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Whole life market sustainability plan (LD/MH/A)

Introduction

Our focus in Wiltshire is to move away from residential care and ensure that we support people to live independently, with their own tenancy wherever possible. This means developing new supported accommodation and providing innovative and flexible care to enable people to live in the community.

Section 1: Assessment of the current sustainability of local care markets

a) Assessment of current sustainability of the adults of working age care market for people with a c Learning Disability, Autism or Mental Health

Levels of diversity in the market

Wiltshire has a reasonable diverse range of care provision within the residential and supported living care market for adults of working age who may present with mental health (MH) needs, learning disability (LD) (with or without dementia), autistic spectrum condition, physical or sensory needs, social, emotional and behavioural needs, speech, language and communication needs. This has in part been an outcome of the commissioning approach which for the last 3 years and has developed easy to access commissioned frameworks and alliances, and close working links with the Integrated Care Board (ICB), Health and social care commissioners have worked closely with care provider partners to develop new innovative models of delivery.

There is a lack of supply to meet increased demand for all care, especially for those with more complex needs and behavioral challenges. There remains more to do in terms of opportunities of models of care and increasing the market to enable people to live safely and independently in their own homes for as long as they can and enjoy the best possible quality of life. Our approach is based on people's strengths and focuses on what people can contribute. This includes supporting people to take risks, try new things, be ambitious and discover their potential.

Complexity of care

Wiltshire is experiencing marked increases in the volume of people presenting with more complex care needs requiring accommodation and a package of care. There is a gap within Wiltshire's care market of providers that are able to offer high quality care for those with complex needs for the following reasons:

  • providers struggle to recruit experienced staff who are skilled in the management of specialist autism and behaviours that challenge
  • there is a shortage of provision of specialist autism providers
  • a shortage of training in the management of complex behavior that challenges

Providers told the Council that the increasing complexity and changing needs of individuals is often impacting on occupancy rates, staff recruitment and retention, and service performance.

Wiltshire Council Whole Life Brokerage service has reported an increase in customers waiting for accommodation and packages of care due to a shortage in Market Capacity.

Inflation

High levels of inflation and the resulting cost of living crisis have added to challenges already being experienced by providers in Wiltshire following the pandemic. Fuel costs and the cost of agency staff are two of the main inflationary pressures.

This is having an impact on their financial viability. We have 3 providers exit the market due to no longer being financially viable and we have seen 10 providers who have either handed back or closed services across supported living, Residential and Day Opportunities. Where possible we have tried to retain the accommodation and recommission the care.

Care workforce

Recruitment and retention of care staff is an ongoing issue within Wiltshire for our providers. There are historic and well cited issues with rurality, cost of affordable housing and the proportion of available workforce in Wiltshire.

Providers have told us that staff recruitment is the most difficult it has been. Providers tell us that the pool of care staff is reducing and there is significant competition between providers to recruit from the same pool of staff, including Wiltshire Council support staff. There has been increased movement within the care sector workforce due to providers offering incentives to attract new recruits. There is also competition from retail companies as well as the health sector, with some care workers exiting the social care workforce entirely for better terms and conditions and work/life balance. LD/MH providers handed back 42 packages in 2023, in 32% of the hand backs providers stated the reason was due to staffing difficulties and insufficient staffing levels. One Provider handed back 6 packages due to financial difficulties, other reasons included breakdown in relationships with customers and families and behaviours that challenge.

Geographical challenges

There are currently imbalances of supply of care provision within Wiltshire:

  • Residential Care homes - Currently residential placements across the county are available, however we do experience a gap in the market for providers able to offer beds for complex behaviours.
  • Nursing Care homes - There are limited provisions of nursing for adults of working age with a learning and physical disability. There are two nursing homes in Wiltshire, one in the north and the other in the east of the county, providing nursing for individuals with these needs. If there is limited capacity to support people, we have started to consider people's presenting need and are therefore looking more towards the older adult market within county.
  • Supported Living - The Council has experienced difficulties when trying to source supported living for people in the county. This is due to:
    • availability of accommodation
    • capacity of providers due to staffing.
    • complexity of packages

Hospital discharge and admission avoidance

We are implementing a recovery pathway which enables people with mental health needs to get the right support in the right place at the right time.

We are working with Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board (BSW ICB) commissioners to develop short-term accommodation and/or support which effectively responds to crises, avoids the need for admission, supports people in an enabling way and supports them towards recovery.

b) Assessment of current sustainability of Mental Health Provision

In December 2023, there were 127 adults in residential care 28% of those adults were out of county. Around 77% had lived in their current accommodation for more than two years.

There were 150 adults receiving supported living, 82% are in Wiltshire. Around 57% had lived in their current accommodation for more than two years.

There are 9 residential care homes in Wiltshire (with two more in Swindon and one in Bath) provided by organisations on the Good Lives Alliance which specialise in providing care and support for adults with mental health conditions Two providers with 4 supported living services are currently on the framework.

Almost half of our residential provision is in Salisbury, and we have a relative lack of provision in the north of the county. We also lack provision for more specialist needs - e.g. people with substance misuse issues, people with forensic histories, hoarders, etc. We are currently commissioning a high number of providers for a relatively small number of customers. This is down to the specific need for accommodation and availability of services at a particular time.

The Council reviewed the tools available for costing residential care and selected CareCubed as an evidence-based tool to deliver fair and sustainable costs of care. A secure online tool, CareCubed supports sharing of cases across multiple users within the Council. It is updated annually to cover market and legislative changes, using authoritative data sources including the National Minimum Data Set for Social Care (NMDS-SC). Thus far, we have only applied the tool to placements for adults with learning disabilities; however, we are exploring rolling it out to Mental Health, Ongoing Support and Children & Young People with Disabilities teams.

c) Assessment of current sustainability of Learning Disabilities Provision

In December 2023, there were 294 adults in residential care, 101 (34%) of those adults are out of county Around 77% had lived in their current accommodation for more than two years.

There were 519 adults receiving supported living, 35 (7%) of those were out of county. Around 41% had lived in their current accommodation for more than two years. There are 31 Supported Living Providers in Wiltshire on the Good Lives Alliance. The 2018 Glenesk report noted that in the previous four years, the costs of residential and nursing care for adults with LD have increased by 20% - this is partly because prices have increased, and partly because of increases in need. In the same period, there had been a 15% increase in the number of people with LD living in supported living. 10 residential care homes have deregistered with a further 4 considering deregistration to become supported living, but commissioners and providers must ensure that this leads to a culture that promotes independence, as well as simply a change in registration status.

d) Assessment of current sustainability of Autism Spectrum Condition Provision

 In December 2023, we have 722 people recorded as having an autism spectrum condition, 573 are supported in county, 149 are out of county.
 92 are in residential care in county, 41 are out of county. 
 168 people are in receipt of supported living, with 6 placed out of county. 
 19 people are supported by our Living Well team, therefore do not have a secondary diagnosis of MH/LD.

Fee rates - Sufficiency of supply to ensure continuity of care

With the fragility of the market currently, providers are handing back packages for customers that they consider too complex or have behaviours that challenge. Complexity of packages and the changes to the discharge model mean that customers who would previously have been cared for in a residential setting are now supported at home. This has the dual effect of requiring highly skilled care workers (e.g., for moving and handling) but also of utilising large quantities of care per package.

Section 2: Assessment of the impact of future market changes between now and October 2025, for each of the service markets

Supported Living, Self-Directed Support and Care Home provision

In 2018, Wiltshire Council commissioned Glenesk to undertake a needs analysis around accommodation-based care and support, to inform our commission intentions. The needs analysis found that:

  • Over 70% of providers who responded to a survey said they did not feel confident in supporting people with complex learning disabilities; and nearly two thirds of providers reported that they have limited or no ability to support customers with autism spectrum conditions.
  • There is likely to be an overall 25% increase in commissioning spend over the following five years if Wiltshire's care market does not change significantly. 72% of this increased spend will be on supported living and residential care for adults with learning disabilities and older adults.
  • Wiltshire makes relatively high levels of out-of-County placements, which are often more expensive and lead to poorer outcomes than in-County. We need to both reduce the number of new out-of-County placements, and support people returning to Wiltshire where appropriate
  • An audit of placements found that for adults with learning disabilities, there is potential for 74% of future demand to shift from residential to other settings.
  • For adults with mental health needs, we are seeing increasing complexity, but people's experiences of having their needs met and aspirations supported are sometimes poor. We need additional supported living in the north of Wiltshire.
  • Wiltshire makes insufficient use of Shared Lives provision.

The above data analysis has informed the Independent Living Strategy and action plans, Market Position Statement, program of work for accommodation and the work under Transformation of Adult Social Care to review processes to improve the outcome of the areas above.

Key strategic risks

The following key strategic risks have been cited by Wiltshire's providers, ICB colleagues and Council Brokerage, Operational and Commissioning teams.

Workforce

  • Providers are competing for the same workforce.
  • There are increasing numbers of care staff choosing to leave the sector.
  • Significant staff shortages are the biggest threat to sufficiency. This will further impact not only on customer / staff experience but also on service provider performance. The following range of factors has been shared by providers that can drive social care staff to leave, including:
    • pay and terms and conditions
    • career progression
    • training opportunities
    • work-life balance
    • motivation and morale
    • flexibility at work
    • organisational culture
    • leadership

Inflation

Annual contractual uplifts will be applied in April 2024 for framework providers only. Uplift mechanisms take into account current inflationary pressures and market factors. We believe this will work towards maintaining the sustainability of the market. Inflation fell by the end of 2023 therefore we don't see this as a significant strategic risk going forward.

Insurance

Care providers have told us that a lack of choice in care sector insurance is causing instability. Insurers are requiring more assurance and demanding a higher premium which could result in providers exiting the market.

New CQC assessment process

Providers are concerned that the new CQC single assessment process implemented in 2023 may be time consuming and an additional burden. There is a risk that the rating landscape is changing.

Payment to providers

Our current payment processes are a disincentive to current and prospective providers when offering capacity to the council. The Council is working on moving from Net to Gross payments.

Further actions Wiltshire Council plans to take to support market sustainability

During the recommissioning of the Good Lives Alliance 2023, we held a number of joint workshops with providers who delivered or wanted to deliver services to Wiltshire residents, operational staff, Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board (BSW ICB), Wiltshire Centre for Independent Living and Wiltshire Parent Carer Council who represent the customer and family voice, came together to look at best practice, value for money and to continue with a consistent method to pricing to support a more sustainable provider market. Wiltshire Council will continue to prioritise the purchase all new business through the GLA 2023 framework.

Fee Setting - CareCubed - GLA Framework

We will continue to engage with the market through our work on Market Sustainability to better understand what the Fair Cost of Care should be on the basis of what is a suitable rate for providers to cover the cost of delivery and make a reasonable return on operations and what is affordable for the local authority, recognising our responsibility to steward public money and it will be influenced by the amount of funding made available by government and its conditions.

We want to work towards a fair cost of care that is built on sound judgement, evidence and negotiation and critically one that is affordable through the funding provided by Government to implement and manage the Adult Social Care reforms, which have now been delayed until October 2025.

Through the framework, supported living rates have been fixed for both tier 1 and 2 providers. We have tried to introduce bed rates for residential services based on the types of support being delivered and the size of the care home.

For those services purchased on a spot contract, CareCubed, a nationally accepted tool for benchmarking care costs against assessed needs, is used to support negotiation of costs.

The Council is working on moving from Net to Gross payments to providers.

Recruitment and retention

The Council, in conjunction with other Southwest ADASS authorities will relaunch its Proud to Care initiative. Working with Health Education England and our providers, we will focus on making social care careers more attractive, rewarding and sustainable.

  • We will work with the ICB to develop training opportunities for care sector workers across BANES, Swindon & Wiltshire Councils
  • We will promote the BSW Academy, an inclusive initiative that will help to unite and develop the BSW Partnership's entire 34,000 strong workforce by investing in leadership, learning, innovation, improvement, and inclusion across the ICS.
  • We will continue to promote and support the Joint Wiltshire Care Partnership and BSW Care Workforce recruitment and retention scheme.
  • We will continue to promote the Bath and North East Somerset, Swindon & Wiltshire Care Skills Partnership (BSWCSP) to
    • Support Independent, Voluntary and Private sector (IVP) adult care employers and Registered Managers (RMs) to access learning and development for RMs and their staff.
    • Provide advice and support on adult training courses with regard to grants and funding which may be available to staff.
    • Provide advice and support to anyone who would like a career in adult social care regarding traineeships and apprenticeships

Working together with Providers

  • We will continue effective, regular and transparent dialogue with our providers, especially in challenging times.
  • We will work with providers to develop value-based commissioning models and continue to embed the Quality Assurance Framework (QAF) in partnership with them to allow regional quality assurance.
  • We will move from paying net to gross and implement a new provider payment portal to ensure timely and accurate payments.
  • We will continue to deliver our Trusted Assessor Model which is managed by Wiltshire Care Partnership and look at its possible expansion with support from providers.
  • We will continue to develop our information services and integrated brokerage service to include a service for self-funded customers to support section 18(3) of the Care Act 2014

Strategic plans

Accommodation Strategy

We have developed an Accommodation Strategy which outlines Wiltshire Council's adults' of working age who may present with mental health needs, learning disability (with or without dementia), autistic spectrum condition, physical or sensory needs, social, emotional, and behavioral needs, speech, language and communication needs. It details our future accommodation aspirations, our future approach, demand and gaps in the market. The strategy was co-produced by the people we support with the assistance of our service user engagement provider.

Carers Strategy

We have developed a draft strategy which addresses the needs all age carers.

Dementia Strategy

We have developed a joint dementia strategy, which will outline how we will ensure we will have high-quality and equitable services to support people with dementia and carers of all ages through their dementia journey.

Technology Enabled Care Strategy

We have developed this strategy with carers, housing and operational teams, with a strong emphasis on prevention and early intervention. 

Autism Strategy

We have developed an all-age autism strategy guided by a vision of an inclusive, vibrant, well-connected Wiltshire, in which children and young people with autism and autistic adults fulfil their potential, be actively involved and included in their communities, make informed decisions, have control over their lives, and be valued and included within society.

LD Strategy

We are developing a draft strategy which aims to set the commissioning intentions of the Whole Life Commissioning Team regarding Wiltshire residents with learning disabilities (LD)

BSW MH Strategy

We are inputting into the BSW led MH strategy. 

WL Statement (MPS)

We have refreshed the Whole Life Market Position Statement since the 2021 Census data has been released and the Council has published its Business Plan and a suite of new strategies setting out Wiltshire's direction of travel. It will be reviewed and updated regularly as our knowledge and understanding grows and our shared thinking around commissioning intentions develops.

GLA Framework

We recommissioned our Good Lives Alliance in September 2023, using an outcome-focused approach to focus on people's strengths, assets and potential, to have a positive and meaningful impact on people's lives, increase choice and control and develop people's life skills. It includes the role of friends, families, broader community, and technology enabled care in promoting independence and resilience to supplement or replace the support provided and funded by Wiltshire Council.

The Alliance encompasses support services for adults of working age who may present with mental health needs, learning disability (with or without dementia), autistic spectrum condition, physical or sensory needs, social, emotional, and behavioural needs, speech, language and communication needs. 

The Alliance gives stability in the marketplace, and to co-produce a long-term vision and delivery model to support people to live as independently as possible in their own homes and communities. We work with residents in Wiltshire, as well as with providers and professionals, to co-design care and support which meets people's needs in an empowering and dignified way. We expect any provider that successfully joins the GLA Framework will embrace the ethos of co-production and participate fully in listening to and learning from the diverse voices of people in Wiltshire. 

Living My Life Framework

This commenced in August 2022 for a term of 4 years. The key objectives are customers are able to make an informed choice about the opportunities they wish to take up. There is increased focus on enablement, with day opportunities being focused on a clear purpose and specific, person-centred goals.

Payments to providers

A high-level project group has been established which will continue to develop timely, consistent processes to improve payments. Good progress has already been made, and the Council continues to work with providers on this important issue.

Community and Voluntary Sector (CVS)

  • We are mapping out the services that Wiltshire's VCS provide which could potentially reduce the volume of non-regulated care and support that our current home care providers are delivering to free up capacity within the home care market.
  • We are looking to micro providers and small enterprises to offer a more diverse range of care and support in the community in order to maximise capacity and increase choice and control.
  • We are piloting a strengths-based approach that will take a different approach to how we review people's care and support.
  • We continuously review our use of Direct Payments and PAs to give people more choice and personalisation and will seek to pilot things such as Individual Service Funds (ISF) and Prepayment cards to provide people with greater choice.
  • We are exploring alternative models of care and support. By utilising Technology Enabled Care (TEC) services and through existing pilots, we may seek to replace elements of POCs through the use of TECs, and in turn reduce demand on more traditional services, such as home care and residential placements to promote independence and enabling us to target our workforce resources more effectively over the coming years.

Incentives and new delivery models

The Council and ICB are currently exploring several incentives and options for new delivery models that could help alleviate pressures on the supported living market.

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