Care Home Provision and Commissioning
To receive a report on care home provision and commissioning in Brent.
Andrew Davies (Head of Commissioning, Contracting and Market Management, Brent Council) introduced the report, which summarised residential and nursing home care in the borough, and provided an overview of the work being done on quality assurance, price setting, and the support the Council had given to the sector over the past 18 months. He advised that, of 57 residential and nursing homes in Brent, 45 were rated ‘good’ and 1 was rated ‘outstanding’ by the Care Quality Commission (CQC). Of the placements Brent made, over 83.5% were in a nursing or residential home rated as good or outstanding, which was slightly better than the London average. Where possible, the Council looked to commission within the borough, but this was not always possible due to pressure from other boroughs for placing residents. As a result, around 50% of placements were made in borough and 50% outside, which was in line with the London average. The number of placements particularly fell during 2020 following deaths due to Covid-19. The NHS took on commissioning of nursing placements for people leaving hospitals, and now the sector was seeing numbers increase to pre-pandemic levels. As a result, it was expected that the Council would spend slightly more than in previous years.
In offering care and support, the Council felt that, wherever possible, it was best to look to support people at home, with residential and nursing home care being the last resort. It was crucial there was a vibrant residential and nursing sector, and the Council spent a lot of time on quality assurance. The Residential and Nursing Team were responsible for quality assuring services, carrying out placement reviews, and taking a lead on safeguarding enquiries in Brent based homes. Each care home had a Placement Relationship Officer managing the close relationship between the Council and the home. They used a quality dashboard and there was good intelligence on the position of all homes in Brent, including those that the Council did not commission services in. The Council also continued to regularly share information with the CQC through quarterly meetings.
In relation to the 9 nursing or residential homes not rated as good or outstanding, an enhanced health and care home improvement programme was running, jointly with the CCG. This focused on medication management, improving links between primary care networks and care homes, and included a peer support programme which ten providers had been through and seen an improvement in their services. Three of the homes that were part of the improvement programme had subsequently been re-inspected by the CQC and had their rating increased.
The current challenge was the impact the vaccination mandate had on staffing levels. Although the mandate was being abolished the day following the meeting, since November 2021 it had been a legal requirement for anyone working in the care home sector to be vaccinated against Covid-19 and staff had left the sector as a result of that. This had not impacted the number of care home beds, and the Council were optimistic they could recover. The guidance from the Director of Public Health was that care homes needed to take precautions around infection control and visiting, and encourage testing for visitors to protect the vulnerable residents living in care homes in Brent.
The Chair thanked councillors for their introduction and invited the Committee to raise comments and questions, with the following issues raised:
The Committee queried whether there were any commissioning policies in relation to diversity, and the different cultural and religious needs of the Brent community. They were advised that Brent’s care homes reflected Brent’s communities, and there were several care homes in the borough that catered for specific ethnic and national groups, set up by people in those communities to care for their elders. The activities in those care homes reflected the client groups within those homes. The Council tried to place people into homes that could provide culturally specific and sensitive support, although that was not always possible and the Council would address that person’s care needs first and foremost. Andrew Davies felt that Brent care homes had become very good at providing culturally specific and sensitive support and providing an environment within homes that took into consideration the range of nationalities and ethnicities of people from Brent.
The Committee queried how this approach factored into assessments. Andrew Davies advised that the assessment process started at the point someone approached the Council for support, or was in hospital or waiting for a hospital discharge, and a view had been taken by a Social Worker that their needs could only be met in a care home. The assessment took into account a person’s entire need including care, culture, religion and food, which helped to determine the home they were placed in. Placement Relationship Officers carried out placement reviews and reassessed people throughout their journey, including with their families, carers and friends, to determine that the placement remained suitable. If a person’s food was not appropriate for them the Placement Relationship Officer would address that with the care home, and remained conscious of any feedback. Often, those placed were not in a capacity to give feedback themselves due to cognitive impairments and Placement Relationship Officers attempted to hear what their family or friends, as advocates of the person in the care home, had to say in that respect, to ensure the placement was meeting the need. If there were specific examples where the Council was falling short of supporting a person’s entire need, members were asked to let officers know.
Continuing to consider diversity within caring, the Chair invited representatives of Brent Youth Parliament to address the Committee. Brent Youth Parliament highlighted staffing challenges, and asked what action the Council were taking to promote and encourage employment of youth into caring careers. Brent Youth Parliament were happy to encourage this as much as possible such as through employment talks and development hubs in order to increase diversity within caring. In relation to staff, Brent Youth Parliament felt that a more robust anti-racism programme to reduce stigma and stereotypes within staff would help patients feel comfortable within their care home setting and take away the need to place people in homes according to their cultural need. Andrew Davies agreed that it was important to encourage young people to work in the care sector as they wanted to grow the workforce with passionate individuals, and the Council were currently working with Brent Works on a programme connecting those who wanted to work in care with job vacancies in the sector. He welcomed working with Brent Youth Parliament and encouraging care providers to speak with Brent Youth Parliament. Work experience within the local authority was also available, and a ‘proud to care’ scheme, where carers received a rewards scheme with discounts and shopping vouchers as an incentive for anyone who worked within the health and social care sector.
Brent Youth Parliament also wanted to know what measures were being used to assess the programmes put in place to raise the ratings in those homes not rated good or outstanding. They were advised that the Enhanced Health and Care Home Peer Support Programme focused on those care homes requiring improvement, as well as care homes trying to make a step change from good to outstanding. The Council were working with providers to support them in the lead-up to inspection so that the registered managers could work together on areas they could jointly tackle to demonstrate their quality to the CQC. Business as usual quality assurance took place regularly through the Residential and Nursing Team, and it was an area the team focused on daily.
The Committee queried the role of the adult fostering service as a way of keeping people in the community. Andrew Davies advised that the adult fostering service focused particularly on respite placements and the importance of giving those caring for people who still lived at home a rest. The service had been rated by CQC as good and was due another inspection in 2022. There were 20 placements currently in the Shared Lives adult fostering service, and there were tentative plans to expand those numbers. There had been various attempts across the past 5 years to recruit carers to the service which had not been successful, which had meant the numbers had remained lower than usual. The Council had spent time and resource developing the Brent Supported Living Service which brought on approximately 70-80 learning disability and disability specialists, reducing the number of people with a learning disability living in residential care from 180 to around 120, and that was the strategic direction the Council had decided to go in. The Shared Lives service was being reviewed to see where it could grow and develop in relation to the strategic direction.
Continuing to discuss respite care, the Committee were advised that respite placements would not be included in the report data as they were temporary. Most of the respite offered in Brent would be part of a care plan when a person’s care was first put in place. For those carers where respite had not been included in the initial assessment who needed respite, the carer would be required to contact the Adult Social Care Front Door and have a separate Care Act assessment with a specific focus on the service user and carers needs. As long as they demonstrated that they did need that support in order to continue to care for a person the Council would offer that respite.
In relation to day centres, the Committee were advised that these had all now reopened. There had been a turnover of service users due to the pandemic. The Council were working with day centres on transforming their models of care to do more outreach work in the community and trying to orient them away from being focused on only delivering services from their respective buildings. The focus was on a more modern and dynamic way of delivering day care in line with what was happening across London, sharing models of good practice with other boroughs. Andrew Davies offered to bring a separate report regarding day care to the Committee.
The Committee queried how assessors concluded what sort of placement was suitable for an individual. For example, the Committee asked what assessment was done to determine if someone was more appropriate for Supported Living. Claudia Brown (Operational Director Adult Social Care, Brent Council) explained that specialist social workers were trained to do a generic, comprehensive assessment of an individual’s needs. A placement would be identified once those needs were assessed. Another scenario was raised, where an elderly widower could no longer be looked after by their family, and the Committee asked whether there was a different approach if a family member approached the Council for their relative to be placed if the relative consented. In the scenario, the widower had deteriorated and were lonely and becoming forgetful. Andrew Davies advised that this was a scenario the Team dealt with on a daily basis. The approach would be the same in terms of social care assessment where the elderly person would be met and their needs assessed. The assessor may determine that their needs could be met at home alongside a care package, or that their level of need was not sufficient to place them in residential or nursing care. If that person chose to fund their own placement or sell their property to move into residential or nursing care then they were free to do that. It was important that the individual remembered that they had a choice, and often the assessor may do a Mental Capacity Assessment to see if they had the capacity to make that choice. They could chose to stay at home with support services provided, or the Council could offer Extra Care, among other options.
The Committee noted the general trend to move towards supported living and asked what the impact of that had been. They were advised that the rationale behind this was that it was felt younger people under the age of 65 were better served with people of a similar age or disability, and that creating those homes where individuals had a community, friendships and relationships developed better ways for young people to live their lives. The savings of the programme had also been a key driver. In terms of satisfaction and soft measures of success, it was felt the Council could do better at asking people about their views of the service and gathering constant feedback. Phil Porter (Strategic Director Community Wellbeing, Brent Council) advised that all service users had an annual review which was person centred and engaged their family and carers, in order to understand the extent their placement continued to meet their need. He felt more could be done to aggregate that data to understand its impact, and the Performance Insight Team were looking into how that might happen. The Council had also begun the design of a service user survey so that every visit a care worker conducted would receive feedback. Co-production was also a focus, getting service users involved when care provision was retendered, and that happened on a regular basis. A post had been created for someone to work specifically on co-production and service user led design which would take into account the views of service users and demonstrate the impact of the service. In terms of how the increased level of independence was measured, Phil Porter highlighted that, because service users had different situations and needs, this was measured for individual cases and not currently aggregated into larger numbers. The Committee considered that this might add value as it would be a holistic view of service performance.
The Committee understood the lack of resources in the care sector, particularly following the pandemic, and asked how many care staff Brent had lost as a result of the mandatory vaccination and what the impact of that was. Andrew Davies would find out the exact figures, but it was noted that it was a much smaller number than was expected and not significant in Brent. Brent Works and providers had worked hard to backfill those posts, but there was now a wider issue about morale in the service now that the mandate had been reneged upon. In order to maximise the vaccination of staff, the Enhanced Health and Care Homes Team had delivered the vaccination in care homes to all residents and staff throughout the various phases. There were also weekly online forums led by public health consultants and NHS colleagues to promote the uptake of the vaccine. The Council had also encouraged GPs to open up their practices to allow staff to be vaccinated closer to their homes.
The Chair drew the item to a close and invited the Committee to make recommendations, with the following RESOLVED:
To recommend the following key areas for improvement:
i) For the Council to work with providers to fund and commission key areas of training and development for care home staff, including conflict resolution training.
ii) For the Council to consider the use of high-level metrics, such as key performance indicators, to monitor and evaluate the performance of the care home sector in Brent.
iii) For the Council to ensure that the wider wellbeing needs of service users, such as social, religious and cultural needs, are considered when commissioning nursing and residential placements.
An information request had also been made during the course of the discussion, recorded as follows:
i) For the Community and Wellbeing Scrutiny Committee to receive further information on the Shared Lives scheme and Day Care services, including any future plans for the development of these services.