Agenda item

Adult Social Care – Commissioning Update


To receive a report on the progress associated with Adult Social Care - Commissioning.




The Chair welcomed the Cabinet Member, Councillor Roche along with Scott Matthewman, Assistant Director Strategic Commissioning, Jacqueline Clark MBA, Head of Prevention and Early Intervention, Strategic Commissioning, and Garry Parvin, Joint Head of Learning Disability, Autism and Transition Commissioning to the meeting.


Councillor Roche introduced the report explaining that the item had been brought forward at the request of the Health Select Commission to provide on update on progress made relating to Adult Social Care contract arrangements, including the introduction of flexible purchasing arrangements, the level, quality and compliance in the care and support market and market shaping undertaken by Adults. A range of services were commissioned, including giving consideration of sustainability for the future for the care market. National and local guidelines were followed when the services were tendered for. It was a very robust process with strict criteria to ensure the best use of public funds. Once a contract was in place, rigorous monitoring was conducted. He clarified that he received monthly reports on how each of the services were performing, detailing any information that he needed to be aware of in the future.


Scott Matthewman, Assistant Director Strategic Commissioning welcomed the opportunity to speak about the progress in terms of Adult Social Care and it is commissioning activities. The presentation would focus on the flexible purchasing system, which was the means of which the Council used for driving up and sustaining quality within the care sector and how the Council could then support the care market to ensure the right care and support was available for Rotherham residents, in terms of their needs now and in the future.  It also provided assurance that the Council through its public funding was receiving the best quality care it could within the financial envelope along with being clear about the requirements the Council set and collaborated with its providers against.


The presentation would cover some elements regarding performance, along with the quality and compliance side of the commissioning cycle and then consider the Care Act responsibilities that the Council had as a local authority to ensure it was looking to shape the market about what the needs were for the residents, making sure there was appropriate care and support along with the sustainability of the market after the challenging times of the last few years with Covid.


He set out some of the key pieces of work conducted over the past few years, in terms of driving up those quality standards within the care market. He clarified that the Council worked closely with the support providers, ensuring it was person centred, that it was focused on the needs of the individual and was about the assets and strength-based approach that was right across health and social care.


In terms of shaping the market moving forward, the Council had implemented a number of dynamic purchasing systems, which were about bringing quality standards, working with the care and support providers to ensure they met the thresholds, the expectations were clearly articulated in terms of the needs for residents, ensuring the appropriate care and support could be commissioned.


A tremendous amount of work had been undertaken around Home Care Support Services, the Domiciliary Care market since 2019. This had been conducted working closely across the joint framework with NHS colleagues. More recently those principles had been taken forward around the Mental Health Recovery Focussed Community services along with the Learning Disability and Autism Supported Living framework.


He explained that dynamic purchasing systems were a means/mechanism. It was a vehicle that the Council would consistently adopt and was seen as good practice and it was focused around the individual needs of residents, in terms of care and support but also to drive up those standards to working with the independent sector and working with in-house provision and ensuring the Council was getting the best quality standards of care that could be achieved.


The mechanism that was in place around those dynamic purchasing systems meant that the Council could look at a number of care and support providers that would come forward, going through relevant process, in terms of procurement, who would then be endorsed to be part of the flexible dynamic purchasing systems. The Council could then look to commission against an approved supplier list whilst being clear about the quality standards and working proactively with the market.


Part of the process involved stringent due diligence, ensuring key thresholds were met in terms of the quality, the cost, and the competitive nature of how the market would operate. It gave the Council the ability to then flex in terms of how it worked with the market. Enabling the ability to draw on specific pieces of work in terms of short to medium term needs of the residents, or a longer commitment and the dynamic purchasing system gave the Council the ability to do that whilst allowing that flexibility within a very clear assurance and governance framework.  It also managed the quality aspect. One of the key things found from the Councils proactive engagement with the independent sector was that they were working together to drive up the quality standards to ensure residents received the highest quality of care that could be provided.


Jacqueline Clark, Head of Prevention and Early Intervention, Strategic Commissioning who explained that the Home Care and Support Service as the first dynamic purchasing system that was introduced and was approved by Cabinet in February 2019. It was a joint approach with health colleagues. Around 2,000 hours of care and support a week were purchased from Rotherham Place and around 16,000 hours a week were commissioned from Rotherham Council at that point. It was sensible to collaborate with a new framework and helped with consistency in terms of people not having to change providers ensuring continuity of care.


When the Council went to tender, it had twelve registered Domiciliary Care providers, who were already contracted with the Council. Under the new arrangements this increased to thirteen providers. The service was commenced in April 2020, which was a difficult period due to the pandemic. The Council had 9 Tier 1 providers, which meant they had a prioritised geographic area in which to deliver care and support. Those areas were divided up as North, South and Central with three providers in each area. There was 1 Tier 2 provider who accommodated where Tier 1 providers were unable to find the capacity due to demand issues. There were also three specialist providers for people who required personal care but had other specific needs such as learning disability along with an unpaid carers service on the framework as well.


The update from 2020 was that all nine appointed Tier 1 providers had sustained in service. Tier 2 providers had increased from 1 to 8, which supported the Council throughout the challenging period during Covid. The dynamic purchasing system was an easier route to the market to secure provision. There were now two learning disability providers available, one unpaid carers provider and it had been extended to include people who lived with mental ill health. In terms of activity, the Council was commissioning around 18,703 hours a week. There had been about a 16% difference from when the framework was first established. In terms of capacity and demand, the Council was challenged during Covid, which was a national issue and not just specific to Rotherham. There was a peak in December 2021 where the council was really challenged and in June 2021 it became apparent there was difficulties. Those difficulties were resolved in April 2023 and now the Council did not experience too much difficulty in finding capacity within the framework. There had been a massive improvement in terms of quality since 2018 with 90% of the contracted providers being either good or outstanding and there was one provider who required improvement.


The Council had set some challenging key performance indicators (KPI). The presentation provided information on the KPI’s as recorded in September 2023. The first KPI was regarding utilising assistive technology, had a target of 75%. It was noted that 72% of customers who were reviewed in the period were introduced to assistive technology or were provided with options. The second KPI around strength-based approaches training. The majority of the workforce received training with the Council training 654 care workers, meaning that 81% of the Council’s care workers had undertaken strength-based training.


With regard to KPI 3 both Level 2 qualifications and Level 5 Manager qualifications were monitored. It was noted that 54% of care workers had achieved Level 2 however the challenge was the churn in the workforce, would expect it to be higher and it was the Council’s ambition to achieve a higher percentage. There had also been challenges during Covid regarding providing direct care rather than taking time to train. In terms of the Level 5 qualification, all registered managers either held or were working towards the qualification.


In terms of KPI4 the Care Certificate. A stretch target of 100% had been set. The Care Certificate set out minimum standards for care and there was high achievement in that area.


Giving consideration to other monitoring conducted, the assistive technology or digital solutions, the Council considered what the workforce achieved in terms of their digital competency, such as using electronic care plans, digital medication administration records, and electronic rostering and call monitoring. The Council did engage directly with people who had the service, the care brokers contracted people directly at home, asking questions and there was a high report of people feeling like they were listened too and had that self-determination.


Moving on to the mental health recovery focussed community services, it was agreed by Cabinet in October 2022 a dynamic purchasing system which enabled a range of services that supported people with mental health recovery. A supported living model, Lot 1, had now been created within the existing budget. This meant that instead of people living in residential care, they now had the option of living in supported living. The tender for this concluded in May 2023 and there were now three care and support providers appointed and eight units of supported living accommodation were in place, with a further four units in development. In terms of the concept of supportive living there were three distinct elements which were tenancy, where people received support to manage the tenancy, registered housing provider, these were not for profit organisations, and care and support provider, this was provision that was under contract with the Council.


Garry Parvin, Joint Head of Learning Disability, Autism and Transition Commissioning explained how the supported living dynamic purchasing system was developed. This was based on co-production with the market but also with people with a learning disability. The assessment involved considering the market as a whole. It was found that there was a number of national providers that dominated in that market. The Council was keen to develop the micro-enterprise presence of independent providers further. The engagement highlighted that there was no supported living provision for people living with autism. Ten new providers were appointed following the conclusion of the tender process in November 2023. He explained that services were being implemented but it was not appropriate to review these at the current time.


Jacqueline Clark, Head of Prevention and Early Intervention, Strategic Commissioning explained that market quality was assessed through a risk-based process using both quantitative and qualitative intelligence to indicate the level of performance and risk. A digital system was procured, called Provider Assessment and Market Management Solution (PAMMS), to make it more efficient. This meant that all 110 service providers received an annual review. Providers undertake a self-assessment against key domains which was then validated by a contract compliance officer and where needed remedial action was taken. Alongside the PAMMS system there was an early warning system using a range of data and intelligence which was added to a provider risk dashboard which rated the service. This provided a visible indication of the level of risk which was used to address issues as quickly as possible.


Scott Matthewman, Assistant Director Strategic Commissioning clarified that the Council was fully committed to its responsibilities of the Care Act 2014 regarding ensuring there was sufficient supply of care and support at the right quality levels within Rotherham.


The Chair thanked them for the comprehensive presentation and report.


Councillor Cooksey explained that she was able understand the report more following the presentation however she would prefer to see more information provided in layman’s terms going forward.  The update mentioned specialist care providers increasing and queried what that meant in terms of unpaid carers? Jacqueline Clark explained there was a provider on the framework who was a charity who provided support to people who provided unpaid care. They were contracted with the Council to provide domiciliary care but the people who received that type of care also received the support services on offer as well. It helped the Council to direct people who had an unpaid carer to access that service. Councillor Cooksey requested figures on the number of clients that were engaged with the service because she felt the voices of patients and carers were really important. Jacqueline Clark explained that fifty-five people had chosen to participate however the Council would probably engage with more.


Councillor Griffin queried if there was any in-house provision of home care, in particular, and if not, why not and whether consideration could be given to establishing some that could operate alongside or as an internally commissioned service? Jacqueline Clark explained that domiciliary care was provided in Rotherham, but it was a dedicated reablement service that supported people up to a six-week said period to help them gain independence. Councillor Roche indicated that discussions did take place regarding bringing services in-house however the costs associated with this were not feasible at this time. He was assured that the service was being provided well and explained that the Council did seek to ensure all providers were paying a real living wage to staff and this was one of the elements included when the Council went to tender.


Councillor Griffin queried if the Council provided an assessment and a prescription for those fifty-five people of what is required for each individual. He queried if there was a review process for those individuals. Jacqueline Clark explained that people would have to be eligible for a review under the Care Act and the social workers conducted that assessment, they would then be referred through to a brokerage service and a provider was sought who would go on to do their own assessment, reviewing that provision. The Council had a contract concerns process, so anyone could report that they were not happy with a service, and this would be captured by the early warning system, which would then follow the appropriate process.


Councillor Griffin said it felt like it was a deficit model that was measured when things went wrong, which lead to intervention. He would have expected to see performance indicators that said in 92% of the care packages the Council purchased, the review showed the Council was achieving what it wanted however that was not there. He said that felt like the most person-centred way of measuring things. Scott Matthewman explained that it was not a process that happened as a default or deficit model, there were, if the Council arrived at that permutation, there were tools that could be used as commissioners to remedy that position, but it was very seldom the Council was in that position due to the proactive work.  He said that assessment of need, that being clear about ensuring what the individual actually required, building on their strengths and assets, that the Council worked with the market, to understand how it could commission that care and support and as part of that continual cycle of engagement with residents, it was taking the live information about what it looked and felt like for them and actually was it meeting their needs.  As part of that formal review process, the Council would make those assessments, and would adjust care and support planning on the back of that work and would make incremental change to ensure that happened but it was very much about strength-based approach. Therefore, to give that assurance, further detail around some of that could be provided if helpful at a future meeting.


Councillor Hoddinott wondered about in-house provision noting that social care was spoken about as a market, and she felt uncomfortable about that. She wondered how the work conducted in social fitted with the Council’s corporate policies around the Ethical Care Charter, the real living wage and the Social Value Policy as she didn’t see those mentioned.  She was keen to understand how the Council was raising the standards using our policies as a Council.


Councillor Roche explained he had been clear that the Council did include the need to pay a real living wage within the tenders however since those tenders had gone out the cost of the real living wage had gone up, so the Council may have to go back to some of the providers to seek where there were on this provision however the wage they paid was entirely up to the individual providers.  Social Value was a criterion of the tender process and following the recent Cabinet meeting an additional criterion would be added to request that workers come from the local community area. Jacqueline Clark indicated that most of the providers paid above £11.12 per hour with most paying well in excess of that now. All contract awarded had to have the social value commitment since the policy was introduced. In terms of the Ethical Care Charter, Jacqueline Clark explained that in terms of paying for travel the providers were committed to that, and the real living ways, and contribute to pensions.


Councillor Hoddinott was keen to understand how many staff actually held the Level 5 Management training and how many were studying towards the qualification? She queried if we described the support provided in supportive living and could this be described as support if it were the provision of just a phone number, for example? Learning disability providers were dominated by national providers, it was known that other Council’s also experienced pressures in this area, because they were raising the unit costs, and was this being reflected locally?


Jacqueline Clark explained in terms of the model for supported living, the providers were registered with the Care Quality Commission (CQC), so it was not just a telephone number. People who lived in supported living had a care plan, which was monitored. Background support was also available, if needed as it was a 24-hour service. Garry Parvin explained the Council did evaluate the fair cost of care. In terms of learning disability supported living provision offered a range. Scott Matthewman explained about how the Council supported the market. Its approach was around having a vibrant market, meaning having some national, some regional and some local providers within the framework to ensure a sufficient make up providing choice for residents. That was essential in terms of the Council’s annual fair cost of care exercise and was central in terms of how the market was stimulated.


Councillor Miro queried how the Council responded to the issue of people having to wait a long time in hospital for care to be organised within the community first and if there was a way of monitoring or responding to the changing needs. Scott Matthewman explained there was a number of professionals who came together to identify the needs of those people as they progress through their care journey. Discharges were planned for and needs predicted as early as possible to ensure that the care and support was available in the independent sector with the principal driver of, could those individuals go home safely in the first instance, and if so what care or support would they need. If not, then the step-down provision is activated to bring them effectively into that reablement, rehabilitation model to support them to return home. A lot of work is conducted across health and social care to understand how people enter and work their way through hospital and then their care and support needs when it was appropriate for their discharge pathway. Michael Wright, Deputy CEO, TRFT explained it was a challenging area, waiting for patients who were waiting for discharge or waiting for care packages. At any one time they could routinely have between 50-70 patients who were waiting for a care home. This was monitored and he worked closely with Scott and his team, meeting three times a week. Particular focus was given to patients who had been waiting for more than 72 hours in those meetings. He felt the current system worked well but was a challenge in every organisation.


Councillor Miro queried how the assistive technology helped the process of ensuring adequate care in the community? Jacqueline Clark explained there was a range of peripherals to support people, such as the community alarm service or Alexa or a pill dispenser. Councillor Roche indicated this was not provided by Scott’s team and if the Commission wished to know more about this area of provision that the appropriate service be invited to attend a future meeting.


Councillor Wilson queried if future modelling was based on robust relationships of feeder services for example? She queried where the data came from for the early warning system and sought assurance that it wasn’t all from self-assessments? Garry Parvin explained that with Children and Young People Services, a mapping exercise was conducted with the preparing for adulthood cohort, which was people moving through, to ensure the Council was as sighted as it could be, given that needs could change, and people could move to other areas. That mapping had indicated the need to have that provision in place to ensure that sufficiency in provision was available. Councillor Roche added that the Council knew there was an increasing pressure coming through and Rotherham was becoming an aging population, which would create further pressure on services. The Council was unable to plan for someone moving into the area within existing care package. Scott Matthewman explained that the Council drew information right across the commissioning cycle. The fundamental basis around the needs assessment was driven through the Joint Strategic Needs Assessment, so they collaborated closely with the Director of Public Health and his service to ensure all the intelligence was brought together along with trying to predict needs over the next 5-10 years, considering how those needs may change and what services may be needed. Jacqueline Clark that data for the early warning system came from a range of sources.


Councillor Foster noted the level of completion for the Level 2 training was around 50% and queried if analysis was being conducted around why there was a high staff turnover. Had staff surveys been conducted and the recruitment policy considered?  Councillor Roche noted that one of the reasons for the high turnover was that people could get paid more working in other employment sectors, such as supermarkets. Jacqueline Clark said it was a very competitive job market, noting that people were using their own vehicles and those working outside in all weathers tended to gravitate to care homes in the weekend and then move back to supporting home care in the better weather.  Work was being undertaken to promote this sector along with enhancing the care worker role to make it a more attractive proposition, however it was a national issue. Councillor Foster asked if consideration had been given to different working patterns or other incentives that were not financial but were beneficial to meet the needs of working or younger parents? Jacqueline Clark said that home care was very flexible, and a number of surveys had been conducted which confirmed staff liked the flexibility. Scott Matthewman explained the Council had a number of provider forums as a way to engage with the market to understand how things looked and felt for them to identify where the pinch points and issues were and how individually and collectively those could be addressed. He was impressed at how the providers had come together, working together to standardise as much as possible to understand the issues coming from the workforce.


Councillor Cooksey expressed her concern upon realising that a lot of care workers were on zero-hour contracts and ask that addressing this be considered with the providers to give people more stability at work. Jacqueline Clark explained that providers had indicated that staff preferred zero-hour contracts because it allowed them more flexibility to choose when to work. She confirmed that the Council had asked both the providers and staff what their preference was regarding zero-hour contracts.


The Chair thanked officers for providing the information, it had helped to build a lot of knowledge and understanding of the commissioning process. A significant amount of work was undertaken addressing quality and standardising processes. There was a commitment within the Council to understand local need and responding to the changes in need.


Scott Matthewman said that quality was paramount in terms of care and support that the Council had for its residents including driving those standards up. The Council had a number of mechanisms within the commissioning cycle and contract management that make sure it happens.


Councillor Roche assured Members that, if any of the providers, particularly care homes had concerns raised then he received a briefing, which was followed up regularly.


The Chair welcomed the return of this item in a years’ time to provide an update on the position at that time.


Resolved: That the Health Select Commission:

1.    Noted the contents of the briefing note and presentation.

2.    Requested information on how many staff actually held the Level 5 Management training and how many were studying towards the qualification.

3.    Agreed that an update on Adult Social Care Commissioning be brought to the Commission in January 2025.

Supporting documents: