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