is at. The peer team would also encourage the council to make more use of the “I” and “we” statements in its work. For example, the ‘stories of difference’, which provide evidence of impact, could be developed to reflect the voice of the person with lived experience of services.  This will bring their voice to the fore and will help staff and partners to really challenge themselves about how they are working for the benefit of local people. 

16. Our understanding of the approach that CQC will take is evolving as the inspection pilots take place. It is now understood that they will ask to see fifty cases from across the service to use as their evidence base for the quality of delivery. The service needs to mirror this approach by robustly checking out the self-assessment with people who draw on support and consider further Quality Improvement work as necessary.

Twelve cases were reviewed by the peer team auditor face to face with the caseworker. A good score of 85 per cent was achieved across the areas that were assessed against the agreed set of criteria. The two strongest areas were in assessing and analysing risk, and information sharing and multi-disciplinary working. 

The quality of written entries was good with a strong emphasis on relationship-based working. There was awareness of the importance of reflective learning and promoting independence, especially with younger adults.

To improve further, the peer team felt the council should seek to ensure that outcomes are described in a way which reflects a more personalised approach, reflective of the person’s own voice. Our case auditor observed that at present, outcomes from assessments tended to be “formulaic” rather than reflecting the adult’s narrative. The adult social care service could consider giving direction and training to staff to use “I” statements in case files where possible to reflect the voice of the user and ensure that when assessments and care plans are sent to clients, this is recorded. Lastly management oversight should be recorded on clients’ case files.

Strengths

17. It was clear to the peer team that frontline practitioners are proud to deliver for BCP Council, and are enabled to be creative, yielding better outcomes for people. 

18. Due to local government reorganisation, there were two management information systems in use but we could see that work was underway to ensure a single case file management system is in place. Officers are seeking to re-configure the case file system to support consistent strengths- based practice and new forms are being designed to support this. 

19. We could see that social prescribing is beginning to be used more regularly, offering more options to service users, and enabling need to be met in different ways that meets the needs of individual’s and bridges gaps in different services. 

20. Adult social care is developing greater self-awareness and there is an improving culture around quality and practice assurance. The council’s use of peer audits will help to maintain objectivity and ensure continuous learning and improvement. There is a ‘Big Plan’ for the Learning Disability Service, which was co-produced, as was the related audit tool. Furthermore case file audits are used to inform improvement plans and activities. 

21. In the management of social work practice and from considering the evidence we have seen and heard there appears to be effective supervision for most staff and clear practice standards for them to follow and assess quality against. 

22. From the limited user testing completed by the peer team it appears that work flow is improved by better relationships between the housing function and adult social care supporting quicker responses, especially for homeless people and those with more complex needs. We got a great sense of council departments working together to support vulnerable adults in the BCP council area. 

23. BCP Council says it has “a strong commitment to developing and embedding strengths based, person centred ways of working, and contracted with Partners4Change in February 2022 to help embed the Three Conversations Model® (3Cs). To date, five innovation sites have been working to the 3Cs principles across several different areas of the business. We have completed an evaluation of the work to date and are now working on plans to scale up the approach as part of our wider transformation plans”. From evidence the peer team saw the Innovation sites give greater staff satisfaction and have improved outcomes for people who use services. 

24. The Self-Funding Team provides good advice to self-funders in hospital, enabling them to make informed choices about their future care that meets their needs and there are positive outcomes for those people accessing support for managing personal finances. 

25. The Community Action Network virtual hub facilitates rapid multi agency responses to deliver better outcomes for people and practice learning reviews demonstrate a learning culture. 

26. The staff whom the peer team met, clearly appreciate a commitment by BCP Council to offer appraisals that supports their development and there are strong and vibrant equalities, diversity and inclusion (EDI) networks which support staff. The commitment to EDI is illustrated by the better outcomes achieved for young people in preparing for adulthood team through a clear commitment to inclusive practice in relation to EDI.

For consideration

27. The peer team heard about the changes ongoing and planned to Mosaic and recommend that the council prioritise work to review and make changes to Mosaic to support practice. For example, it is currently not able to produce three conversations assessment process which would be a key component of the model’s successful implementation. The council will need to ensure that there are sufficient resources available to reconfigure Mosaic within a reasonable timeframe in order for the council to carry out their statutory duties. 

28. The service could consider wider use of individual service funds, contributing to a more personalised offer for adults which is an expectation of the assurance framework. The use of individual service funds will offer more options to people wanted to have greater flexibility and control over the way in which their care can be delivered and may be simpler and easier to use than traditional direct payment options.  

29. The peer team recommend that the service ensure it is able to articulate a robust story in relation to backlogs of work, including assessments, care plans and reviews. In doing this the Council needs to be able to show a coherent understanding of attendant risks and the service’s management of them. In some cases, there is an inconsistent use of the Red, Amber, Green (RAG) recording approach. A further benefit will be in managing expectations of service users until backlogs have cleared. 

30. The service recognises the need for the development of live performance data, at a team level, to enable effective management. This will need corporate support to ensure there is enough capacity to deliver and embed it. For individual teams, having data at this level will enable better oversight of caseloads, as well as the opportunity to manage budgets more effectively

31. BCP Council is working towards the provision of reporting in relation to mandatory training compliance. This will be an important aspect of the adults service story in terms of how it assures the quality of delivery and the council’s on-going commitment to staff development. It may also support a narrative in relation to the retention of staff. 

32. The peer team recommend BCP Council considers how to strengthen the ability to describe the characteristics of the diverse population, particularly around protected characteristics. We observed that there had been a lot of development of the workforce in terms of the awareness and understanding of the council’s equalities’ duties, and efforts have been made to support an increasingly diverse workforce through leadership and staff networks. This now needs to translate to a stronger understanding of the communities the council supports, a focus on access to services by all sectors of the community and an ongoing dialogue about their needs. We would add however that there is strong practice in relation to some protected groups such as people with learning disability, autism or mental health. 

33. From the present understanding of the CQC approach to inspection it seems the assurance process will challenge the service to demonstrate more strongly how it is meeting a diversity of need, beyond which we the peer team can currently see. 

34. We could see that the council is addressing the issue of a low uptake of direct payments (DPs). There is an opportunity to consider the development of an all-age policy for the council to ensure that the experience of young people as they prepare for adult hood is a seamless one.

Strengths

Workforce

35. Against a backdrop of significant workforce challenges BCP Council is ‘growing’ its own workforce through apprenticeships and support to newly qualified staff in a number of areas, supported by a principal social worker and a well organised workforce development team. The service is able to demonstrate that by relaxing human resources processes the council is enabling staff to work in different contexts, offering new experiences and development opportunities. 

36. A recent joint recruitment event enabled some successful recruitment that led to reduced waiting times for packages of care. The NHS funded healthcare workers have strengthened domiciliary care delivery and staff embrace the opportunity of the new council to take on best practice and improve its own practice and achievements. 

37. There is a developing partnership with Bournemouth University to expand care courses and offer student placements into adult social care. 

Commissioning

38. Within the BCP Council area there is a high percentage of residential providers who are rated good or outstanding and the service is enabling delivery to a wide range of needs, promoting equity for some groups. For example, the services designed for people with learning disability or autism have been co-produced with demonstrable positive outcomes. 

39. The Dorset Insight and Intelligence System (DiiS) is used to risk stratify long term conditions allowing outcomes based commissioning. This is possible by collating primary care data, helping to analyse levels of need. This enables preventative opportunities for individuals as well as enabling commissioners to predict trends, to inform service development. 

40. BCP Council has positive relationships with the local provider community and providers report they were well engaged in the fair cost of care exercise and whilst “fee banding” (a new more differentiated approach to the fees offered to care providers) was met with some challenge, it has enabled BCP Council to offer fairer rates for residential providers. 

41. BCP Council is getting a better understanding of residential care occupancy rates through providers’ compliance with the capacity tracker. Within the council area, there is a high proportion of people who can meet the costs of their own care (self-funders). The council needs to be aware of the impact of these people, should their funds fall to the level at which the council would then have to meet need as this could create significant further financial pressures for the council. 

42. The views of service users are gathered as part of quality monitoring and insights from safeguarding referrals which are used to inform quality improvements with providers. Furthermore team managers and service managers work together in a quality assurance forum to improve quality. 

43. As part of the commissioning process to shape the carer’s strategy, groups with protective characteristics were engaged as well in the current day opportunities review. We could see that the teams supporting this work were creative in the ways in which they tried to involve people and enable participation. 

44. There was good evidence that there is a strong infrastructure and culture of coproduction with those people with a learning disability and those with autism. There was also evidence of engagement to create the carers strategy and day opportunities review work. 

45. There is broader council support to adult social care including comprehensive integration between housing and adult social care. 

46. The BCP Council housing strategy offers housing options to meet a wide range of needs (such as older people, those with a learning and physical disability and the migrant population, etc.), with support for homeless people at the point of discharge. The inclusion of housing in discharge planning to be celebrated. Housing is often a challenge for people whose homes may not be suitable for their recovery. By considering housing needs, people who may have been homeless prior to a hospital admission have a greater opportunity for recovering their health and wellbeing. 

47. The prevention offer includes occupational therapists specialising in housing as part of access to adult social care front door.  By enabling appropriate and decent housing for people, or facilitating aids, equipment and adaptations, the council will reduce some of its demand for social care support since this can often be influenced by unsuitable housing.  

For consideration

48. Take the opportunity to engage providers in the development of the next market position statement and embed the evidence included in the market sustainability plan to create a longer term view of the care market expectations. Providers will be able to provide insights as to what works and will help to develop more innovative care and support solutions. By working more closely with providers, the council will also be able to help them to develop their own businesses to meet future emerging needs. The council has a strong basis of co-production with services users that could be extended to include providers, who were evidently keen to be involved in co-production. 

The service should seek to ensure there is clear visibility of staff compliance with mandatory training and the peer team pose the question of whether the workforce strategy is underpinned by the right level of data. This is particularly important for the workforce coming from three legacy councils with possibly different learning/ training requirements and records, to unify the mandatory requirements and develop a clear career pathway for all staff.  Accurate learning and development data will also support staff with meeting their statutory and professional registration requirements.

49. The peer team noted the work that the council has done via the assertive engagement team in a number of areas of service development. The peer team thought that the council could use these examples to show how it is meeting the requirements in the assessment framework to achieve equitability in service delivery. 

50. The service is aware that the affordability of local housing is a barrier to attracting and recruiting workforce in the area. 

Strengths

51. BCP Council works in partnership with Dorset Council and local NHS bodies through the Dorset integrated care board (ICB), which was formed in July 2022. There are two place-based partnerships, one covering each council area, and the existing health and wellbeing boards cover each place. There are three foundation hospital trusts in the Dorset ICB area, three acute hospitals and eighteen primary care networks. From the evidence that the peer team read, heard and saw there are positive and productive relationships emerging with ICS partners delivering improvements in ‘no criteria to reside’ (NCTR) performance. 

52. Another example of successful working with the ICS is the home first accelerator programme where joint work seeks to ensure that people have time to recover before onward care planning, leading to better outcomes. 

53. The service has seen better outcomes for adults such as prompt crisis management, quicker and more holistic assessments and management of transitional safeguarding issues through more coordinated services in safeguarding due to multi-agency teams. 

54. From the evidence seen there is strong partnership working evident in the joint ambition to end homelessness; there is also strong partnership working to build community resilience, supporting people to deal with cost of living and end food poverty. 

55. Practice in preparing for adulthood is strong, focused on enabling positive risk taking and better outcomes for young people. The peer team recognise that the adults social care service has created a preparing for adulthood team which has improved arrangements to support the transition of young people and was described as “robust” and “aligned to national best practice in a recent external review. 

56. BCP Council and health partners share risk around people requiring s.117 aftercare (Some people who have been kept in hospital under the Mental Health Act can get free help and support after they leave hospital), focusing on the delivery of outcomes through s.117 hub seeking to ensure that the needs of individuals discharged under the Mental Health Act are met in a joined up way. 

57. A partnership of BCP Council and health staff is developing a database designed to enable better monitoring and review for those involved in s.117 decisions; a similar approach is being adopted around CHC funding showing a learning approach to improvement. 

58. The Safeguarding Adult Board partnership is well led, offering a comprehensive training programme for a range of partners, which also extends to providers. There is also a proactive approach to provider improvement and learning from SARs and SI reporting. 

59.  BCP Council hosts a multi-agency hoarding panel where there is regular discussion of cases and solutions created and monitored to manage risk. There is the facility for other staff to drop in on the monthly basis to discuss and hear advice. 

60. Mental health support to assist discharges from hospital acute discharges show a focus on the holistic needs of individuals and helps to ensure that people with mental health conditions receive the right support for recovery after a hospital episode. 

61. A new manager has been employed to oversee the Multi-Agency Public Protection Arrangements (MAPPA) and Multi-agency Risk Assessment Conference (MARAC) meetings as well as the prevent work seeking to prevent people from being drawn into terrorism. 

62. ASC has a recent history of using two pre-existing management information systems and has moved to a single system that will help the organisation to embed stronger performance management arrangements, as we described earlier. This approach will also help to strengthen oversight of safeguarding. 

63. The recent external safeguarding Peer Review report, completed by the LGA Partners in Care and Health outlined how making safeguarding personal is given priority in the council’s work.

For consideration

64. The peer team recommend that the service should be able to offer a narrative around the high safeguarding referral numbers; a strengthened multi-disciplinary approach to initial contact may help with this. Improved triaging of cases and a stronger link to the contract quality functions may help to determine which cases warrant further inquiry from a safeguarding point of view, versus those matters which are more related to contract/provider quality.

65. The peer team pose the question of whether the service understands the relationship between the referral rates and conversions to section 42 enquiries? The service may want to assure itself that this is clear to all. 

66. There is good practice where the service uses the intelligence from these referrals, to support work to improve provider quality.

67. BCP Council recognises the need to be able to demonstrate a grasp of the risks and impact associated with long waiting lists for Deprivation of Liberty Safeguards (DoLS) and have a narrative of how these are be addressed.

Strengths

68. The peer team had the privilege of meeting the adult social care staff at BCP Council, who at all levels of the organisation demonstrate enthusiasm and commitment to what they do. They have a strong desire to improve what they do and are working hard to support and care for adults. 

69. Since the council was created in 2019 (by reorganising legacy authorities Borough of Poole, Bournemouth Borough Council and the Christchurch area of Dorset County Council), BCP Council has demonstrated a strong and supportive leadership against a backdrop of significant change. This was described as one of the most complex and fastest council reorganisations. Since the creation of BCP Council there is an on-going process of harmonising policy, practice and culture across the council. This includes an asset rationalisation process which has been delivered at pace, enabling flexible staff working practices. 

70. From speaking with staff it is evident that the culture of the organisation is one where those involved positively embrace change. Senior managers are respected for the way they support their staff, who are given permission to be creative. There is also visible and supportive leadership in the “innovation sites” described earlier in our report, and in adult social care there is a developing culture around co-production. 

71. As the local government structures have changed, there have also been new structures and new leaders within the new NHS structure. This has been seen as an opportunity to re-start joint and integrated working. Relationships appear already to be open, trusting and productive, for example rapid progress has been made on the implementation of a new discharge model and partners are working towards a more integrated approach to health and care commissioning. 

72. BCP Council and its NHS partners recognise the strength of the local voluntary and community sector (VCS) and the opportunities its offers for future service delivery. To enable this, the NHS has funded a VCS assembly to help to stimulate, recruit and source input into health service changes and health partnerships state a strong desire to do things differently, especially around early help and communities. 

73. The adult social care service manages performance and quality through structured approaches. However, there is a need for team level data, mirroring that which exists for financial data, to enable managers to be responsive to operational challenges. This could include waiting times for assessments, how long it takes for a care package to be put in place following assessment, timeliness of reviews and cost of care packages. This approach will enable managers to get to grips with some of the current challenges within the system and support a better understanding of resource use.

For consideration

74. The peer team would like to suggest that BCP Council be more explicit in describing its culture, particularly in what it looks like in the future. This would potentially include greater clarity on how staff work with the local community and how it wants staff to work together to deliver improved outcomes for local people. As is stated elsewhere in this report, that narrative needs to include the voice and assurance of personal lived experience. 

75. The challenge for the new political administration is to take the reins quickly and address the underlying budget challenges facing the council as a whole and adult social care in particular. Looking at the size of the deficit, this is no easy task. 

76. There is an opportunity as the council inducts new and existing council members over the coming months to openly discuss these challenges and to reflect on the future roles of the Health and Adult Social Care Overview and Scrutiny Committee and the Health and Wellbeing Board in supporting on going challenges around demand management and resource use.

77. For the CQC inspection, the council will need to show it has robust plans in place to manage the risk from growing demand in adult social care and that it is coordinating change plans effectively into the longer term, to ensure sustainability in the delivery of services to meet future need. 

78. The peer team can see that staff rise to the challenge of delivering a complex change agenda and have been doing so for some time. The peer team suggest BCP Council consider the risks of “change fatigue” and of staff wellbeing, especially when thinking about the impact of the ‘Pay and Reward’ process. 

79. To support and benefit from the opportunity for health integration, there is a need to improve the quality of data across the health and care system and work towards more systematic ways of enabling data sharing. Something of which BCP Council is aware.

The peer team 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. Paul Clarke, LGA Principal Adviser is the main contact between the council and the Local Government Association. His contact details are email: [email protected], Telephone: 07899 965730. There is also Claire Bruin, Care and Health Improvement Adviser who can be contacted at email: [email protected] or Tel: 07584 272635. 

In the meantime the LGA is keen to continue the relationship formed with the council throughout the peer challenge. The LGA will endeavour to provide signposting to examples of good 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 BCP Council please contact:

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.