Agenda item

Adult Social Care - 6 Month Update


The Director of Adult Social Care introduced the report to the Panel.


She began by explaining some of recent funding decisions that had been announced. She said that in December £50m had been allocated nationally to allow for international recruitment to take place and that B&NES was still awaiting its precise allocation.


She stated that a Discharge Grant of £0.6m had also been announced in December specifically for B&NES and that the ICB had also received the same grant for £1m to help with local services.


She added that on 16th January it had been announced that £200m had been allocated nationally for work to help with hospital discharges and that this would be allocated through the ICB.


She stated that Discharge Grant had already been used for work in the Care Coordination Centre, to buy further domiciliary care and to buy more beds in the community and that this had already helped to improve the flow of patients both in and out of the RUH.


She informed the Panel that she had last week met with ministers for Social Care and Local Government to discuss the challenges and good work going on within B&NES. She added that there is an interest nationally around hospital demand and what social care can do to support that demand. She said that she anticipated that further meetings of this nature will take place in the future.


She stated that the current forecast financial position for Adult Social Care was to break even as the underlying variances will be covered by a transfer from the Adult Social Care Reserve fund.


She addressed the Panel regarding the Community Resource Centres (CRCs). She explained that the Council runs 9 in house services consisting of 3 Care Homes (1 with nursing), 5 Extra Care schemes and a home care agency (United Care BANES – UCB). She said that due to the national shortage of staff in the care sector, these services remain reliant on a high use of agency staff.


The 5 Extra Care services have been inspected and all have a rating of good from the CQC.


She said that the provision of care within the 3 Care Homes was the thing that concerns her most within her role. She stated that it was the team within the Council that identified the safeguarding concerns at Charlton House to the CQC in October following initial concerns having arisen over the summer and having brought in additional clinical leadership and managerial staff to attempt to improve the quality of care.


She said that over the past couple of months that Council staff have been working continuously with the team at Charlton House to make improvements. She informed the Panel that they have recently secured a Senior Nurse from the RUH to work there and that a new registered manager was also now in place. She added that action plans were now in place and that wrap around support was in place from the Corporate Management team, Human Resources and Health & Safety.


She said that the CQC visited Charlton House last week and were pleased with the improvements that have been made and that we would be required to report to them regularly on the progress of the action plans.


She stated that a multi-agency large scale enquiry was ongoing to investigate how the issues at Charlton House occurred and to monitor the improvements.


She said that she was personally so sad with what has happened and has spoken with the residents and their families to address their concerns.


She explained that there are 14 residents in Charlton House and that those numbers would not be increased while these initial improvements are taking place.


She stated that it was not the role of Councillor Born to personally oversee the provision of care at these homes. She said that she was accountable in her role and that alongside lead members of staff she intended to make the necessary improvements required.


Councillor Alison Born, Cabinet Member for Adult Services made a statement to the Panel, a summary is set out below.


B&NES decided to take the services back in house after the previous provider gave notice on the contract in 2019. Charlton House is the only nursing home within the three care homes.


The contract for these services had been underfunded and the previous provider realised that it could not make the investment needed to provide high quality services; staff had been undertaking industrial action prior to the transfer back to B&NES in October 2020.


The decision to take the services back in house was made in the knowledge that they would require investment, but it was not foreseen that they would transfer back in the midst of the Covid pandemic. It was clear from the outset that the services were struggling and needed investment but the circumstances of the transfer ie the pandemic, made it more difficult to undertake all of the remedial work required as quickly as we had planned. The immediate focus was on staying open and keeping residents safe by minimising the risk of covid transmission.


The recent CQC inspection at Charlton House was prompted by a number of safeguarding alerts made by staff within the service, who recognised that there were some problems with care and who rightly raised the alerts. We knew that improvements were needed but the report makes very sobering reading and we agree with the CQC that some aspects of the care that residents received was unacceptable. 


We are extremely sorry that we have let people down and have not provided the consistently high quality of care that residents and their families expect and deserve. We make no excuses for this and are working hard to improve the service provided but we recognise that this will not happen overnight due to the context that we are operating in.


While we have taken measures to improve recruitment such as our local “Proud to Care” campaign, innovative work with the RUH to bring more staff into the area to provide home based care, by increasing pay and benefits packages and through the creation of a specialist social care recruitment post within the council, we remain more reliant on the use of agency staff than we would choose and are not always able to cover all shifts fully.


The timeline included in your papers demonstrates the efforts that have been made to recruit over the past two years and the difficulties experienced. It also shows that as part of the local partnership response to the pandemic, we agreed to re-purpose some of the nursing beds at Charlton House as Discharge to Assess (DtoA) beds.


However, the DtoA beds placed additional pressure on the service at Charlton House as it was managing more turnover and more complexity of needs. With hindsight, this was not a good move because the service lacked resilience but it was made in good faith to try to support our partners in the local health and social care system at a time of crisis.


Our response to the CQC report has included the temporary closure of one of the floors at Charlton House (which included the DtoA beds) and to close it to admissions. This has enabled us to reduce our reliance on agency staff and we are focusing on stabilising and developing the permanent staff team, strengthening our systems and delivering the best possible care to residents.


We are very grateful to the staff who have remained in the service and those who are joining it who are delivering the improvements in the action plan.


Councillor Liz Hardman said that it is hard to understand why Charlton House has deteriorated quite quickly in its care of residents. She asked could it be because it was turned from a residential home to a nursing home, without proper staffing in place - Is this correct?


The Director of Adult Social Care replied that the home was a nursing home at the point of transfer to the Council.


Councillor Hardman commented that she felt that one of the tipping points seemed to be from March 2021 to September 2021 when Health and Social Care systems requested additional support to manage hospital pressure. She added that the local community ward in Charlton House closes as Discharge to Assess happens and because of this the service user needs became more complex but under the wider system they were unable to respond to service user needs. She asked why was this not picked up the inability to deal with the D2A.


The Director of Adult Social Care replied that the system recognised that therapy and social work input was needed to manage a robust D2A service, however ongoing workforce challenges for these roles and the lack of long-term beds in the market to move people to made the delivery of this aspect of the service difficult.


Councillor Hardman said that another tipping point appeared to be from September 2021 to December 2021 when there were significant changes of senior management and an inability to recruit a new registered manager and residential nurses. She added that this resulted in a head of service leaving post and lead nurse/nursing posts being filled by agency staff.


She asked why was this not picked up as it led to workforce shortages and consequent problems.


The Director of Adult Social Care replied that additional HR and recruitment resources have been made available by the Council to address these issues which have occurred over many years. She added that despite this, the Council along with many other providers and other local authorities are experiencing significant difficulties in recruiting and retaining a skilled and experienced workforce. She said that Skills for Care figures show that there are over 5,000 care staff vacancies in England alone.


Councillor Hardman referred to the inspection from the CQC in July 2022 that gave a rating of requires improvement. She said that there appears to be no oversight of an improvement plan by BANES and then in October 2022 the deputy manager raised significant safeguarding concerns.


The Director of Adult Social Care replied that there was a CQC action plan to address the RI rating, however the speed of improvement was not sufficient to address the issues raised in the timescale required. She said that it became apparent that a review of the leadership roles was required in order for the quality of care and the improvements needed to be delivered. She stated that a new registered manager is now in post they have met with CQC and are leading delivery of the improvements needed. She added that oversight is provided by the Head of Service with assurance provided by the Improvement Board.


Councillor Hardman said that when CQC investigated at Charlton House later in 2022 it was found to be inadequate. She asks why this was allowed to happen so quickly between June and October 2022. She said she believes the action plan is robust, but asked why did Charlton House have to get to it being deemed inadequate before a robust action plan was put in place and who bears overall responsibility for this.


The Director of Adult Social Care replied that the Council has a dedicated team working to the DASS (Director of Adult Social Services) for the delivery of Adult Social Care, with a new Assistant Director of Operations who came into post in July. She said that many of the concerns had been identified and actions were put in place, however as stated previously the pace of change was not rapid enough from the RI action plan to the point of the October inspection.


Councillor Hardman commented that in the report it says that Combe Lea requires improvement. She asked if this is at the same stage as Charlton House was in July 2022. She added that an action plan has been set up, but can we be assured that this is robust enough to address the issues raised by the CQC.


The Director of Adult Social Care replied that Coombe Lea is rated good in 2 areas (Caring and Responsive) and RI in 3 areas, this is not at the same stage as Charlton House and the areas that require improvement are being addressed across all of our services. She added that Combe Lea has a dedicated action plan which is overseen by the Improvement Board.


Councillor Hardman asked were senior managers aware of the seriousness of the situation at Charlton House prior to the summer of 2022.


The Director of Adult Social Care replied that she had visited the site regularly because of the concerns that had been raised and that the Assistant Director – Operations had visited the site. She said that she did not feel there was one particular moment and that it had been a build up from seeing the audits and the record keeping whilst also receiving feedback. She added that she felt that it finally came to a head when the Deputy Manager conveyed his concerns.


She added that when the Requires Improvement report was received from CQC that’s when the extent was realised and the improvement plan was drawn up and put in place.


Councillor Alison Born commented that she had received regular updates from the Director of Adult Social Care that there were potential issues to be concerned about but not the extent of the problems prior to receiving the audit reports.


Councillor Michelle O’Doherty commented that one of the solutions to ease pressure at Charlton House was to remove the Discharge to Assess beds that had been put in place. She asked if there were enough staff in place to enable the Discharge to Assess model to work locally.


The Director of Adult Social Care replied that 23 beds were opened in Ward 4 (St Martin’s) by HCRG for step down. She added that what they were looking to develop for B&NES was a more community based service with domiciliary care rather than a bed based service. She said that they were already drawing up plans to prepare for next Winter.


Councillor Michelle O’Doherty asked if the Panel could be updated on the view that the CQC currently have of Charlton House following the action plans that have been put in place.


The Assistant Director of Operations replied that the CQC had visited Charlton House last week and had agreed that good progress had been made. She said that it was likely that unless notified they would return for a further inspection within the next 4 – 6 months.


Councillor Joanna Wright asked what would be done differently now, in comparison, if concerns were raised at another home.


The Director of Adult Social Care replied that she would make sure that a robust clinical leadership team and senior management were in place and seek to maintain permanent staffing levels as much as possible.


Councillor Paul May commented that he could see the impact that this has had on officers and acknowledged the work that had been done regarding the action plans. He questioned whether the managers of the previous contract were subsidising the sites.


He added that he welcomed the openness of the report and the discussion that had been held today and that it shows how difficult the role is for the staff involved.


He asked how many Local Authorities actually directly run their own care homes.


The Director of Adult Social Care replied that it was very few and that B&NES, for its size, has quite a number. She added that to have a varied market was important as it drives up quality and competition and that over the coming years over models may need to be looked at.


Councillor Hardman referred to the Adult Social Care Outcomes Framework (Appendix 3) within the report and the fact that the measurements for benchmarking performance show BANES is in the worst quartile for five of these measurements out of 14 LAs. She said that particularly worrying was the low percentage for overall satisfaction of people who use services with their care and support and overall satisfaction of carers with social services.


The Director of Adult Social Care replied that we are working with our prime delivery partner HCRG to understand these measures and to focus on the improvements needed to increase our resident’s satisfaction. She added that one element of this will be the new Carer’s strategy and new practice model of ensuring that services are meeting the outcomes determined by people who use services.


Councillor Hardman commented that given that the numbers of our ageing population have now risen with an increase in more complex needs, we are still experiencing major staffing issues, coupled with the collapse of the NHS. She asked what submissions have been made to the budget process with these results in mind to ensure adequate funding for these services.


The Director of Adult Social Care replied that they had secured growth of £5.213m in 2023/24 and that £1.904m of this growth was being funded from direct government grants (Market Sustainability and Improvement fund and ASC Discharge fund). She added that there was a need to secure full time staff within the CRCs and reduce the number of agency staff to enable effective use of the budget.


Councillor Wright asked what the Panel can do to support the work that has been highlighted, particularly with regard to domiciliary care.


The Director of Adult Social Care replied that focussing on some of the Public Health work regarding the inequalities that older people can face would be good. She added that this includes the use of Primary Care Networks, their work in the community and domiciliary care.


The Chair asked if following the CQC inspection in July 2022 did they give 28 days to undertake any remedial action before returning to Charlton House.


The Assistant Director of Operations replied that the 28 days to respond only comes into effect when a warning notice has been issued. She said that more recently the Council had until 6th January 2023 to respond to its breaches allegations and then the CQC returned on 9th January 2023.


The Director of Adult Social Care added that following the inspection in July 2022 the Council formally notified CQC of their own safeguarding concerns and that is when they returned in October 2022.


The Chair asked if the initial response to the inspection was deemed not good enough.


The Director of Adult Social Care replied that the focus at first was on clinical practices and that it was at a later point that the safeguarding issues were then identified. She said that they were in essence two separate processes.


The Chair asked if the CQC were happy with the improvements that had been / were being made following the second visit.


The Director of Adult Social Care said that they visited prior to Christmas 2022 and then again on 6th January 2023 and were happy with the progress so far, but have said that they could return within 4 – 6 months to carry out a full inspection. She added that the action plan was now in place and that they were seeing its delivery.


The Assistant Director of Operations added that to demonstrate continuous improvement they have to supply an action plan every two weeks to the CQC. She added that as long improvements remain ongoing they would likely return to being under the normal inspection process.


The Chair suggested that the Cabinet Member for Adult Services should arrange for a press release to be made that details the steps that have occurred regarding the inspections so that the public are fully aware of the situation and that the issues raised have been addressed.


Councillor Gerry Curran asked whether the occupancy rate at Charlton House could yet be increased following the recent CQC visits.


The Director of Adult Social Care replied that the decision to reduce the number of beds in use was taken by the Council and that the CQC were not involved. She added that there were no current plans to increase the occupancy levels and that when do make that decision there will be a specific criteria to be met to allow that to happen – a resilient workforce and well trained staff.


The Chair commented that the pay for staff working in care homes and similar places needs to be much more adequate.


The Panel RESOLVED to note the update and thanked all the officers concerned and Councillor Born for their attendance and input into the discussion.

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