Part 3: Lambeth Social Care Commissioning

Report author

Name Liz Clegg

Role Assistant Director, Integrated Commissioning

Organisation Lambeth CCG and Lambeth Council

Date of report 7th December 2016

Period covered by report 2015-16 & Q1-Q2 2016-17

Summary of safeguarding adults assurance report

o If trend seen in Q1 and Q2 continues, the total number of safeguarding concerns being

reported to local authority by social care services in 2016-17 will be more than double that

recorded in 2015-16.

o In Q1 to Q2 of 2016 more than half of safeguarding concerns (60%) related to neglect and

acts of omission, with the next highest category of abuse being Physical Abuse (14%).

o The Policy for Responding to Concerns Relating to Social Care Providers in the Borough of

Lambeth was signed off in June 2015. It sets out clear processes for aggregating information

about a provider and the thresholds to determine action to be taken.

o Lambeth has implemented the London Living Wage (LLW) for all staff working for providers

on the Community Support Approved Provider List and reports back from providers has

been positive with regards to staff recruitment and retention.

o As a response to the increased number of safeguarding alerts relating to medication a new

medication policy has been developed for Community Support providers. The

implementation of this policy has been supported by a specific training sessions offered to

all community support providers free of charge and funded by the CCG. To date 36 sessions

have taken place with over 400 carers trained

Note:

The way data has been collected has changed based on what the HSCIC’s statutory returns

required. Therefore yearly results are not wholly comparable.

Data reports have however increasingly allowed for more detailed filtering on source of risk

sub-categories to identify more specific areas.

Safeguarding Activity within Social Care Services:

o If trend seen in Q1 and Q2 continues, the total number of safeguarding concerns being reported to local authority by social care services in 2016-17

will be more than double that recorded in 2015-16.

2 Number of adult safeguarding concerns related to risks posed by your social care provider services

2015-16

2016-17

Q1 Q2 % change on

previous quarter

A

Total number of adult safeguarding concerns reported to the local authority related to risks posed by social care services?

405

169 182 8%

B Of (2A), how many were reported by your social care services’ staff (should be equal to (1B))?

91 46 38 -17%

C

Of (2A), how many were reported by someone other than social care services’ staff (should be equal to 2A - 2B)?

314

123 144 15%

1 Number of adult safeguarding concerns reported by your social care provider services

2015-16

2016-17

Q1 Q2 % change on

previous quarter

A Total number of adult safeguarding concerns reported to the local authority by social care services

220 102 115 13%

B Of (1A), how many related to risks posed by your own organisation or services?

91 46 38 -17%

Diagram 1: Graph showing category of abuse where source of risk is Independent Social Care Services, Voluntary Social Care Services or ‘LB Lambeth

Other’

o One case related to risk of financial and material abuse where source of risk was the service user’s lodger. The service user was living in Lambeth

Council Housing which may indicate confusion with location of risk as suggested above. The Safeguarding Enquiry was undertaken alongside a Lambeth

Housing Officer, and as a result of the enquiry, Extra Care Housing is now being explored by the social work team.

o Of cases in Q1 to Q2 2016-17 where source of risk was recorded as Lambeth Adult Social Care, Independent Social Care Services, Voluntary Social Care

Services or ‘LB Lambeth Other’

32% recorded care homes as location of risk.

60% recorded location of risk as being service user’s own home.

Adult safeguarding concerns regarding risks posed by social care servicesQ1 - Q2 2016

Domestic Abuse Financial or Material Abuse

Neglect and acts of omission No actual or risk of Abuse or Neglect

Organisational Abuse Physical Abuse

Psychological Abuse Self Neglect

Sexual Abuse

o In Q1 to Q2 of 2016 more than half of safeguarding

concerns (60%) related to neglect and acts of

omission, with the next highest category of abuse

being Physical Abuse (14%).

o Within the figures for adult safeguarding concerns

posed by social care services, 317 cases related to

independent social care services, 13 related to

voluntary social care services, and 10 were attributed

to ‘Lambeth Other’.

o There are instances where source of risk has been

incorrectly recorded, possibly being conflated with

location of risk.

o Where ‘Other’ was selected as source of risk, 3 of

these cases related to Lambeth Council Services;

Lambeth Living Housing, Lambeth Environmental

Health, Lambeth Rapid Response Team. The remainder

related to other providers such as Mencap, Red Cross,

Careline Home Support and care home providers.

3. Findings of adult safeguarding enquiries concluded in period where risks were identified from social care provider services

2015-16

2016-17

Q1 Q2 % change on

previous quarter

A

Number of adult safeguarding concerns concluded in the period where social care provider services was identified as a source of risk

191 (9%)

96 123 28%

B Of (3A), number where there was evidence abuse or neglect took place

85 (42%) 40 64 60%

C Of (3A), number where there was evidence there was risk of abuse or neglect

31 (16%) 21 24 14%

o Where there was evidence that abuse or neglect took place by a social care provider service, the key themes that appear in these cases are as

follows:

Missed calls by home care workers or care workers who were frequently late, and misuse of log books.

Carer’s not administering medication in timely manner, or administering medication incorrectly.

Numbers of care staff/monitoring of care home residents, leading to incidents such as injuries which are not noticed until sometime after the

event, infections developing or residents going missing from the property.

Unexplained bruising noticed by carers or family members.

4. Outcomes monitoring for adult safeguarding enquiries concluded in period where risks were identified from social care services:

2015-16

2016-17

Q1 Q2 % change on

previous quarter

A Of (3A) how many showed that the person said their outcomes were met

126 (66%) 72 76 6%

B Of (3A), how many showed that the person said their outcomes were partly met

59 (31%) 23 41 78%

C Of (3A), how many showed that the person said their outcomes were not met

6 (3%) 1 6 500%

o So far in 2016-17, 68% of adult safeguarding concerns concluded in the period where social care provider services was identified as a source of risk

showed that the person said their outcomes were met. This is a slight increase on 2015-16 figures.

o The percentage of adult safeguarding concerns concluded in the period which showed that person said their outcomes were not met has so far

remained consistent at 3% in YTD 2016-17.

Have there been other achievements in the period or that are planned that you want to bring to the attention of Lambeth Safeguarding Adults Board?

The below information is an update following the last themed report (completed in April 2015) from Social Care Commissioning, to the LSAB:

1. Contractual Arrangements The governance of commissioned adult social care services is provided through the contract that is in place with the service provider. The contract has the specification for the service as an appendix with any other key documents. This ensures that providers are held to account for all aspects of service delivery, including safeguarding, and the mechanism for doing this is through the contract management process. In the Integrated Commissioning Teams, (Older Adults / Disabilities / Mental Health) in Lambeth, Commissioning Development Officers are responsible for the monitoring of services provided under a Lambeth contract. In the case of nursing and residential homes, the Council does place in homes outside of the borough but we contract monitor homes only within the borough of Lambeth and there are reciprocal arrangements whereby the host authority monitor homes in their council area. The key contracts that are in place currently for older adults, disabilities and mental health are as follows: Older Adults Residential and Nursing care - Excelcare block contract (3 homes, 2 in Lambeth and 1 in Southwark) Residential and nursing care - spot purchased (12 homes) Community support services – Approved Provider List : 38 Spot purchases : 23 Extra care housing- Block contracts: Allied Healthcare, Sanctuary Housing and Notting Hill Learning Disabilities 15 providers with a range of residential (spot purchased) and supported living services Mental Health 12 providers with primarily residential care (spot purchased) Supported Living/Floating Support In addition to adult social care funded services Lambeth also funds through Supporting People budgets: 12 supporting people contracts for people with a learning disability with 6 providers 11 supporting people contracts for people with mental health needs with 8 providers 2. Monitoring of Quality of Services Monitoring of providers is carried out by Commissioning Development Officers who use a number of mechanisms to review and monitor the quality of care provided. This includes:-

Operational meetings with providers, which include colleagues from care management Contract management meetings with providers Visits to provider sites e.g. nursing and residential care homes and community support provider offices The frequency of monitoring is determined by the risk score calculated from intelligence gathered from a wide range of sources and collated by the Commissioning Development Officers Where there are particular issues (particularly related to the quality of services) with providers, more senior level meetings will take place with key personnel from commissioning and care management and the provider organisation

2.1 Provider intelligence and risk assessment This information is now collated in the one place with one Sharepoint folder. It has been developed by the Integrated Commissioning Older Adults and is in place for community support and care homes monitored by that team. This is now being rolled out to the commissioning teams for disabilities and mental health. The information collected includes:- Number of hours commissioned year to date Number of hours commissioned in previous years Hours in current year as a % of the previous year Number of clients seen Number of complaints in the past 12 months Number of complaints as % of clients Number of safeguarding concerns that lead to enquiry in last 12 months Number of SA enquires completed where evidence that abuse or neglect took place Number of concerns that lead to enquiry as a % of all clients CQC rating at last inspection Financial viability – Dunn and Bradstreet score Electronic Call Monitoring compliance Number of ECM recorded missed visits (average of the first 2 weeks of the month recorded) Result of last monitoring visit Date of last monitoring visit Assessment of management arrangements e.g. new or temp manager Other concerns which have been raised The information collected for nursing and residential homes includes:- Total number of people in the home placed by other boroughs, CCG and self-funders Number of placements made by Lambeth Percentage of Lambeth placements in the home Weekly spend by Lambeth Number of safeguarding concerns that lead to enquiry in last 12 months Number of SA enquires completed where evidence that abuse or neglect took place Number of concerns that lead to enquiry as a % of all clients LBLB ASC training accessed by provider in year Date of last CQC inspection CQC rating at last inspection Number of social care reviews escalated to commissioning in the past month

Financial viability – Dunn and Bradstreet score Notes and comments are attached and the reports of the monitoring visits are also downloaded onto the Sharepoint file The information is discussed at the monthly meetings between the lead commissioners and the CDOs, to agree what actions need to be put in place to address risk. The register is also discussed in detail on a quarterly basis at the wider Integrated Commissioning Older Adults team meeting. Invites to these quarterly meetings have been extended to the Care Quality Commission local and area managers and to LBL ASC care management colleagues. Based on the scoring received, the provider/service will be assigned a level of monitoring (low-medium-high). The basic principle is that the level of monitoring applied to a particular provider or service should be proportional to the assessed risk. Processes are being put in place for care management and brokerage departments to have full access to the database to inform the decision making process prior to placing care packages or agreeing placements and to gather intelligence as part of the client review process.

2.2 Provider Concerns Policy The Policy for Responding to Concerns Relating to Social Care Providers in the Borough of Lambeth was signed off in June 2015. It sets out clear processes for aggregating information about a provider and the thresholds to determine action to be taken. It also takes into account the London ADASS Safeguarding Adults policy in particular the Provider Concerns section, new adults safeguarding processes required by the Care Act and the Lambeth Adult Social Care Good Practice in Safeguarding Adults Guidance (May 2015). The policy also contains the process followed when a provider alert is received from another authority.

3. Provider issues

3.1 Community Support There are now a total of 38 providers of community support on the council’s approved provider list. The amount of hours allocated to each provider will vary. In 2015/16 this ranged from over 150,000 hours for Allied Healthcare (much of this will be long term care packages as Allied used to be the main block provider) to under 200 hours for one agency. Not all agencies on the framework will be allocated hours as this will depend on carer availability and price. There are still a number of agencies that are not on the framework. In 2015/16 676,404 hours of community support were allocated to providers on the approved list and 111,937 to providers not on the list. Intelligence on all providers is collected as outlined in section 2.1. Since the last report the issues relating to two of the main providers (Allied and MiHomecare) concerning missed and late visits and poor working practices with instances of care staff working excessive hours per day and for many days in a row without a break have now improved and the suspensions previously in place at the time of the last report have now been lifted. In February 2016 a suspension notice was issued by CQC to Xtracare, a community support provider based in Southwark, due to failure to comply with Regulations 9, 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This provider was not on the

LBL Approved Provider List but at the time of the suspension was providing a service to 26 Lambeth residents receiving over 500 hours per week. As a result of the suspension the company decided to cease trading and the 26 service users were found alternative provision without any interruption to the care required. At time of reporting there are two community service providers who have suspensions in place. These are Oasis Care and Training Agency (based in Southwark) which was suspended in August 2016 and Sonia Heway Care Agency (based in Bexley) which was suspended in October 2016. While both these agencies are based on other boroughs LBL Commissioning and care management staff are working closing with colleagues in Southwark and Bexley as Lambeth have more service users with those care agencies than their host boroughs. Improvement plans are in place for both organisations and these are monitored jointly by Lambeth and the respective host borough. Monitoring includes announced and unannounced site visits to the office bases, face to face and telephone reviews with service users and their families/carers, safeguarding case conferences and regular monitoring meetings with the registered manager and other senior staff. There is also a regular communication with local CQC Inspectors who also attend the Older People’s Commissioning Team meeting 2-3 times per year. The key themes identified are:- Poor recruitment practice including failure to comply with DBS regulations Poor record keeping of training and staff supervision Failure to comply with local policies

3.2 Electronic Call Monitoring Electronic Call Monitoring has been introduced to eleven providers of community support to Older Adults. It replaces hand written timesheets with electronic capture, analysis and reporting. This has provided commissioners with information regarding missed and late calls to clients which constitute safeguarding concerns and to therefore initiate the provider concerns procedure. The data provided by ECM has allowed us to evidence these practices, to quantify the improvements required and to accurately monitor on-going performance in these areas. ECM is currently being introduced to an additional 12 adult community support providers, including ALD, PD and MH clients (representing 424 service users) and a third phase will introduce ECM to a further seven providers (186 service users). All service providers with ten or more adult clients will then be covered by ECM. Phases 2 and 3 are expected to be complete by summer 2017

3.3 London Living Wage Lambeth has implemented the London Living Wage (LLW) for all staff working for providers on the Community Support Approved Provider List and reports back from providers has been positive with regards to staff recruitment and retention. Two thirds of the staff receiving the LLW live in Lambeth. The rate paid to service users who receive a direct payment and employ a Personal Assistant (PA) has also been uplifted in 15/16 to enable the users to pay their PA the LLW. These rates and Community Support rates will be uplifted in 16/17 to take account of the increase in the LLW. There are also plans to implement LLW for Extra care providers as of the 1st April 2017

4. Residential and Nursing Care There continue to be quality and safeguarding concerns about a number of Lambeth homes. In 2015/16 the suspension of new placements into Dulwich Care Centre continued. A robust action plan was put in place and the home was improving under the new manager and LBL were likely to partially lift the suspension; however the parent company felt that they could not guarantee the continued improvement and ensure financial sustainability of the home and so therefore took the decision to close the home in June 2016. At the time of this decision the home was operating at a third of its capacity which meant that 31 residents required new placements. Lambeth staff (commissioners, care management and brokerage) worked closely with colleagues in Southwark and other London boroughs who had residents in the home to successfully manage the transfer of the 31 residents within the time frame agreed with Dulwich Care Centre of the end of August 2016. Families were kept updated through meetings, written briefings and individual reviews and discussions with care managers. Healthwatch played a key role in working with relatives and families of residents at the home throughout the duration of the suspension and subsequent closure In October 2015 referrals were suspended to Collingwood Court and this remains in place at time of reporting. A robust improvement plan is in place and the situation in the home is improving, however Collingwood Court is undergoing a major refurbishment and so it is unlikely that the suspension will be lifted until this work is completed. In December 2015 a suspension was placed on The Laurels Nursing Home. New management arrangements and compliance with a detailed service improvement plan has resulted in significant improvements and in November 2016 the council made the decision to lift the suspension to allow for a mutually agreed number of new placements per month Monitoring includes announced and unannounced site visits to the homes, face to face and telephone reviews with service users and their families/carers, safeguarding case conferences and regular monitoring meetings with the registered manager and other senior staff. There is also a regular communication with local CQC Inspectors who also attend the Older People’s Commissioning Team meeting 2-3 times per year From analysis of safeguarding and other concerns key themes include:- Support for residents with challenging behaviour – increase in the number of resident to resident alerts raised Staffing numbers , supervision and management evidenced by the increased reporting of un-witnessed falls and injuries, increased incidence of pressure sores Increased requests for 121 care Homes being unable to take residents with higher level needs e.g. tracheostomy and PEG tube feeding Difficulties in recruiting and retaining qualified and non-qualified staff. It is hoped The 40% rise in the nursing care contribution by CCGs will have an impact on recruiting and retaining nursing staff however some homes have reported that they are struggling to recruit

care staff due to the different pay rates between residential and domiciliary care which now attracts the London Living Wage

5. Other Initiatives and Developments Workforce Development The care workforce is key to future development of models of care we need in Lambeth. Some of the challenges include:

Understanding the size and shape of the Workforce for integration

Growing the Workforce for integration

Skilling the Workforce

Career progression for care staff

Developing Personal Assistants to support personal health budgets

Developing care co-ordination / navigation roles

Enhancing roles to take on more complex health and social care A Health & Social Care Skills and Market Shaping workshop was held in Lambeth at the end of 2015 and an outcome of the workshop was to establish joint work streams focusing on:

a skills gap analysis to for Adult Social Care, drawing on Lambeth’s National Minimum Data Set;

co-ordinating and making better use of available training provision in the area;

introducing new qualifications training such as the Care Certificate, and the Integrated Health and Social Care Apprenticeship;

developing and promoting new progression and career pathways for Health and Social Care assistants;

co-ordinating and combining organisational resources in order to improve workforce recruitment, training and progression routes.

Provider training Classroom and online training in safeguarding is available to providers. Most providers have registered for online training, via MeLearning, but the take up of safeguarding training has been rather lower than, for example, training in the Care Act. Encouraging wider use of the training available to providers is an item for discussion at the next provider forum. A Medication Policy has been developed for Community Support providers and is based on a Generic Medicines Management Assessment Tool and a clear protocol in relation to support provided by care staff to help people receiving social care services to take their medicines as prescribed. As part of the roll out of the new policy and to address issues identified by through safeguarding alerts the council has commissioned bespoke training for community support providers which they are mandated to attend. Feedback from providers is that this course has increased their knowledge regarding what is (and is not) expected of care providers in this area; it has increased the confidence of carers attending the course and has consequently improved provider capacity

to provide a safe medications service to our clients. At the time of reporting 36 sessions have been held and over 400 carers have attended the training. A further 12 training sessions are planned for 16/17 Community Support Provider Forum Forums for providers of community support to older adults take place every two months. They are well attended and providers have expressed that they find the meetings reassuring in regard to the intention of commissioners to work with them to improve their performance in difficult market conditions. Recent discussions include ways to increase ECM compliance, improved information sharing between service providers and care management and how to safely reduce the number of safeguarding alerts in order to make best use of provider and care management resources in this area Lambeth and Southwark Care Homes Network The Network is a collaborative meeting of cares home in Lambeth and Southwark that meets quarterly. The network includes care home managers and nurses, Geriatricians and clinicians from the Care Home Support Team, commissioners from Lambeth and Southwark Councils and CCGs, GPs that support the nursing homes. The Network focuses on collaborative discussion and problem solving and has looked at such things as reducing avoidable A&E admissions, implications of safeguarding legislation for care homes, supporting people with dementia in care homes, and improving discharge from local acute hospitals into care homes.

Market position statement A Market Position Statement (MPS) for adult social care has been developed which will provide an overview of the current market and the strategic direction for services for all adult care groups. The Market Position Statement maps out the local context in Lambeth in relation to the current social care market and sets out the model of services Lambeth wishes to commission in the future.

The Market Position Statement is an important part of the process of initiating a new dialogue with care providers in Lambeth as we want to develop a partnership with care providers where:

Market information can be pooled and shared

The Council is transparent about the way it intends to strategically commission and influence services in the future and how it wishes to extend choice to service users and carers.

Services can be developed that people need and want.

It is planned to publish a full version and a summary version of the Market Position Statement in January 2017.