Self-assessment - LGA Peer Challenge

Contents

Introduction – our leadership team

Tandra Forster – Director of Integrated Adult Social Care

Tandra was appointed as Director of Integrated Adult Social Care in August 2022 having worked in local government since 2004, starting as a Reviewing and Monitoring Officer in the Supporting People Programme.

In 2013 she became Head of Adult Social Care for West Berkshire Council, responsible for leading operational delivery and commissioning of social care services. In 2018 she also took on responsibility for Public Health.

In 2020 Tandra was appointed as the Executive Director for Adults and Communities at Southend-on-Sea City Council. Responsibilities included those of the statutory Director of Adult Social Services, strategic lead for health integration, overseeing Southend’s cultural assets, and being corporate lead for community development.

She is an active member of the Association of Director of Adult Social Services, most recently chairing the Eastern Branch; she is co-lead on the workforce group and is the current Chair of the National Commissioning Network.

Tandra says:

Arriving in Devon I was immediately struck by the scale of the county, the diversity of our coastal and market towns and the rurality of many of our communities. Devon is undeniably beautiful, but this can mask the realities of those living in our most deprived communities who do not always have the outcomes and experiences of those who live in more affluent communities.

Another key challenge is the physical delivery of care and support across our landscapes. Travel times can be long, and access difficult, both for those delivering care and those seeking it, especially in the most rural areas. That said, we have an incredible internal and independent workforce, but sufficiency is a challenge we are constantly faced with in a competitive labour market where housing costs are high..

Through our transformation work, and through our restated Vision and Strategies, we have set a framework for ensuring we have a focus on shaping the care market, so it is more accessible, provides the support people want across the range of needs we seek to meet, and people have choices as their circumstances, strengths and aspirations change.

We work hard to ensure that the voice and the experience of those who receive care and support, those who provide unpaid care, and their families, are heard; that they shape our work, co-produce our priorities and how we collectively deliver them; we have adopted the Social Care Future vision, and our promoting independence approach is collectively understood and embedded across our service.

I have been struck by the strength of the voluntary sector in Devon, its diversity and its connectedness to communities: it has a leading role to play in ensuring the people can achieve their best possible outcomes and the things that matter most to them, and at a time when for many, things have never been so tough. I have also been heartened by the strength of our partnerships and relationships with statutory organisations right across Devon, the many providers we commission services from, and our system governance.

New senior leadership at the top and across the organisation is learning about Devon, about our strengthens and our challenges. We have made Equality, Diversity and Inclusion a focus for to ensure that our staff and the wider provider workforce can work in safe environments wherever they may be and both staff and people in communities achieve equality of access, experience and outcomes. We also know that being financially sustainable is a precursor to our aspirations to build resilient individuals, families, neighbourhoods and communities.

Councillor James McInnes – Lead Member for Integrated Adult Social Care and Health

James has been a county councillor since 2005, holding a number of roles in that time including Cabinet Member for Children’s Services. James is currently the Cabinet Member for Integrated Adult Social Care and Health, Chair of the Devon Health and Wellbeing Board, and also Vice-Chair of Cabinet.

James brings his experience and insight gained from these roles into the active and valuable role he plays at the system level through his chairing of the Integrated Care Partnership Board, ensuring Devon County Council is shaping and influencing through its relationships with NHS and other partners, encouraging public services to work together to address the wider determinants of health to the benefit of the people and communities we serve.

James says:

Devon County Council has enjoyed political stability for a number of years, but that does not mean we have been spared financial challenge; when necessary we have made tough decisions, implementing changes to how services are delivered to meet needs.

In my time as Lead Member, member officer relationships have been open, honest, and collaborative. Together we have explained our challenges, delivering key changes across the organisation. We actively seek and welcome constructive scrutiny, internally and externally, and celebrate success as readily as we shine a light on areas for improvement.

Our ‘Team Devon’ approach was strengthened through the pandemic, bringing the majority of local authorities across wider-Devon together to work in greater partnership, joining-up our agendas and delivering our different but linked statutory duties collaboratively. Our Housing Taskforce, for example encompasses, many facets of our collective work, including developing housing options suitable for those with more complex needs, and providing housing for the caring workforce. In Devon we have complex system arrangements, but that doesn’t make us unique. What makes us unique, I think, is the strength of our relationships, that I am confident will see us through changing and challenging times.

As Chair of the Devon Health and Wellbeing Board, I know the importance of prevention and maintaining a focus on good health, and that means many organisations working together on our collective agenda.

Our Integrated Care Partnership builds on this, and as the Chair of the Partnership, I see the start of collaborative journey that is empowering the voluntary, community and social enterprise sector with a greater focus on prevention and the wider determinant of health. The Partnership must stay focussed on this and support our Local Care Partnerships to lead communities and deliver on the priorities that matter to communities. We must ensure that governance arrangement help us do that to the best of our ability.

Keri Storey – Head of Integrated Adult Social Care Operations

Keri’s role is Head of Integrated Adult Social Care Operations. This role holds accountability for the operational delivery of adult social care on behalf of the Council, primarily through the functions of our operational services, delivered in partnership with people who use them and their carers, NHS commissioners and providers, care providers and the voluntary sector.

She has worked across Devon for nearly 30 years in roles across health and social care. She is passionate about doing what matters and relentlessly optimistic.

Several members of her team work in integrated roles overseeing community-based health and care services on a locality basis with professional backgrounds including nursing, social work and occupational therapy; they also provide our professional leadership are active in Principal Social Worker and Principal Occupational Therapy networks regionally and nationally.

The staff and services they are responsible for regularly get recognition in regional and national awards including winning Social Worker of the Year Awards multiple times in recent years and some of these are featured below.

Keri says:

For more than 15 years we have had joint teams with NHS provider organisations, working to primary care boundaries that mirror the natural geography and local communities across Devon. These teams are connected to, and work alongside, the voluntary sector and independent care providers, promoting independence and looking to support people where possible in the community without unnecessarily drawing them into ongoing adult social care provision.

Our waiting lists and outstanding reviews numbers are higher than we would wish, driven by the volume of people who approach us, including a significant growth in safeguarding concerns requiring our response, and the staffing capacity and recruitment challenges we are experiencing locally and nationally. Our approaches to address this challenge include ‘grow your own’, our apprenticeship schemes and our wide-ranging ‘Unleashing Potential’ programme that includes developing career pathways across health and care. We also ensure we are part of system efforts including overseas recruitment.

Technology Enabled Care Solutions are developing all the time, and quickly; we must ensure we are tapping into this and can continually inform and empower staff so they can build it into their offer, to achieve better outcomes for people, to make our workforce go further, and support financial sustainability.

Solveig Wright – Head of Integrated Adult Social Care Commissioning (interim)

Solveig leads the adult social care commissioning team, with overall responsibility for the strategic commissioning of services to meet the social care needs of people in Devon.

The team has responsibility for market development and sufficiency; quality assurance and contracting; managing countywide arrangements that meet the needs of carers, people with mental health needs, and those who require advocacy; determining and implementing change programmes and projects; and leading on performance, policy and involvement – all underpinned by our commitment to enable people to live as independently as possible.

The services the team commission include integrated community services (through the voluntary and community sector as well as independent sector), care homes, and housing with support, covering adults of all ages.

Solveig is the South West regional lead for Commissioning for the Association of Directors of Adult Social Services (ADASS), a role which ensures Devon gets to influence the regional and national agenda for social care, as well as benefitting from sharing and learning from best practice across the region.

Members of her experienced leadership team come from a wide range of professional and career backgrounds and are active in regional and national networks, including the ADASS co-lead for Standards, Performance and Informatics who represents local authority interests in a number of decision-making boards within the Department of Health and Social Care (DHSC).

The functions they are responsible for often receive national recognition. DHSC acknowledged the best practice of our Management Information Team in drawing insights from data to set strategy and improve outcomes while a recent House of Lords report recognised the work our Involvement Team is doing in co-production.

Solveig says:

We are led by what people tell us matters to them, this is a golden thread across our vision and strategies – people want to live safely at home in their community, surrounded by their family and friends, and be independent for as long as possible with choice and control.

Carers are at the heart of our work and are involved at all stages of planning and delivering care. We continue to make sure that their views and experiences are heard, considered and influence how we achieve the best possible support for people.

Our work is getting tougher though, as the population is ageing and growing. We are focussed on ensuring sufficiency of the independent provider market at a time of unprecedented pressures and strains on the workforce and the reality of being in the caring workforce at such a challenging economic time following the pandemic.

We are working hard to encourage people to work and remain in the provider workforce, and we do this with system colleagues, including with a joint approach to international recruitment. We are proud of the provider market in Devon and its history of quality levels better than our local, regional and national comparators.

We work hard to ensure strong relationships and connections and that they have influence within our system governance. We have contributed some funding towards provider-led representative groups – Devon Care Homes Collaborative and Devon Integrated Social Care Alliance. Engaging with these groups through our Provider Engagement Network and other forums ensures we have on-going dialogue and interaction.

Through the pandemic the strength of our relationships grew as we co-produced and delivered much of our work during this period including local guidance and approaches. Our relationships meant we could do things quickly and earlier than others; during the first wave of the pandemic, we saw far fewer care homes deaths than other areas, largely as a result of local policy decisions and support including the provision of agency staff.

Context – our place and its population

The Devon County Council area is a mainly rural county including one city and over twenty market and coastal towns accommodating a population of 810,000 people that is among the oldest and most rapidly ageing in the country. Although known for the beauty of its landscape, its road network of over 8,000 miles and its widely dispersed population also challenges service delivery, as do its low wage and high house price economy.

Within the area eight districts: East Devon, Exeter, Mid Devon, North Devon, South Hams, Teignbridge, Torridge and West Devon. Devon also includes Dartmoor and Exmoor National Parks and two coastlines, as well as five Areas of Outstanding Natural Beauty. Plymouth City Council and Torbay Council are responsible for services within parts of the geographic county and partners within our One Devon Integrated Care System.

The following are highlighted in our the Joint Strategic Needs Assessment as the main current and future health and wellbeing challenges across Devon:

An ageing and growing population, with significant differences in the demographic profiles of communities.
Access to services, including the challenge of delivery in rural areas socio-economic and cultural barriers.
Complex patterns of urban and rural deprivation, which is often hidden and hard to reach.
Housing issues including its quality and affordability with increasing levels of fuel poverty.
Earlier onset of health problems in more deprived areas and households.
Comparatively poor mental health and wellbeing, social isolation, and loneliness in some areas.
Comparatively poor health outcomes caused by modifiable health-related behaviours in some areas.
Pressures on health and care services caused by increasing long-term conditions, multi-morbidity, and frailty.
Shifting to a prevention focus across the health and care system when financial sustainability is challenging.
Unpaid care and associated health outcomes for carers, sometimes with multiple responsibilities.

Two infographics, the first showing deprivation and inequalities in health across the One Devon area; the second showing differences in the distribution of the over 85 population in different parts of Devon compared with the England average.

In adult social care, our particular challenges are:

A more aged and rapidly ageing population than nationally with growing levels of frailty and dementia.
Extending life expectancy and increasing complexity of need of people with learning and physical disabilities.
The growing number of people with long-term conditions with insufficient capacity to address them.
A changing profile of mental health needs including growth in demand from autistic people.
More younger adults being served than is typical, especially those with learning disabilities.
Service costs rising more rapidly than elsewhere, especially for older people.
High levels of social isolation resulting in loneliness in all age groups exacerbated by the pandemic.
A sparse and predominantly rural population with patterns of hidden and hard-to-reach deprivation.
Significant inequalities in healthy life expectancy between the most and least deprived parts of the county.
The growing number of people with often multiple unpaid caring responsibilities.
Improvements in health-related behaviours in younger age groups not mirrored by older generations.
A disparity between the quality of indoor and outdoor environments in Devon.
Incomes lower than the national average, house prices higher, and housing quality variable.
Changes in the benefits system having unforeseen consequences, exacerbated in rural areas.
A working age population that is not growing at the same rate as the non-working population.
Consequent recruitment and retention challenges in our workforce escalating.
A complex organisational geography with multiple NHS partners and district councils.

Context – the pandemic, cost of living crisis and recovery

As elsewhere, during the COVID-19 pandemic we experienced significant numbers of outbreaks of COVID-19 in care homes and other care settings requiring a whole system response and enhanced infection prevention and control protocols.

Chart showing outbreaks of Covid-19 in care settings in Devon during the pandemic period

Looking back over the pandemic period through to the end of 2022:

There were 199 deaths in care homes attributable to Covid-19 per 100,000 of the 65+ population in Devon, ranking 27^th lowest of 152 local authority areas in the country, with most of those being London boroughs where there are fewer care homes.
The percentage of deaths in care homes attributable to Covid-19 as a percentage of all deaths in Devon has been the 9^th lowest of 152 local authority areas in the country.
Almost thirty local authority areas experienced double or more this percentage of fatalities.
Some of the approaches to working with care homes in outbreak management developed by public health and adult social care colleagues in Devon were picked up and used regionally, and influenced the national response.
Our vaccination rates are high, with 96% of residents and 94% of staff in care homes in Devon receiving at least two doses, among the highest in the country.

We mourn the deaths of the 414 people whose deaths are attributable to Covid-19 in care homes in Devon during the pandemic period, many of whom could have looked forward to a longer life, and thank all of the staff who’ve been involved in the response across the health and care system, especially frontline care-giving staff who have often been working in trying circumstances.

During the pandemic, much of our capacity was dedicated to pandemic response involving senior managers in leadership positions and frontline managers chairing Outbreak Control Meetings and working closely with care providers in their patch. Frontline operational staff were focussed on ensuring people were receiving the right support in the right place for them in the circumstances, including ensuring discharge from hospitals operating under additional pressure and with reduced capacity. Registered managers and frontline care staff were working under trying circumstances and received our round-the-clock support.

Consequently, some of our non-vital activities were stood or slowed down, meaning during 2022 and 2023 we have faced the challenges of recovery under budgetary pressure as government has withdrawn additional funding. The longer-term impacts of the pandemic and the new challenges that have emerged are articulated in our most recent Annual Public Health Report. Recovery has coincided with the cost-of-living crisis meaning our income has fallen below inflation, but our costs have often exceeded the headline level with care homes in particular impacted by escalating food and fuel costs. For the first time for many, leaders are managing budgets in a highly unpredictable environment after years of low inflation.

Also, while our relationships with each other, our providers, other parts of the council, and our partners were galvanised by the pandemic, the post-pandemic period has thrown up unexpected changes. After a long period of stability, there has been significant change in council and NHS leadership. Providers confronted by challenges to their financial sustainability have been faced by a Council less able to support them than during the pandemic. We are now resetting our vision, strategy and delivery plans to respond to these changed circumstances, be clear on our intentions and constraints, and manage the expectations of stakeholders facing their own challenges in recovery.

Context – our services and who they serve

This section summarises and updates section 7 of our Annual Report for 2022

In Devon, of the 454,804 people aged 18-64 resident in the county in May 2022 the county council was supporting 4,694 working age adults, approximately 1% of that age group:

54% were men, indicative of the higher prevalence of some health conditions and disabilities among men.
12% were in long-term residential and nursing care, with almost all of the remainder supported to live in their own home, which can be in a housing with support setting such as supported living or shared lives.
44% were supported mainly because of their learning disabilities although many clients have more than one reason for their support.

Charts depicting the number of people aged 18-64 who use adult social care services funded by Devon County Council

The significant majority of people receiving care and support in Devon in this age group are funded by the council. Of the services they receive:

The number of people aged 18-64 in residential and nursing care has been in long-term decline as the transferring care partnership initiative nationally has aimed to bring those with more complex needs back into their communities and locally we have been working to place people in housing with support settings such as supported living and shared lives. This trend slowed in the pandemic period due to some community-based services being suspended. Only around 50 people this age are in nursing care at any one time.
The number of people aged 18-64 receiving personal care over the 2017-22 period and the total number of hours provided has been consistent at around 500 people receiving 7,000 hours of care.
Because there is no national benchmarking information regarding unregulated support, this significant and most rapid growing area of spend on adults aged 18-64 is often overlooked, but growth in this area is the most significant change in adult social care provision in the last decade in Devon, moving towards 1,800 people receiving 50,000 hours of support.
Similar to the trend in unregulated support, which is often what direct payments are used to purchase, the number of recipients of direct payments aged 18-64 has been on a long-term rising trend, sometimes alongside council arranged support, and is now approaching 1,600 people.

In Devon of the 207,846 people 65 or over resident in the county in November 2022 the county council supports 6,204 older people, approximately 3% of that age group:

64% were women, indicative of their longer life expectancy, but also raising the concern that older men may be more reluctant to come forward.
43% were in long-term residential and nursing care, with almost all of the remainder supported to live in their own home.
63% were supported mainly for physical reasons and 21% mainly for dementia with many others also having that condition.
Additionally, up to a third of recipients of personal care and a half of people in a care home fund themselves.

Charts depicting the number of people aged 65+ who use adult social care services funded by Devon County Council

Of those receiving services that the council funds in part or whole:

The number of older people the county council supports in residential care in Devon is broadly stable, fluctuating around 2,500 with notable reductions in winter periods associated with influenza and now Covid-19. Typical numbers in nursing care have increased by over 25% in the same period, mainly due to more people from hospital being transferred into these settings.
With insufficient personal care and significant pressures on hospital discharge there is an increasing risk that short term placements into care homes become long-term, contrary to our conviction that home is the best place for all but a small minority.
The number of older people the county council supports in their own homes through regulated personal care has been on a reducing trend since 2017, reducing by a third in that period, the total number of hours delivered also falling, despite unmet assessed need of up to 5,000 hours.
Given the growth in those 65+ and especially those 85+, older people now are about half as likely to receive local authority funded support now as they were before the austerity period began, partly because we are more effective at promoting their independence by preventing, delaying, and reducing the need for care and support.
Although on a rising trend, some 400 older people are in receipt of unregulated support, far fewer than working age adults, and some of this increase may be due to insufficiency in the personal care market.
The number of older people receiving direct payments, typically around 600, declined somewhat during the pandemic period due to some community-based provision being suspended but expenditure has been on an upward trend in part due to insufficiency in the personal care market, in part because it is an effective mechanism for giving people choice and control.

Carers in Devon are mainly supported through our contractual arrangement with Devon Carers:

42,000 carers are known to Devon County Council of the estimated 130,000 unpaid carers in Devon providing care of a value of £1.6bn.
It is estimated from census results that more than 20% of these provide upwards of 50 hours care per week, making them far less likely to be economically active.
26,700 carers are registered with Devon Carers for support.
1,900 carers accessed peer support during 2021-22 and this number is rising.
Carers made 13,691 calls to the Devon Carers Helpline, 1,300 email contacts, and initiated 1,560 webchats.
286 carers accessed training – and more wish to do so.

This section summarises and updates section 10 of our Annual Report for 2022

The adult social care market in Devon is dominated by small and medium sized enterprise, with care homes often owner operated and singular or in small groups. Most of these are in converted rather than purpose-built buildings and a comparatively low proportion are of 60 beds or more. A consistently higher proportion (88.8%) are rated Good or Outstanding by the Care Quality Commission than the national, regional or comparator average. Of the 313 care homes in Devon, 64 (2,830 beds) are with nursing, 249 (5,359) without. About half of people in care homes in Devon fund themselves. Occupancy levels are currently as high as at any point in the pandemic or post-pandemic period with around 600 beds vacant at any time.

Charts depicting total residents and total council funded clients in care homes in Devon over time. (Source: Capacity Tracker.)

A significant minority of placements are out of area in three cohorts:

In neighbouring authorities, where mutual quality assurance arrangements are in place.
Further afield, usually because of family choice.
Those with specialist needs, where local provision isn’t available, managed by a specialist team.

There are 155 locations in Devon providing regulated community-based services, 139 being personal care providers, the others specialists in accommodation with support such as extra care housing or supported living. Again, the proportion rated Good or Outstanding consistently exceeds all comparator averages. Our challenge has been maintaining sufficiency and coverage, especially in isolated rural areas, with more than 6,000 hours per week being unallocated as we emerged from the pandemic due to workforce issues; initiatives such as overseas recruitment have reduced this to below 2,000 hours and we are now seeking to consolidate capacity and capability.

Charts depicting total staff delivering and total people using regulated community services in Devon over time. (Source: Capacity Tracker.)

The capacity of the unregulated care market is more difficult to assess but our own data suggests that while the hours of regulated personal care have been reducing over time, especially for older people, the number of hours of unregulated support we are purchasing from a diverse market of providers including many self-employed personal assistants has been increasing. This is an area of commissioning and quality assurance we acknowledge we need to increase our grip on.

The recruitment, retention, and development of staff across the adult social sector continues to be our top priority, leading the way nationally through our Love Care programme and Proud to Care initiative, attracting attention from the Department of Health and Social Care and others as we seek to raise the profile of the sector as a key employer, with 26,000 people working in adult social care across Devon, contributing to the health wellbeing of fellow residents of the county and boosting our economy.

The profile of this workforce is not atypical for the South West region:

11,500 in care homes, 14,000 in community-based settings, the remainder in the local authority.
50% full-time, the rest half-time, with only 17% on zero-hours contracts, far fewer than nationally.
81% female, 90% White British, with an average age of 45.
High turnover (38.7%) and vacancy (9.6%) rates but with signs of improvement in 2023.
Higher than typical fees meaning higher typical wage levels, although not significantly so.
Similar levels of training and experience to elsewhere, with 51% having a relevant qualification.

A joint initiative in international recruitment with NHS partners and independent care sector providers has proved successful, with significant work done not just in attracting new staff, but ensuring they are accommodated and made welcome in their communities. Of some concern has been a recent trend residential and nursing care homes of filling gaps in rosters by the greater use of agency staff, often at greater cost.

How we work – our vision and strategies to promote independence

This section summarises our vision and strategies that were approved by Cabinet in June 2023.

The role of our vision and strategies:

Our ‘Promoting Independence’ vision describes what we are trying to achieve for people who need adult social care services in Devon now or may do in the future.
It seeks to align to the government’s vision for adult social care, One Devon health and care system strategy, and the Devon County Council strategic plan while articulating our distinctive role and objectives.
Our ‘Promoting Independence’ policy sets the policy framework by which we operate and the ‘Commitment to Carers’ underpins our approach to unpaid carers.
Our ‘Living Well’, ‘Ageing Well’ and ‘Caring Well’ strategies describe how we apply this vision and policy to people aged 18-64, people aged 65+, and unpaid carers and have been updated involving many stakeholders.
These updates have been informed by changing national and local circumstances: the coronavirus pandemic, the cost-of-living crisis, financial sustainability challenges, and changes in legislation and leadership.
Our Annual Report or ‘Local Account’ assesses our delivery against our vision, strategies and plans each year, using national surveys, performance information, and activity/cost/spend data to compare with others.
This informs our self-assessment for the Care Quality Commission who began to assure local authority adult social care functions from April 2023 and any sector-led improvement activity such as peer challenge.

Our vision and strategies are summarised in this infographic:

A summary infographic of our vision and the aims, outcomes and priorities developed in our ‘Living Well in Devon’, ‘Ageing Well in Devon’ and ‘Caring Well in Devon’ strategies

People tell us they want to live in the place that they call home, with the people and things they love, in communities that look out for each other, doing the things that matter to them. We start with the assumption that the more independent people are, the better outcomes they will achieve, and at lower cost. Once someone is receiving adult care support, they risk their needs escalating unless we work with them, and the people who care for them, to keep them as independent as possible in the place most appropriate to their needs at that time. For most people most of the time that will be in their own home which is where people tell us they want to be. For some people some of the time this will be in hospital or specialist settings where we will endeavour to get them home whenever it is safe.

The key points of our strategies are:

Prevention: including providing accessible information and advice and responding to people in crisis.
Community and the voluntary sector: with more focus on early intervention and enabling life experience.
Housing: giving people more affordable and quality options for them appropriate to their time of life.
Strengths-based and personalised practice: building on assets, recognising risks, providing contingencies.
Safeguarding vulnerable adults at risk from harm: including through greater public awareness.

Identifying and addressing inequalities: in our employment, commissioning, and the experience of services.

How we work – our council

Devon County Council has enjoyed political stability in its form and leadership since before the austerity period, with the current administration and leader of the council coming into power in 2009.

Chart showing political organisational structure of Devon County Council as it relates to Adult Social Care

Links for further information on the above chart:

For most of that period, there was continuity of Chief Executive and Director of Adult Social Services with Donna Manson and Tandra Forster having been in post for under a year and under six months respectively. There has also been significant change in the Strategic Leadership Group in recent months. With a new Chief Executive in post, a corporate review of our governance arrangements is now underway.

In contrast, Keri Storey (the Head of Integrated Adult Social Care Operations) and Solveig Wright (the Head of Integrated Adult Social Care Commissioning) have enjoyed the majority of their careers in the Devon health and care system and are supported by experienced and stable leadership teams.

Organisational structure chart: Devon County Council Director of Integrated Adult Social Care and Senior Leadership Teams

How we work – our partners

As the county council in Devon, we work closely with our eight city and district council partners in Team Devon, taking joint approaches to shared challenges such as responding to the Coronavirus pandemic or climate change.

As a council, we are proud to be part of One Devon: a partnership of health and care working with people in their communities and local organisations to improve people’s lives that includes three local authorities, four NHS trusts, five local care partnerships, and thirty-one primary care networks.

Chart showing organisational structure of One Devon Integrated Care System as it relates to Adult Social Care

Links for further information on the above chart:

The One Devon Integrated Partnership Board, chaired by the Lead Member for Integrated Adult Social Care and Health in Devon, has declared the twelve challenges our local health and care partnership needs to address.

Infographic depicting the twelve challenges to the health and care system identified by the One Devon partnership

Map of the localities in the One Devon area and its partner organisations

We are now finalising our joint forward plan to lay out how we intend to deliver on our collective vision and priorities over that time period:

The One Devon joint forward plan, it's 9 key delivery programmes and 10 enabling programmes

Delivery principles – we will find solutions that follow these principles:

Seek solutions that work for the system.
No organisation will knowingly create an adverse impact on another or the system.
Standardise practice and services where it makes sense to do so.
Focus on cost reduction, cost containment and productivity improvements.
Recognise that participation will be required at system, locality, neighbourhood and organisational level on the priority areas.
Ensure equitable distribution of funding and outcomes by locality.
Not make new investments that lead to a deterioration in the underlying position.
Consider financial decisions alongside quality, safety and any impact on patient experience of care.
Share risks and benefits across the system and ensure they are fully understood by all parties.

How we work – our operational services

In 2008, Devon County Council took the opportunity of having good relationships with its NHS partners and being early implementors of electronic social care records to transform the delivery of its operational services:

Building on a government pilot, our telephone-based Care Direct service became the heart of a Devon County Council customer service centre, aiming to resolve queries over the phone and online by deploying skilled and knowledgeable call handlers using web-based information systems.
Introducing the innovation of telephone-based Care Direct Plus centres in each locality, undertaking assessment, review, care and support planning and brokerage functions for people with less complex needs.
Forming Community Health and Social Care Teams based on Primary Care Network boundaries bringing together co-managed and co-located frontline health and social care practitioners in community hospital and other sites.

Map showing the locations of Devon Community Health and Social Care Teams with locality and local authority boundaries

These arrangements have matured over time, improved by advancements in technology and developments in good practice, and are supported by:

Memoranda of Understanding with our partner NHS Trusts covering management and staffing arrangements with annual strategic agreements covering budget and performance targets.
A Section 75 agreement with Devon Partnership Trust assigning the staff and budget necessary to meet our statutory responsibilities towards people with Mental Health needs.
A contract with Devon Carers giving information and advice to and assessing the needs of unpaid carers.

Our approach to working with people is based on a partnership through conversation that is based on people’s strengths, acknowledging the networks of support within their family and community. Where appropriate, we sign post people to our online self-help tool which directs people to advice specific to their needs and is a gateway to online self-assessment where appropriate. We are currently tendering for a new care management system which we anticipate will improve operational efficiency and our capability to interact with people online.

A diagram depicting what happens when someone in Devon contacts adult social care for help

Within our operational services, we have a range of specialist staff and/or functions that:

Assess and review people’s needs and arrange any necessary short or longer-term care and support
Support and advise unpaid carers through our arrangement with Devon Carers
Promote and advise on options for independent living
Conduct financial assessments, delivered through colleagues in Client Finance Services
Receive and prioritise safeguarding concerns and arrange consequent enquiries
Provide Occupational Therapy support
Undertake Deprivation of Liberty Safeguards assessments under the Mental Capacity Act
Provide out of hours cover including through Approved Mental Health Professionals
Support young people transitioning to adult services
Provide support to people with sensory impairments
Provide support to autistic people and people with ADHD
Provide support to people with a range of disabilities and long-term conditions embedded in our Community Health and Social Care Teams with a dedicated countywide review team
Provide support to people with complex needs placed outside Devon
Are embedded in Community Mental Health Teams
Facilitate discharge for people going home from hospital
Deliver short-term services to promote people’s independence such as Social Care Reablement and Reaching for Independence.

How we work – our approach to safeguarding

Safeguarding vulnerable adults by protecting their rights to live in safety, free from abuse and neglect is a core statutory duty that runs through everything we do in adult social care in Devon. Our governance of safeguarding incorporates our role in system governance via the Torbay and Devon Safeguarding Adults Board and our arrangements for organisational governance focussed on a recently reconstituted Safeguarding Adults Governance Group.

Diagram depicting the governance arrangements for Adult Safeguarding in Devon

The Torbay and Devon Safeguarding Adults Partnership covers two local authority areas, facilitating strong partner representation with an independent chair; it publishes its annual report and business plan laying out its achievements, concerns and priorities to address them.

Combining resources enables us to provide a well-resourced offer regarding learning and development, policy and guidance, and information and advice as well as topic specific content on health and wellbeing, exploitation and abuse. It has an important role in raising public awareness through advertising, media and clarity of guidance on reporting concerns.

The Safeguarding Adults Governance Group within the Council is chaired by the Head of Integrated Adult Social Care Operations and its membership includes our professional and practice leads and representatives of our frontline managers and staff and relevant support staff such as those providing and analysing quantitative and qualitative information. It also includes managers responsible for quality assurance of in-house and external provision.

A typical agenda includes:

Feedback from local and national learning from Safeguarding Adult Reviews, Serious Care Reviews and Domestic Homicide Reviews.
Highlight reports from initiatives in practice improvement.
Updates from operational teams on practice issues to inform learning, development and guidance.
Analysis of relevant data and feedback.

This Board oversees our operational Safeguarding arrangements:

A Safeguarding Hub embedded in the Care Direct Plus centre in each locality.
Triage of concerns and prioritisation of enquiries by a responsible manager.
Response by frontline practitioners in integrated teams.
Out of hours coverage by our Emergency Duty Service.
A domestic and sexual violence and abuse website and helpline.

How we work – our approach to commissioning

In March 2023, Devon County Council published the outcomes of its Fair Cost of Care engagement with providers and its Market Sustainability Plan which highlighted:

The population of Devon is growing, but the working age population is declining as a share of it, with an already aged population still ageing rapidly.
The employment rate is above the national average, but with lower-than-average wages and higher than average housing and living costs, and a competitive labour market in lower paid sectors including retail, tourism, and social care.
These factors mean more pressure on demand for adult social care and more constraints on the workforce necessary to deliver it. There is high turnover within the sector, but more than 60% involves people moving between employers.

Regarding our care home market:

Provision tends to be high quality but dominated by small and medium sized enterprises limiting its capacity and capability to innovate and adapt e.g., to meet growing demand for dementia and other specialist care.
Its building stock is often in rural locations, smaller in size and significantly older than is typical, with over 50% pre-dating 1980 and under 5% being built since 2016. Consequently, rooms are less likely to have en suite bathroom or wet room facilities and utilities are more expensive.
11 care homes closed during 2021-22, and 2 nursing homes and 4 learning disability homes deregistered, equivalent to 3.6%; small care homes in rural areas are particularly vulnerable to closure as their viability often depends upon their being owner operated.
With staffing and cost pressures, this trend is likely to continue, but expected closures are anticipated to be more than compensated by new builds and extensions, with a potential net capacity growth of almost 1,500 beds although increasing build costs may restrict this new supply
Our care home fees have been increasing faster than inflation, and are now above what is typical elsewhere for older people.

This exercise afforded an opportunity to think though our commissioning intentions in the care home market:

Although there is a market for short-term residential care following crisis or hospital discharge we are concerned that lack of reablement, rehabilitation and recovery capability too often means these placements become long-term, and trends in our data illustrate this risk.
Our intention remains to support as many people at home as is possible, with care homes catering for people with increasingly complex needs, avoiding out of area placements unless that is the person’s preference.
This will require a shift from generalist residential care to specialist and nursing care, but change risks the emergence of geographic insufficiencies given our dispersed rural population.
Maintaining sufficient nursing care capacity is challenging due to a shortage of nurses and older buildings in often rural locations not being fit for purpose.
Attracting capital investment into a market dominated by SMEs will be a challenge, with larger providers unwilling to extend into the rural periphery of the South West Peninsula, and interest rates increasing.

Regarding community-based providers:

The market in Devon is dominated by smaller providers operating in limited geographies with two-thirds having under 1% of market share and none 10% or more.
During 2022, eight providers entered the market and six exited or amalgamated and this pattern of growth in capacity has increased into 2023, reducing insufficiency in the personal care market which peaked in 2023.
However, workforce retention issues in some providers have led to increasing hand backs, with some providers choosing to focus on the unregulated market or housing with support; this can be a particular challenge in the summer season when some staff choose to work in the tourism sector.
In recognition of this, we increased our fee levels significantly in 2020 to among the highest in the country with additional recognition of rural provision, encouraging providers to pay at least £10 per hour to frontline personal care staff.
Nevertheless, cost pressures are significant, with fuel prices a key determinant of costs in rural areas, as are travel times.
As with the residential market, smaller providers tend to achieve better CQC ratings and the proportion achieving Good or Outstanding ratings is consistently above the national, regional and comparator averages.
Over 50% of direct payment holders employ personal assistants with emerging micro-providers bolstering this capacity.
About 284 providers currently deliver enabling services and we now purchase more hours of unregulated support than regulated personal care.
Our thriving market of Personal Assistants offers many opportunities to those using Direct Payments to organise their own care and support but can also have limitations, especially regarding coiverage and contingency.

We are also reconsidering our commissioning intentions in the community-based sector:

Interim market interventions to consolidate recent capacity growth in the personal care sector to ensure it is financially sustainable and can maintain sufficient workforce.
Through a review of community services which has delivered its stage 1 report, with a final report proposing new models of commissioning and delivery due in April 2024.
This complemented by an updated needs analysis, considering changes in needs, means, and preferences of people during and since the pandemic.
This leading to a co-designed and co-produced model of service delivery that will maximise reablement and recovery and take a step change in our use of Technology Enabled Care Services to promote people’s independence.
Seek growth of volume through strategic partnerships, focussing on those with the potential to grow the workforce, not just recirculate it.
Continue to promote direct payments where they achieve better outcomes for people, further developing the market of personal assistants and micro-providers.

In particular, we are working with city and district councils to take a Team Devon approach to improving housing with support options including Supported Living, Extra Care Housing, and Shared Lives Schemes that enable people of all ages to live in appropriate accommodation, with the right care and support where it is required, in the community.

An infographic depicting the spectrum of housing options depicting how higher cost options are also those where people's independence is most compromised.

In both residential and community markets we are bolstering our Quality Assurance arrangements by deploying the Provider Assessment and Market Management System in partnership with most other local authorities in the region. As well as improving market intelligence, this will give us better visibility of out-of-area placements and to better facilitate mutual approaches.

With recent focus on this mandatory planning exercise, we recognise our Market Position Statement predates the pandemic and is in need of updating to align to this more recent analysis. Since its update in 2020 we have issued Market Sufficiency Statements in 2020 and 2021 to keep the key aspects of our analysis and statements of intention current.

Nevertheless, our Market Position Statement offers a thorough summary of the market with our data tool kept up-to-date to allow analysis of the latest information and our commissioning analysis and intentions laid out by sector: care homes, extra care housing, individual purchasing, supported living, regulated personal care, supporting independence, services to adult carers, replacement care, and technology enabled care services.

Our current review of our change programme to align change proposals driven by our revised vision and strategies, our assurance work, and our financial sustainability programme will enable us to prioritise and schedule commissioning work, with our delivery plans due to be published in the autumn.

Our commissioning activity is only made possible by close joint working with our corporate procurement and contracting function. Our Devon County Council Procurement Strategy 2021-26 clearly lays out the approach we take, including to:

Support organisational objectives such as the Climate Emergency.
Prioritise local economic development.
Promote social value.
Enable digital transformation.
Manage the delivery of contracts.
Realise benefits and achieving value for money.
Work in partnership, including where we procure jointly.

For most people most of the time, their experience of adult social care is through the services delivered to them by the many independent and voluntary sector providers in Devon, ranging from individual personal assistants to national organisations. While the local authority has a duty to ensure a sufficient, diverse, and high-quality market, and to assess the needs of people and arrange and fund services for those without the means to do so themselves, everyday delivery is mainly through this diverse market of providers with few care and support services remaining in-house.

We work with adult social care providers in Devon through the Provider Engagement Network, maintaining a Provider Reference Group and facilitating locality and sector specific forums as well as online resources, communicating with them via a regular newsletter and topic-based webinars, offering support with:

Contracting with Devon County Council.
Our approach to Quality Assurance.
Funding opportunities.
Business continuity planning.
Our Market Position Statement, Market Sustainability Plan, and Cost of Care assessment.
Managing outbreaks of infectious diseases such as Coronavirus, influenza, and norovirus.
Vaccination for staff and service users.
Workforce development and wellbeing.
A directory of local and national resources.

Our market management function manages our business relations with providers by:

Working with our social care provider partners so that we can deal with any arising issues quickly and effectively to ensure continuity of service for those that need it.
Working with our commissioning colleagues so that we can develop the marketplace including through the Market Position Statement, Market Sufficiency Statement, and Market Sufficiency Plan and Cost of Care publications.
Working with our operational colleagues on addressing provider failure and business continuity issues.

The Quality Assurance and Improvement Team offers support including:

Helping providers identify the reasons for any non-compliance following a CQC Inspection and supporting them to develop an action plan to return to compliance.
Helping to identify where systems and processes are not effective and where improvements can be made.
Giving providers supportive resources, advice, guidance, and information on improving quality in all aspects of service provision.
Supporting providers to develop and implement effective quality assurance arrangements, including through our challenge and support.
Prioritising referrals to leadership and management development training.
Chairing weekly locality huddles involving colleagues from across operations and commissioning to pick up and act on early indications of risk to provider quality or sustainability.

Over 26,000 people work in adult social care in Devon, all but a few hundred of them in the independent and voluntary sector. Without an adequate, committed, experienced and well qualified workforce, the adult social care sector cannot deliver sufficient, diverse, and high-quality services to meet the needs of our population, whether they fund their own care or are supported by the local authority or NHS.

Working with our Provider Engagement Network and countywide bodies such as the Devon Care Homes Collaborative and Devon Integrated Social Care Alliance we have developed a comprehensive workforce development offer including:

Our Proud to Care recruitment service and its network of ambassadors for care work.
Career pathway initiatives such as trainee Nursing Associates and Apprenticeship schemes.
A learning and development offer across the range of roles including eLearning and in-person training.
A range of wellbeing support, discount and benefit schemes.

Our LoveCare programme was initiated by an Appreciative Inquiry into adult social care and its workforce challenges bringing together national and local system leaders with care workers, care providers and people who use their services. Out of this event and a visit from colleagues in the Department of Health and Social Care we launched a prospectus for change for the One Devon health and care system, aspiring to develop our collective workforce into one that is sufficient, caring, confident and collaborative.

Since then, we have been working together to:

Agree five principles relating to workforce that can be embedded across the whole system: system working, stability, learning and education, enhancing technology, and sustainability.
Address future thinking with Health Education England (HEE) and the staff college to develop future scenarios that reflect what the system and workforce could look like in 2035.
Further develop LoveCare, to test, learn and develop the local care workforce within Devon and campaign for national change on pay, reward, and career pathways.
Maximise the value of Proud to Care, our recruitment service for health and care in Devon.
Undertake joint overseas recruitment, pooling resources and requirements.

We are also focussed on developing our own workforce through our ‘Unleashing Potential’ Programme and an ongoing recruitment campaign, by:

Benchmarking salary and other employee benefits across the region
Reviewing our career pathways across the health and care system
Promoting our existing staff benefits including opportunities for secondments, career breaks, flexible retirement, and unpaid leave.
Extending our social work apprenticeship scheme and considering similar for occupational therapy as part of our ‘grow our own’ workforce strategy.
Looking at international recruitment following successes in the wider sector.
Using a range of media, social media, and other opportunities to promote opportunities to work in adult social care in Devon County Council.

Our ‘Unleashing Potential’ Programme also includes initiatives to:

Scope, grow, and invest in our internal workforce to maintain capacity and develop capability and better define career pathways for progression.
Share best practice and celebrate the successes of our workforce, including through award schemes.
Ensure we have the right knowledge and skills through a learning and development programme focussed on the frontline.
In particular, improve our disability practice to build on people’s strengths and promote their independence, from transition through adulthood..
Improve the quality and consistency of professional supervision and appraisal.
Reinvigorate and make better use of practice quality assurance.
Review and update practice policy and process guidance.
Better use innovative technology, such as the full range of Technology Enabled Care Services.
Define and promote the core values applying to our operational and commissioning practice.
In particular, focus on equality, diversity and inclusion and our Race Audit Action Plan.

An infographic depicting the core values of the Devon County Council Integrated Adult Social Care Unleashing the Potential Programme for our care management and commissioning practice

How we work – listening to those we work with and for

Devon County Council is committed to enabling people who receive our support to have their say in the planning, commissioning, and provision of services, whenever possible. We have a number of different ways of engaging with people who use services and carers and the wider public, so we learn from their experience of adult social care, including.

The Joint Engagement Forum: a quarterly gathering of people who use services, carers, and relevant organisational representatives.
The Learning Disability Partnership Board: of people with learning disabilities, carers, relevant providers and health and social care managers.
The Autism Involvement Group: a specialist forum for autistic people, those with ADHD and related conditions and their carers.
The Commissioning Involvement Group: a network of people with lived experience of receiving social care services and equality issues.
Carer Ambassadors recruited by Devon Carers to actively represent the views of carers, a number of whom sit on the Carers Partnership Steering Group.
Mental Health engagement: services are delivered and jointly commissioned by Devon Partnership NHS Trust who have developed the LEAP programme.
Older people’s engagement: set up to deliver all forms of engagement opportunities with our partners Age UK Devon.

We also commission services that further facilitate the involvement of people with lived experience in making their voices heard:

Living Options Devon coordinate a network of organisations who help us engage with people through statutory consultations and more informal listening events and surveys.
The Equalities Reference Group is made up of people from organisations representing each characteristic protected by the Equality Act (2010) and helps us undertake Impact Assessments.
Healthwatch Devon is the statutory health and social care consumer voice organisation for the Devon County Council area, and receive their reports at our Health and Care Scrutiny Committee and our Health and Wellbeing Board.
Our corporate Customer Relations service that facilitates formal complaints and other feedback.

We are increasingly going beyond listening to and consulting with people to actively work with them in our Co-Production Working Group whose aim is to develop the council’s approach to participative involvement in commissioning, planning, designing, and evaluating services.

Like other local authorities we participate in statutory surveys of the people who receive adult social care services, annually for service users, and every other year for carers, enabling us to listen to the views of hundreds of people locally on the services they receive and the impact of their lives, and to compare their experiences with those who live elsewhere. We have been incorporating these insights into our annual report for many years and share and discuss them widely with stakeholders to better understand what factors informed people’s responses.

We are currently improving how we capture and make use of the feedback from people who use our services, their unpaid carers, and other stakeholders – recording key comments from our various involvement groups, categorising them by the themes and quality statements used by the Care Quality Commission and replicated in our Assurance Framework, and including them in the information that informs the thematic deep dives we conduct at our monthly Assurance Board.

We have a well-defined and advertised process for making formal complaints about adult social care in Devon, in particular relating to our own services and also encourage comments and compliments we can learn from. Our annual and quarterly reports are published inline to encourage transparency. However, we recognise that we need to improve the timeliness and quality of reporting of customer feedback to focus more on learning from them and actions taken as a result and have raised this with our corporate customer relations team as an area for rapid improvement; their manager is invited to our Assurance Board present a contemporary and improved format report in July 2023.

During the pandemic, with many staff working from home, we undertook six staff surveys focussed on their wellbeing, informing how we ensured colleagues could:

Stay connected through more regular supervision by managers and team socials and check-ins.
Maintain a healthy work-life balance by taking regular breaks and leave.
Work differently using new technology such as Microsoft Teams and SharePoint.
Learn from specialised training and support such as learning that promotes individual and team resilience.
Adopt a hybrid working style that recognised the benefits of being with colleagues and working from home.
Benefit from new office facilities redesigned to facilitate different ways of working such as Luccombe House.

As we moved into the recovery period, the focus of our staff surveys has shifted to meeting the new challenges we are facing including the cost-of-living crisis, with council income falling and demand for its services rising.

The initial areas of focus of our new Chief Executive and her leadership team following staff engagement in the early months of 2023 are:

People First, redefining our workforce strategy on themes of voice, belonging, wellbeing, learning, recruitment and reward.
Performance and Governance, ensuring we make the right decisions in the right way, in a one council approach with clarity of roles and responsibilities and a focus on improving outcomes and performance within the limits of a sustainable budget.
Leadership and Direction, updating our strategic plan to ensure our priorities are responsive to changing circumstances.

Although we seek to have conversations with frontline staff regularly, with both of our Heads of Service having monthly online drop-on sessions and encouraging similar openness and two-way communication between managers and staff across the organisation (including through our Staff Reference Group for frontline staff and Social Care Leadership Group for frontline managers) we know that things don’t go right in all services and places all of the time and regularly remind staff they are able to raise concerns formally through our whistle blowing policy and grievance process if they feel they have not or would not be listened to.

One area where we know we don’t always do as well as we aspire to is in challenging inequality and celebrating diversity. In 2021, Devon County Council commissioned a Race Equality audit and received some difficult messages, including:

Denial that racism is an issue, despite feedback from people who experience it on a regular basis.
The excuses of their being small numbers in Devon and a lack of data limiting insight when people are reporting incidents in their work and in their communities.
White fragility in leadership, with the vast majority of senior managers being from White British backgrounds, leading to lack of credible leadership and role models.
An unwelcoming culture for Black and Asian people in particular, including in care work.

Equality, Diversity and Inclusion are now recognised as priorities for the organisation with a particular focus on the racism experienced by our staff, by staff of the organisations we commission services from, and in our communities.

This has reinvigorated some of our mechanisms for addressing inequalities:

A corporate and directorate change programme for addressing race inequality.
A new Equality Commission drawing on our Staff Diversity Network and Equality Reference Group.
A clear Equality Policy making real our commitment to the Devon Joint Declaration for Equality.
A statement of Equality objectives with an accompanying action plan, extending into frontline services.
Comprehensive guidance on equalities issues for leaders, managers and staff with mandatory equalities training across the organisation.
Ensuring Impact Assessments are undertaken to inform key Council decisions about service change.
Work across the Council such as our Gypsy and Traveller Liaison Service, our Homes for Ukraine Scheme, our work addressing domestic violence and abuse, and our Safer Devon Partnership.

How we work – managing change

We take the following approach in managing change:

Chairing of our Transformation Board and Assurance Board by our Chief Officer to ensure she is sighted on and directing change and assurance activity.
Reviewing change programme and governance 6 monthly to align to service priorities and maximise use of resources.
Allocating a Senior Responsible Owner to each Project and Board to ensure ownership by a member of our Joint Strategic Leadership Group, and Senior staff and deliver on their workstreams.
Using involvement and engagement opportunities with people who use our services in their carers to inform and where appropriate help shape and deliver change.
Using formal Programme and Project Management proportionate to the complexity and priority of the initiative, allocating appropriate Change Delivery resources.
Ensuring a plan on a page and concise highlight reporting as accessible means of monitoring progress.
Making all programme and project documentation available through our use of facilities such as Teams, OneNote, and SharePoint outlined in our PMO Standards handbook.
Considering issues and risks arising through maintaining registers that also inform our corporate Risk Register.
Maintaining close alignment to corporate and system-wide change programmes, some of these projects being our delivery of their requirements.
Consulting on changes that affect people’s lives and undertaking impact assessments to inform decision making.
Working with Devon Audit Partnership to give an independent view.

Our change programme itself changes as our priorities change but to illustrate the assurance and exception handling groups, plus the broad work areas see the chart below.

An infographic depicting the governance of change management as it relates to Integrated Adult Social Care in Devon County Council

With change management and governance now in place, though Q1 and Q2 23/24 we plan to extend our approach by:

Bringing together change required by financial sustainability, government reform, and operational recovery from the pandemic into one programme, including those articulated in our strategies.
Scheduling our programme plan into the medium term in recognition that we currently don’t have the capacity to deliver everything we would like to.
Better aligning our adult social care priorities and our corporate and One Devon system strategies and plans by ensuring that the voice of adult social care is prominent in both.

How we work – ensuring financial sustainability

With Devon County Council spending close to half of its net budget on adult social care and with demand rising due to population change and the pandemic and costs rising more rapidly than income, the whole council is focussed on using its resources effectively, prioritising its statutory responsibilities, especially those to more vulnerable people.

Our budget pages include an archive of the budgets and outturns of previous years. The Local Government Finance Settlement announced late in 2022 contributed towards enabling the Authority to budget an unprecedented increase in funding for services of £114 million as detailed in our 2023/24 budget book, responding to pressures driven by high inflation and post-pandemic demand for public services. Here you will find detailed exposition and analysis including:

The detail of the Integrated Adult Social Care Budget on p.40-48
The breakdown of our operational budgets on p.42-4
The breakdown of our commissioning budgets on p.46-48
Backward and forward looking analysis of our Medium Term Financial Strategy on p.87-95
Our long-term strategic challenges and solutions on p.98-106.
Analysis of financial sustainability and risk on p.96-97 and p.152-60

Despite that level of investment, significant budget savings were required both within 2022/23 and of £47.5mn for 2023/24, with a cross-organisational financial sustainability programme identifying options, the majority falling to Integrated Adult Social Care as the highest spending service. We are facing similar savings targets in 2024-25 and expect to extend our financial sustainability planning into our Medium Term Financial Strategy with our new Chief Executive identifying opportunities including addressing the very high usage of agency staff in some parts of the council and focussing more clearly on our statutory duties measured by a corporate performance framework aligned to Oflog.

In Integrated Adult Social Care, we are determined to use our limited resources to best effect by setting and managing our budget in accordance with our ‘promoting independence’ vision and accompanying strategies by:

Providing information and advice so that people can help themselves and be supported in their communities.
Using intelligence to identify those at most risk of crisis or escalation, having contingencies in place should that occur.
Using equipment and technology to keep people in their own homes.
Managing demand through approaches to preventing, reducing, and delaying the need for ongoing support.
Ensuring equality of access and provision for people of equivalent need.
Using strengths-based assessment and review to promote independence.
Reabling and enabling through short-term support.
Supporting people in the best setting for them at the time, usually at home.
Ensuring direct payments are being used for their intended purpose.
Charging people appropriately and recouping that income effectively.
Developing the care market to meet complex and changing needs in Devon wherever possible.
Getting best value from the providers we commission from.
Collaborating with partners and providers to make the cost of care affordable.
Ensuring all discretionary expenditure is making a difference.
Using benchmarking to assure ourselves we are making the best use of resources.
Using joint funding across health and care fairly to ensure people are receiving optimum support.

In 2024/25, the corporate approach to the Medium Term Financial Strategy will be to focus on:

Reducing staffing costs by addressing the number of staff employed via agency or on temporary contracts in some parts of the Council.
Looking at contracts across the council, especially where multiple contracts are commissioned from a single provider.

In the remainder of 2022/23, in Integrated Adult Social Care we are additionally progressing a number of initiatives to generate additional savings with minimum adverse impacts on the lives of the people who we support:

Improving cost control, especially the use of enhanced payments to secure placements.
Getting best value from direct payments.
Using Technology Enabled Care Services more effectively.
Working with district councils to rapidly improve housing with support options.
Developing short-term service offers for people with dementia and with anxiety.
Better contracting with care homes accommodating people with more complex needs.

Analysis – the outcomes we achieve

This section summarises and updates section 11 of our Annual Report for 2022

Data collections that feed the Adult Social Care Outcomes Framework (ASCOF) were hampered in various ways during the pandemic period, but surveys of service users and their carers have been reinstated (with many hundreds being surveyed, statistically sampled, and adjusted, nationally defined, and locally delivered) and we now have a complete picture for the first time since the pandemic.

Using the 26 indicators of the ASCOF framework, in 2021/22 Devon ranked in the top two quartiles of 19 of them and while national trends are mainly downwards, Devon’s performance was maintained or improved in 21 of them with early indications being this performance profile will be sustained in 2022/23.

Quartile one

1A – social care-related quality of life score
1B – proportion of people who use services who have control over their daily life
1E – proportion of adults with a learning disability in employment
1I (1) proportion of people who use services who reported that they had as much social contact as they would like
2B (2) Proportion of older people (65+) who received STS services after discharge from hospital
2D – the outcome of short-term services: sequel to service
3A – overall satisfaction of people who use services with their care and support
3D (2) – proportion of carers who find it easy to find information about services

Quartile two

1C (1A) – proportion of people who use services who receive self-directed support
1C (2A) – proportion of people who use services who receive direct payments
1F – proportion of adults in contact with secondary mental health services in paid employment
1G – proportion of adults with a learning disability who live in their own home or with their family
2A (1) – LTS needs of younger adults (18-64) met by admission to residential and nursing care homes, per 100k pop
2A (2) – LTS needs of older adults (65+) met by admission to residential and nursing care homes, per 100k pop
3B – overall satisfaction of carers with social services
3C – proportion of carers who report they have been included in discussion about the person they care for
3D (1) – proportion of people who use services who find it easy to find information about support
4A – proportion of people who use services who feel safe
4B – proportion of people who use services who say that those services have made them feel safe and secure

Quartile three

1C (2A) – proportion of people who use services who receive direct payments
1D – carer-reported quality of life
1H – proportion of adults in contact with secondary mental health services living independently
1J – adjusted social care-related quality of life – impact of adult social care services

Quartile four

1C (1B) – proportion of carers who receive self-directed support
1I (2) – proportion of carers who reported that they had as much social contact as they would like
2B (1) – proportion of older people (65+) who were still at home 91 days after discharge from hospital into STS

Of particular note are the following:

Overall satisfaction rates in Devon remain higher than the national, regional and comparator averages as has been typically the case over the last decade and we now rank 15 of 152 local authority areas in the country, a testimony to those working in the adult social care sector around the county.
In the similar indicator for unpaid carers, the national and regional trend has been mainly downwards, whereas in Devon we have seen improvements in the last two surveys and now rank 40 of 152 local authority areas and above the national, regional and comparator averages.
ASCOF includes indices that measure people’s quality of life, for service users including questions regarding their control, dignity, personal care, food/nutrition, safety, occupation, social participation, accommodation. In Devon we now rank 5 of 152 in the country with improvements in performance and ranking in each of the past four surveys.
The equivalent indicator for unpaid carers is also a composite index that captures multiple facets of their lived experience including occupation, control, personal care, safety, food/nutrition, safety, social participation, encouragement, and support. The survey of carers is biennial, and Devon has been on a declining trend since its inception, similar to the regional and national trends. Although our ranking has improved to 94/152 it is still below all comparator averages and our absolute performance is at its lowest ever.

As we complete our statutory returns for 2022-23, we are able to give some provisional indications of likely movements in indicators relating to ASCOF, although benchmarking information won’t be published until the Autumn:

11 have improved and 7 declined, meaning our overall comparative profile is unlikely to decline from its favourable position in 2021-22 and may improve further.
Indicators relating to the employment and suitable accommodation of people with Learning Disabilities have improved further.
We anticipate that the indicator relating to permanent admissions for residential and nursing care of older people has increased and therefore worsened and suggest this is due to hospital discharge pressures, including from short-term residential placements becoming long-term.
Four indicators used in the ASCOF have improved, and four have worsened. Most of these changes have been marginal, meaning the overall comparative performance profile is likely to be similar.
The most significant improvements have been in the overall satisfaction rating which could take us into the top 10 in the country and the proportion of people who find it easy to find information about services which could take us into the top quartile.
The most significant decline is in the proportion of people who use services who say they have control over their daily life. While we were in the top 10 in the country last year, this is a concern if indicative of a local rather than national trend.

ASCOF indicator	22/23 provisional	21/22 final	21/22 rank	D of T
1A: Social Care quality of life	19.4	19.6	5th	DOWN
1B: Proportion of people who use services who have control over their daily life	79.6%	82.8%	8th	DOWN
1C1A: Self-Directed Support (Service Users)	98.5%	99%	76th	DOWN
1C2A: Self-Directed Support (Carers)	100%	80.5%	126th	UP
1C1B Direct Payments (Service Users)	30.7%	30.2%	49th	UP
1C2B Direct Payments (Carers)	100%	80.5%	99th	UP
1E: Proportion of people with a Learning Disability PSR in employment	7.6%	7.0%	33rd	UP
1G: Proportion of people with a Learning Disability PSR in settled accommodation	84.9%	84.4%	58th	UP
1I1: Proportion of people who use services who report that they have as much social contact as they would like	45.8%	45.5%	18th	UP
1J: Adjusted social care related quality of life – impact of adult social care services	0.407	0.408	77th	DOWN
2A1: Permanent admissions to residential/nursing care (18-64)	9.2	9.5	45th	UP
2A2: Permanent admissions to residential/nursing care (65+)	515.3	462.9	51st	DOWN
2B1: Proportion of people still at home 91 days post-discharge into rehabilitation/reablement services	72.7%	67.1%	40th	UP
2D: Sequels to short-term services	95.6%	92.9%	40th	UP
3A: Overall satisfaction of people who use services with their care and support	71.2%	68.7%	15th	UP
3D1: Proportion of people who receive services who find it easy to find information about them	69.6%	66.9%	55th	UP
4A: Proportion of people who use services who feel safe	70.0%	70.7%	60th	DOWN
4B: Proportion of people who use services who say that those services have made them feel safe and secure	87.0%	88.5%	45th	DOWN

Table showing movements in Adult Social Care Outcomes indicators between 2021-22 and 2022-23 (provisional)

The survey of Adult Carers in England is biennial with the next not being due until 2023/24.

Analysis – our operational performance

This section summarises and updates section 14 of our Annual Report for 2022

There is a lack of national data regarding some aspects of comparative performance of council operational services in different areas. The Adult Social Care Outcomes Framework focusses on what matters most to people in their lived experience and while processes such as assessment and review are important entry points to services, they do not constitute the ongoing support that makes most difference to people’s lives.

In Devon, we continue to monitor these operational processes because they help us deploy our limited capacity effectively and identify and seek to address areas of lower productivity and are well positioned to work with the Care Quality Commission to fill these gaps in data.

We aspire that at least 75% of people approaching is for an assessment of their care needs have that assessment completed within 28 days, acknowledging that for some with the most complex needs that timescale is difficult to meet.

Before the pandemic, we were on an improving trajectory towards meeting this target, subsequently, performance has been in decline and is currently under 60%.

A graph showing the proportion of people whose assessment is completed within 28 days between 2017 and now

An assessment is only really completed from the person’s perspective when any services arising from that assessment are put into place. We aspire that at least 90% of people receiving an assessment should be in receipt of those services within 28 days of the assessment being completed and have consistently been meeting that target since the pandemic period.

A graph showing the proportion of people who receive the services they are assessed as needing within 28 days between 2017 and now

Reviews can respond to changes in people’s needs or circumstances, be targeted according to the services they receive, or scheduled to ensure that needs and circumstances haven’t changed, and the services being delivered are meeting them. The Care Act (2014) highlights the importance of periodic review, and we recognise the importance of this in promoting people’s independence. Nevertheless, a decline in performance in this area was evident before the pandemic period but is only recently beginning to improve with still less than 50% of people receiving services for more than a year receiving a review in the previous 12 months. An important reason for this is that although staff capacity has not been increased, safeguarding activity has doubled in this period.

A graph showing the proportion of people who have been receiving services for more than 12 months and have been reviewed in the last 12 months

This turnaround in performance is mainly driven by a targeted review programme which is based on reviewing those cohorts of people who data suggests are most likely to benefit from a reassessment of their needs, meaning the number of people with an outstanding review has reduced to around 3,000, a similar number to at the start of the pandemic.

A graph showing the number of people who have been receiving services for more than 12 months and have not been reviewed in the last 12 months

The context of these performance challenges in undertaking timely assessment and regular review is a considerable increase in the number of safeguarding referrals in Devon in recent years, with volumes now typical of comparators proportionate to population from being a low outlier five years ago.

A graph showing the growth in safeguarding referrals in Devon

We have also devoted considerable capacity to undertaking Mental Capacity Act assessments in Devon, only having capacity to address backlog during a two-year period when the Council afforded the budget to increase the number of staff devoted to this function.

A graph showing the number of Mental Capacity Act assessments undertaken in Devon

Analysis – our safeguarding performance

This section summarises and updates section 12 of our Annual Report for 2022

Recorded safeguarding activity in Devon has tripled in the last five years because of concerted action to address the low rate of reported concerns by raising awareness and improving practice.

We are now above our comparator group average but still below the England average. It is a national challenge in monitoring and improving performance that adult safeguarding practice differs widely around the country with no consensus regarding what is good.

The rate of concerns relative to population between localities in Devon does not differ significantly.

Two charts showing Safeguarding concerns. The first shows the increase in concerns from 2017-18 to 2022-23. The second shows how the rate of concerns in Devon compares

There has also been a large increase in the rate of enquiries (concerns that meet the threshold for further investigation) which has brought us closer to but still behind the England average compared to previous years, and we now exceed the average of our comparator group, meaning a 50% increase in activity year-in-year.

The rate of enquiries between localities in Devon relative to population differs significantly, with that in North being almost double that in East and three times that in South or West and this is being investigated as it may suggest the legal definition is being applied differently.

Two charts showing Safeguarding enquiries. The first shows the increase in enquiries from 2017-18 to 2022-23. The second shows how the rate of enquiries in Devon compares regionally, nationally and with similar authorities.

When we look at the details of the risks safeguarding Enquiries are about, we have now completed our return for 2022/23 and can report:

For the first year in several years the rate of safeguarding concerns has levelled out and safeguarding enquiries fallen
The conversion rate between concerns and enquiries has fallen to 20.3%, well below many comparator authorities, and this merits further investigation.
The demographics of people who concerns are raised about is similar to previous years and similar areas
The three highest occurring types of abuse are neglect, psychological abuse, and self-neglect – trends observed during and since the pandemic.
Over 70% of abuse is perpetrated by people known to the individual.
Risk was reduced in around 60% of cases following a completed S42 Enquiry and over 93% of people have the outcomes they are seeking met in whole or part.
The number of people being supported by a paid or unpaid advocate has increased.
There were four Safeguarding Adults Reviews have increased from two to four in the latest year and relate to the deaths of nine individuals.

In 2021/22, service users in Devon generally felt safer than all of our comparator groups with performance improving to 60/152 Local Authorities in England (Quartile 2).

When considering the impact of social care services on perceptions of safety we have seen a significant and sustained improvement over time now ranking 45/152 Local Authorities in England (Quartile 2).

While not confirmed, initial indications from 2022/23 including regional benchmarking indicate that while Devon’s performance in these indicators has declined marginally, ranking is not likely to change significantly.

Charts showing survey indicators relating to people's perceptions of safety.

While applications for and assessments of Deprivation of Liberties Standards is not a focus of the Assurance Framework developed by the Care Quality Commission, as with changes in Safeguarding activity it is an important context in which to consider other aspects of operational performance.

In Devon, we have continued to see an increasing trend in the number of applications received, which has jumped significantly in 2022/23 with waiting lists continuing to grow, the period of significant decline in 2018/19 relating to the Council making short-term additional investment in capacity during that period.

Two graphs showing the increasing trends in applications for Deprivation of Liberties Standards and consequent waiting lists.

Analysis – our activity, cost and spend

This section summarises and updates section 15 of our Annual Report for 2022

In our 2022 annual report, referring to comparative data from 2021/22, we noted:

Devon spends £52.9m per 100,000 population (18+) which is more than all comparator averages but has reduced by 4.6% due to loss of specific grants relating to pandemic response.
A greater proportion of the Devon County Council budget is spent on adult social care than ever before, now approaching half of the authority’s expenditure, and a greater proportion of this spend on people aged 18-64, in line with national and regional trends over the last decade.
We consistently spend more and serve more people aged 18-64 and spend less on and serve fewer people aged 65+ relative to our population than is typical nationally or regionally, especially relating to those living in the community.
The main drivers of increasing spend are increasing demand from people aged 18-64 and increasing unit cost of community based and residential/nursing care for older people 65+.
Our income (including from charging people and via the NHS) is £21.35mn per 100,000 population (18+), also in excess of all comparators, mainly due to relative wealth of those aged 65+.
Our hourly rates for regulated personal care are among the highest in the country and the weekly cost of residential/nursing care has been rising more rapidly than is typical elsewhere.

Exploring comparative spend on adult social care in Devon in 2021-22 using further analysis by the Local Government Association (including using their Use of Resources Report and undertaking deeper analysis with them using their Better Lives Framework relating to people with Learning Disabilities) we jointly conclude that our own previous analysis was sound, and the challenge was to understand the root causes where we are an outlier, and to act on that through our change programme, given that key features of the profile of activity, cost and spend in Devon had been apparent over a number of years.

In the following charts Devon is the circle, similar authorities the square, and the England average the diamond:

Devon is in the 2^nd quartile of spenders relative to its adult population overall, partly due to having a comparatively aged and ageing population.
We are comparatively high spenders on working age adults and this is because of the number of people we serve rather than the amount spent on each individual.
We are comparatively lower spenders on older people relative to our elderly population and this is because we serve fewer people than is typical as our service unit costs have become more expensive than is typical in recent years.

A sequence of charts comparing spend on adult social care in 2021-22 in Devon with that in similar authorities and the England average by quartile.

We have recently completed our Short and Long Term services (SALT) return and can make some preliminary observations:

The number of working aged adults supported has levelled out after an increasing trend over recent years, including a decrease of 55 in the number of people with learning disabilities supported (including 25 fewer in residential care) where we have been a high outlier.
The number of older people supported has also levelled out after a decreasing trend over recent years with a continuing shift from people supported primarily for their physical needs to those supported because of their dementia.
Also regarding older people, while those receiving community services has continued to decrease against demographic trend, but those in residential care has increased for a second year, and looking across data sources there is evidence this is because people are being admitted into short-term placements to enable hospital discharge that then become long-term.
We have changed the methodology for assessing the number of carers we support to align better to practice elsewhere meaning comparisons between this and previous years should be treated with caution. All carers who receive funded packages of support in Devon do so via direct payments, mainly to access respite care.
Our targeted reviews programme which began in late 2022 is beginning to impact on our performance, with a greater proportion of people receiving services for more than 12 months than previously receiving a review, albeit from a low base and still well below last year’s regional and national averages.

In common with other local authorities whose NHS delivery partner has been impacted by a cyberattack on the provider of a case management system commonly used by Mental Health Partnership Trusts, our 2022/23 return has been marginally impacted by an under-reporting of activity relating to people with mental health needs.

We have not yet completed our Adult Social Care Finance Return (ASC-FR) but do not anticipate any significant shifts in our comparative position judging by known trends in activity and cost.

Analysis – our provider market quality and sufficiency

This section summarises and updates section 13 of our Annual Report for 2022

In Devon, the proportion of Good and Outstanding ratings the Care Quality Commission gives to providers in Devon is consistently greater than the regional and national averages overall and when judged against the five key questions regarding whether they are safe, caring, well-led, effective and responsive.

We are proud of the comparative quality of adult social care providers in Devon and of the work we have done in partnership with them to assure and improve their quality over many years and look forward to extending that approach regionally using the Provider Assessment and Market Management System.

For residential services on 1 May 2023 over 89% of services in Devon were rated Good or Outstanding with Outstanding ratings more than double that seen nationally.

Infographic depicting the comparative ratings of regulated residential and nursing care providers: Devon, regional, national.

For community-based services on 1 May 2023 almost 83% of services in Devon were rated Good or Outstanding with Outstanding ratings more than triple that seen nationally.

Infographic depicting the comparative ratings of regulated community social care providers: Devon, regional, national.

Our Market Position Statement tool identifies 312 care home providers with a total bed capacity of 8123. We currently commission placements from 284 of these providers.

In the 12 months to 1 May 2023, we were commissioning a total of 3,373 beds: 769 nursing placements and 2604 residential placements. Overall, the number of beds is below the regional and comparator averages and weighted more towards residential than nursing care.

While there are generally sufficient residential and nursing care home beds across the county for long-stay care, there are times when it is difficult to identify a suitable care home for someone to live in at short notice that both meets their needs and is in proximity to their family and friends, and short stay care to provide replacement care can be particularly difficult.

On occasions, we struggle to source appropriate care for people with more complex needs in the area where they live.

Tabular infographic depicting our market position statement data regarding nursing and residential services

Over time we have seen a reducing trend in the number of personal care hours commissioned resulting in circa a third fewer older people being supported in their own homes compared to 2017.

This may be reflective of the impact of promoting independence by preventing, delaying and reducing the need for care and support.

Market sufficiency, however, remains a challenge, where we are currently short of circa 1,071 hours per week, a significant improvement on the peak of 6,000 hours as we emerged from the pandemic, but nevertheless a concern mainly due to being unable to recruit and retain staff in a competitive labour market and a situation which we monitor daily including the contingency arrangements we have in place to meet people’s needs.

Devon’s response to these challenges (Proud to Care and Love Care, including our recent international recruitment drive) is highly regarded by the Department of Health and Social Care delegations from which have visited Devon twice in the past two years.

Tabular and graphical infographic depicting the unsourced hours of personal care in Devon and the contingency arrangements in place for the people impacted

Analysis – our risks and how we manage and respond to them

We assess strategic risks on a quarterly basis using a matrix that scores impact or severity and likelihood or probability before and after agreed mitigating actions according to a standard methodology.

The higher scoring risks assessed within our commissioning and operational leadership teams are escalated to our Integrated Adult Social Care Leadership Team, and the highest to our Corporate Strategic Leadership Group and reported to our Audit Committee.

A diagram depicting the quarterly cycle of risk management in adult social care in Devon County Council.

The highest rated risks in adult social care following mitigating actions include:

Having sufficient budgetary resources to meet statutory duties where there is rising demand e.g., in meeting Care Act eligible needs, advocacy requirements, undertaking Deprivation of Liberties Standards assessments.
Working effectively in partnership across the health and care system given recent changes in leadership and financial sustainability pressures.
Safeguarding adults at risk with care and support needs when concerns raised have tripled over five years.
Meeting our Care Act market sufficiency duty in the residential (especially for people with more complex needs) and community (especially in more isolated rural areas) sectors given workforce pressures.
Maintaining Social Care Reablement capacity and capability to promote recovery and rehabilitation given competing demands on the service.
Lacking practice quality assurance data from over and since the pandemic period limiting our insight into the quality of operational practice including safeguarding.

We contribute to reporting to Audit Committee regarding risk management, internal and external audit programmes, and the statement of accounts.

Our audit plan for 2022-23 included activities focussed on:

Our supported living tender.
Our care home fee model.
Preparations for the introduction of Liberty Protection Safeguards.
Pandemic response.
Replacement care.
Care provider failure.
Care management system replacement.
Disability practice.
The recruitment and retention of social workers and occupational therapists.

In Devon we take a partnership approach to Emergency Planning Preparedness and Response covering:

Preparation and planning, with business continuity plans on record for each adult social care service and setting we operate, and tools we use to prioritise the services we deliver and the people receiving them.
Business continuity advice to providers in the independent and voluntary sector through our Provider Engagement Network, with regular items in our newsletter and a warning system for extremes of hot and cold weather.
Emergency response arrangements for how we respond to major incidents in and out of hours and how we recover them and rebuild community resilience.

Our arrangements were well tested during the pandemic with strategic, tactical and operational command structures deployed to effectively respond to an often fast-changing situation:

Strategic through a ‘Team Devon’ Local Outbreak Management Board linked to the Local Resilience Forum and making key decisions including on communications messages to be delivered to staff and public from across the partnership.
Tactical through a whole council Incident Management Team with key representation from across the organisation analysing data, responding to changing government guidance, deploying financial and other resources including government grants, and ensuring focus was evidence-based and guided by risk.
Operational with a dedicated Incident Management Team in Adult Social Care working in concert with Public Health colleagues locally, regionally and nationally within a cellular structure, with senior managers leading on aspects such as PPE provision, vaccination, and care home response.

During and since this period, our arrangements have also been tested by incidents including:

A one-ton unexploded bomb being discovered on the boundary of a care home leading to an exclusion zone and evacuation of properties within a 500m radius with residents and other vulnerable people being reaccommodated.
Storm Eunice meaning up to 20% of properties in the county were without power, some for up to a week, with a multi-agency response ensuring the most vulnerable continued to have their needs met including through emergency supply and accommodation.

Learning from the pandemic and these incidents is currently informing a corporate review and improvement programme including training for involved managers and staff on topics such as legal advice and logging, and exercising, in conjunction with NHS and other partners.

Our adult social care out of hours arrangements include:

An emergency duty service with Approved Mental Health Practitioner capacity and capability
An on-call senior manager duty rota covering overnight, weekends and bank holidays, bolstered by a deputy in peak periods, and supported by an information pack updated weekly.
WhatsApp groups to mobilise support during an emergency.
Complementary on-call arrangements within the Emergency Planning Team, the Public Health Team and the Corporate Leadership Team.

Self-assessment: our approach to assurance and improvement

The Health and Care Act (2022) gave the Care Quality Commission (CQC) new regulatory powers to undertake independent assessment of local authorities’ delivery of regulated care functions set out in Part 1 of the Care Act (2014).

The assessment framework draws on the new CQC approach that defines a set of quality statements that are arranged under topic areas and describe what good care looks like. The framework aims to:

Set out clearly what people should expect a good service or system to look like.
Put people’s experiences of care at the heart of judgements.
Ensure that gathering and responding to feedback is central to the expectations of those assessed.

Infographic depicting the CQC single assessment framework

This assessment framework has been grouped into four key themes, each with several quality statements mapped to them:

How local authorities work with people – assessing needs, care planning and review, direct payments, charging, supporting people to live healthier lives, prevention, wellbeing, information and advice, equity in access and outcome.
How local authorities provide support – market shaping, commissioning, workforce capacity and capability, integration and partnership working, supporting carers in their role.
How local authorities ensure safety – safeguarding enquiries, reviews, Safeguarding Adults Board, safe systems, pathways, transitions, and continuity of care.
How local authorities lead the care system – culture, strategic planning, learning, improvement, innovation, governance, management, and sustainability.

Illustration of the four themes and nine quality statements of the CQC framework as it applies to local authorities

With CQC assessment beginning in 2023, Devon County Council could be asked to provide information including a self-assessment and facilitate an inspection visit at any time, with the first judgements on how local authorities are meeting their statutory duties expected to be published in the Autumn and all 152 scheduled to be assessed within a 2-year baselining period.

Each year in Devon we have maintained the discipline of writing and sharing an annual report which is our assessment of how we are performing. For the 2022 annual report, we extended the range of evidence we use to represent the lived experience of the people we serve to include:

Some key facts about the population of Devon and the people we serve.
The money we spend on those services, activity levels and their cost.
The outcomes we achieve, including those defined by the government in the adult social care outcomes framework which we can benchmark against other local authorities.
What people say about their lives and the difference services make to them, through structured and statistically sampled surveys, at the various involvement groups we facilitate, and through the organisations that give them a voice such as Healthwatch.
How our operational services perform in meeting our statutory responsibilities to assess and review people’s needs and arrange services to meet them.
In particular, how well we fulfil our safeguarding duties compared with other councils, with analysis of who and what concerns are about, and their resolution.
The quality, sufficiency, and affordability of our market of independent and voluntary sector providers of adult social care services.
The recruitment, retention, demographics and continuing professional development of our internal and external workforce.
What we learn from complaints, audits, and other formal feedback.

We are now revising our Assurance Framework to better align to our updated Vision and Strategies, using the wider evidence base contained in our annual report, and aligned to the structure of the CQC assessment framework. This has been accompanied by changes to our Assurance Governance to give all stakeholders a clearer and more complete view of how we are doing.

Infographic depicting the approach to governance of assurance in Integrated Adult Social Care in Devon County Council

An Assurance Board has been established to coordinate assurance governance relating to Adult Social Care in Devon County Council by overseeing our gaining insights and determining improvements from:

Our use of performance and outcomes data recognised as examples of best practice by DHSC and LGA.
Reinvigorating our approach to practice quality assurance and provider quality assurance.
Distilling, listening, and responding to all forms of stakeholder feedback.
Identifying, managing, and mitigating risk strategically, tactically, and operationally.
Learning from independently facilitated audit, complaints, and other feedback.

The Board oversees and complements existing performance management and quality improvement arrangements where the operational detail of assessing and improving performance and quality is undertaken.

This document was informed by the use of the LGA Self-assessment Toolkit, with a lead and team drawn from across the organisation assigned to each theme. Findings were then tested with a wide range of stakeholders including staff, other colleagues in and members of the Council, partners, providers, and representative users of services and their carers.

Self-assessment: working with people – assessing and reviewing needs

Through self-assessment, we have identified our key strengths as:

Showing trends in the indicators that form the Adult Social Care Outcomes Framework, especially regarding service user overall satisfaction, quality of life, and promoting independence.
Transforming our approach to person-led reviews to increase their quality and frequency with a programme of reviews targeting those who may benefit most from approaches which promote their independence.
Using enabling services such as reaching for independence to have a positive impact on people’s lives where they are received.
Increasing choice and control through the use of self-directed support.
Using quantitative information to understand and improve performance, with tools available to inform leaders and managers at every level strategically, tactically, and operationally.
Using triage and dynamic risk assessment to focus our limited staff capacity on those with most pressing need and/or at greatest risk.

Through self-assessment, we have identified our key challenges as:

Addressing the growing waiting lists in assessment, review, and DoLS assessments with an aspiration to completing assessments within 6 weeks and reviewing annually.
Making sure that our first response is preventative wherever possible, promoting independence.
Responding to people in crisis with short-term care and support consistently and effectively, targeted to maximise independence before assessing and meeting any long-term needs.
Being consistent in our home first approach, making sure that the right care to the right people at the right time avoids care home placements that are not the right place for the person then.
Improving how we support unpaid carers by recognising the detrimental impacts of social isolation and how they can be addressed in practice including through respite and replacement care.

Following self-assessment, we aim to use evidence better by:

Extracting learning from practice quality audit to assess individual and collective quality, understand strengths, and target individual and collective areas for improvement.
Using compliments and complaints more systematically to identify best practice and where we need to improve e.g., in consistently applying our promoting independence and supporting policies.
Using supervision to individually identify best practice and where we need to improve e.g., in embedding the wellbeing principle.
Having better information about contacts at our front door, the support given, and the impact and outcome of that support.

Following self-assessment, we aim to improve by:

Encouraging and increasing the use of our self-help and self-assessment tools to enable people to meet their own needs wherever possible and to initiate formal assessment where necessary.
Improving our front door arrangements by changing from a three to two-tier operating model to reduce hand-offs and ensure people speak to those with the right expertise sooner.
Improving our practice in direct payments to make sure it is consistently promoted to those for whom it might be the best option; informing those who hold them how to use them best by using e-learning.
Creating more capacity for targeted short-term interventions that promote independence by continuing to improve sufficiency in the personal care market, avoiding those services being diverted in contingency.

Self-assessment: working with People – supporting people to live healthier lives

Through self-assessment, we have identified our key strengths as:

Having a population with life expectancy and healthy life expectancy in the top quartile and significantly above the national average.
Giving access to intermediate and reablement services that have positive impacts including avoiding admissions and readmissions to hospital and in not requiring further ongoing support.
Making available preventative services that adapt people’s homes and provide equipment to improve their ability to live independently.
Showing an upward trend in the indicators in the Adult Social Care Outcomes Framework that measure access to information about services for both people who use services and their carers.
Having a consistently higher than average proportion of people learning disabilities in employment and living in appropriate accommodation, maximising their life chances including social opportunities.
Responding to the pandemic with a whole system approach to preventing outbreaks and supporting settings where they occurred, limiting fatalities in care homes to among the lowest in the country.
Promotion the uptake of vaccinations, with uptake among care staff and in care settings among the highest in the country.

Through self-assessment, we have identified our key challenges as:

Delivering on a strategy that emphasises the promotion of wellbeing and independence through prevention and short-term targeted intervention in a period of financial challenge.
Working with Public Health to ensure that preventative approaches are targeted on preventing, delaying, and reducing needs for adult social care and central to One Devon and Council strategies and plans.
Addressing how we support working age adults, especially those with lower-level needs who are more likely to receive ongoing support in Devon than elsewhere.
Refocussing a public health system that was mainly focussed on local outbreak management for over two years to addressing the wider determinants of health by encouraging healthier behaviours.
Making more progress in driving up the uptake of and modernising our Technology Enabled Care Services and other aspects of our Digital Care programme.

Following self-assessment, we aim to use evidence better by:

Improving how we evidence and evaluate the impact of preventative services such as Technology Enabled Care Services and home adaptation.
Improving how we evidence and evaluate the impact of short-term interventions we commission, building on our approach to monitoring the impact of those we provide.
Improving how we evidence and evaluate the impact of partnership working and initiatives jointly funded through the Better Care Fund or otherwise at system or Local Care Partnership level.
Seeing more join-up between the approaches of adult social care and public health in the use of data.

Following self-assessment, we aim to improve by:

Creating clear leadership responsibility to focus on prevention and early intervention including front door and information advice.
Joining this up with our leadership roles that focus on support to unpaid carers and Technology Enabled Care Services.
Extending our review of governance into partnership working including our memoranda of understanding, section 75 agreements, governance of Better Care Fund, and Local Care Partnerships.
Working more closely within the council and across the system to fulfil the priorities and ambitions of our One Devon strategy and plan to achieve its ambition of there being equal chances for everyone in Devon to lead long, happy, and healthy lives.
Securing a stronger commitment to prevention in the update to the council’s strategic plan, linking it to both promoting wellbeing and managing the demand for statutory services such as adult social care.

Self-assessment: working with people – equity in experience and outcomes

Through self-assessment, we have identified our key strengths as:

Having a well-developed and embedded approach to involving people with lived experience in our work strategically and in the commissioning and development of services.
Involving people with particular disabilities and conditions through their own groups (e.g. autistic people, people with learning disabilities) and those with protected characteristics through our equalities reference group and representative user-led organisations.
Supporting decision makers with impact assessments that encourage all involved to consider people with the range of protected characteristics, including through accessible consultations.
Commissioning a Race Equalities Audit and responding to its findings by developing and beginning to deliver a resulting action plan demonstrating increased commitment to anti-racism in initiatives such as international recruitment.

Through self-assessment, we have identified our key challenges as:

Fulfilling the commitments that followed from our Race Equality Audit involving raising staff awareness, encouraging staff commitment, and addressing inequalities in our employment practice.
Seeking to broaden that corporate approach to be more externally focussed on those we serve and to consider other groups with needs associated with their protected characteristics, or other factors such as their faith, who may also experience disadvantage.

Following self-assessment, we aim to use evidence better by:

Seeking, creating, and triangulating practice quality assurance data with insights from people with lived experience to inform, co-produce, and improve the quality of our operational practice.
Ensuring equity is fully considered in impact assessments, where the distributed and varied nature of people from ethnic minorities and LGBT communities sometimes means their particular needs are not always considered.
Broadening our Race Audit Action Plan seeking to use data to demonstrate whether people from ethnic minorities achieve equality of access to, experience of, and outcomes from the services we deliver and commission.
Ensuring our analysis of complaints addresses potential inequalities by being more mindful of the protected characteristics of complainants and including that in reporting.
Ensuring equalities in general, and regarding ethnicity in particular, are featured in our self-assessment for LGA peer challenge and CQC assessment and feature more strongly in our annual report to inform improvement planning.

Following self-assessment, we aim to improve by:

Considering a co-production group of people with protected characteristics to support and challenge our commissioning and service development building on the council’s commitment to an Equality Commission.
Continuing to ensure staff are challenged to consider their attitudes to race and other protected characteristics through a monitored learning and development programme.
Continuing to ensure leaders are additionally challenged to consider their attitudes to race and other protected characteristics through a mentoring programme and related means of challenge and support.
Exploring differential take-up of services and inequalities in access, outcome, and experience with relevant communities e.g., regarding safeguarding.

Self-assessment: providing support – care provision, integration, and continuity

Through self-assessment, we have identified our key strengths as:

Enjoying a high quality market of independent and voluntary sector providers, with a greater proportion of those in both residential/nursing and personal care sectors in Devon being rated Good or Outstanding by CQC than the national and regional averages, with particular strengths in being safe, caring and well led.
Having 19/26 indicators in the Adult Social Care Outcomes Framework (ASCOF) in 2021-22 in the top two quartiles with service user overall satisfaction and quality of life being consistently high.
Strengthening relationships with providers during the Coronavirus pandemic, with communication and engagement based on mutual respect.
Demonstrating effective partnership in the same period, with adult social care providers and health and care support organisations working well together to address shared challenges.
Paying providers higher than average fees to stabilise their finances and encourage workforce recruitment and retention through higher wages.
Offering a wide range of free training to provider staff, including giving access to resources designed to improve their physical and emotional wellbeing.
Working together to improve recruitment and retention e.g., through ‘Proud to Care’ and ‘One Devon’, with international recruitment helping to reduce insufficiency in the personal care market by two-thirds.
Embedding the Equality Act 2010 within our commissioning practices including in impact assessments, tenders, and contracts.

Through self-assessment, we have identified our key challenges as:

Sustaining market and workforce sufficiency, particularly in the personal care market, and in complex dementia support in residential settings.
Developing our contracts and contractual frameworks to give more clarity on expectations regarding service delivery and cost.
Undertaking timely reviews of individuals on a scheduled basis to pick-up on changing needs of the individual or otherwise unidentified risks.
Monitoring out-of-area placements more effectively, ensuring quality assurance of providers and the review of high-risk services and individuals.
Profiling risk across all types of providers with subsequent management to mitigate against and minimise provider failure.
Supporting providers to embrace change and innovate e.g., in digital and Technology Enabled Care Services (TECS), especially the small and medium sized providers that dominate the Devon market.
Improving the wellbeing of staff across the sector in recovering from the pandemic with absence and turnover levels still indicating burnout.
Securing more options in specialist provision such as for the homeless, those with mental health needs, and unknown vulnerable adults.
Having a care market dominated by smaller organisations and settings, which although being correlated with better CQC ratings, are also more likely to experience challenges to their financial sustainability and deliver services less adaptable to changing needs.

Following self-assessment, we aspire to use evidence better by:

Improving how we evaluate the effectiveness of some of our support and challenge to providers such as interventions by the Quality Assurance and Improvement Team.
Capturing the impacts of investments and initiatives such as the Better Care Fund (BCF), community catalysts, and Technology Enabled Care Services (TECS).
Seeking feedback from providers in a more structured way that enables us to target and drive improvement.
Obtaining better evidence to demonstrate whether people of all backgrounds are experiencing equal access to and outcomes from services and having their particular needs met.
Make better use of Capacity Tracker, building on it becoming a statutory provider return to ensure provider information is complete and contemporary, and using it to track monitor capacity and workforce.
Completing the implementation of PAMMS to support the quality assurance and risk profiling of individual providers and enhance market intelligence including making out of area placements more visible, enabling mutual quality assurance arrangements.
Improving access to and analysis of data on out of county placements and then ensure that effective quality assurance and review arrangements are in place to ensure people’s needs are being met in settings where we have the same expectations of providers as we would if they were in Devon.
Deploying the PAMMS Landscape tool to improve market intelligence and inform better commissioning including through better forecasting of changing demand for services.

Following self-assessment, we aspire to improve by:

Updating our Market Position Statement and delivering on our Market Sustainability Plan through a clear set of commissioning intentions and plans aligned to our vision and strategies.
Encouraging providers to reshape their business models to meet those commissioning intentions underwritten by the changing care and support needs of the population we serve.
Updating our carers strategy delivery plan and working with Devon Carers to improve the outcomes we achieve for carers within the limits of our resources.
Continuing our initiatives to improve the recruitment and retention of frontline care staff, evaluating approaches to understand which make most difference, and focussing on those e.g. in improving staff health and wellbeing to reduce absence.
Supporting safer recruitment, in particular when recruiting internationally, to bring people with the right values and aspirations into the care sector in Devon, and work to reward them better.
Extending the approaches, we have developed to manage, and quality assure regulated providers into the unregulated sector.
Maximising operational staff capacity to undertake more reviews, gathering and using intelligence on provider quality, including out-of-area placements.
Using data from our public and provider web pages to assess their reach and effectiveness.

Self-assessment: providing support – partnerships and communities

Through self-assessment, we have identified our key strengths as:

Understanding the diverse health and care needs of our populations and communities in commissioning through needs analysis and operationally through multi-agency teams embedded in communities.
Having operational arrangements that are flexible, joined-up with the NHS, support choice and promote independence including through short-term interventions such as reablement, intermediate care, and end-of-life care.
Developing locality provider forums which are now embedded in all localities and bring together health and care commissioners and operational managers with independent and voluntary sector providers.
Working with the voluntary sector to support and facilitate new approaches e.g., dementia memory cafes which are now self-sufficient.
Sharing learning and collaborating on system and service improvement e.g., hospital discharge initiatives such as the Devon Carers Hospital Service and the provision of 1:1 agency staff to get people with complex needs home quickly while their longer term needs are assessed, and solutions and their funding agreed.
Supporting Personal Assistants and micro-providers, including social enterprise opportunities.
Building strong relationships within the council to secure their support in meeting adult social care priorities e.g., with public health in preventing and managing outbreaks in care homes, with Economy and Enterprise in promoting health and care as the largest sector and employer in the local economy.

Through self-assessment, we have identified our key challenges as:

Understanding the needs of self-funders, supporting them to make decision and ensure market sufficient to meet needs.
Ensuring equitable access i.e., developing the market in less well provided for areas to increase provision where there are gaps in service provision, especially in rural areas where the population is dispersed.
Maintaining system flow, especially during winter and other periods of high demand on hospital services.
Managing a budget which is under pressure through rising demand, increasing costs, insufficient supply, cost of living pressures, and falling council income.
Supporting unpaid carers to meet their own needs and enable them to maintain their caring role without detrimental impact on their health and wellbeing.
Being active within housing planning and development to encourage affordable and incentivised housing to support workforce expansion.
Sustaining the good relationships we have enjoyed across the Integrated Care System through changes in leadership and challenges with continuing to deliver good outcomes when under financial pressure to deliver on the One Devon five-year forward plan.
Taking local best practice often growing from local expertise and enthusiasm and spreading it across the county.

Following self-assessment, we aim to use evidence better by:

Making better use of research and best practice to inform our commissioning strategies and plans.
Using Capacity Tracker data and ONS research to improve our understanding of demand from self-funders and how the adult social care market is meeting it.
Working with District Councils to better understand the take-up of social housing and housing with support by people with current or potential adult social care needs.
Working with NHS trusts to improve our understanding of the journeys of people through the health and care system and inform the planning, delivery, implementation and evaluation of system-level change e.g., through joined-up Client Level Data and pathways analysis.

Following self-assessment, we aim to improve by:

Targeting market development on services (e.g. care homes specialising in dementia support) and geographies (e.g. personal care in the South Hams) where there is lack of provision.
Working across the partnership to improve how we minimise and respond to individual crises and larger-scale incidents through more proactive ‘business as usual’ approaches.
Participating fully in corporate approaches to reduce spend that does not add value e.g. on agency staff or on functions that do not deliver our statutory duties.
Working with carers who surveys indicate are often less satisfied, have a lower quality of life, and feel more socially isolated than the people they care for to improve their outcomes.
Ensuring a stronger voice in the One Devon Five Year Integrated Care Strategy and the Joint Forward Plan to ensure the council’s adult social care priorities and plans are fully reflected.
Strengthening joint approaches to commissioning, market management and quality assurance.
Extending co-production from pockets of good practice into our usual approach to service commissioning, development, and improvement.
Working more closely with other local authorities in the system, region and beyond to learn from and cooperate in shared challenges and successes e.g., in specialist commissioning.
Building on ‘Team Devon’ of local authorities in Devon and the housing forums we have established to deliver on our shared aspirations to improve housing options for people with care and support needs and of key workers e.g. through planning powers, the use of Section 106 funding and public sector land assets.
Improving our commissioning of community mental health services including undertaking a joint review of the functions we delegate through our Section 75 agreement with the Devon Partnership Trust.

Self-assessment: ensuring safety – safe systems, pathways, and transitions

Through self-assessment, we have identified our key strengths as:

Having a greater proportion than the national average of people using adult social care services feeling safer and that the services they receive make them safer.
Responding to emergencies effectively, our arrangements having been tested during and since the pandemic by a major unexploded bomb being found on the boundary of a care home, by Storm Eunice leaving many care settings and service users without power, and by a fire in a care home in South Molton requiring the re-accommodation of all residents.
Supporting to care providers in maintaining business continuity, with our 24/7 agency staffing support during the pandemic commended as a national exemplar.
Having effective multi-agency and adult social care specific winter plans and governance arrangements.
Monitoring provider risk, enabling proactive interventions where risks are emerging to avoid reactive scenarios relating to provider failure.
Maintaining effective links between the on-call manager, the emergency duty service, NHS and council on-call arrangements, and national agencies such as UKHSA, all tested daily though the pandemic and recently during periods of industrial action.

Through self-assessment, we have identified our key challenges as:

Working with children’s services to improve SEND services to children and young people and their ILACS rating from Ofsted.
Using our integrated operational arrangements to avoid funding disputes relating to hospital discharge, CHC S117, and FNC when council and NHS budgets are under pressure.
Experiencing hospital discharge pressures leading to consequent decisions that may mean people are not always receiving the right support for them at that time, including the use of short-term residential placements that become long-term with sub-optimal outcomes.
Monitoring services where people move in and out of area where quality assurance and case review arrangements are less secure than those accommodated within the county.

Following self-assessment, we aim to use evidence better by:

Implementing PAMMS to better monitor provider and individual risk in settings outside of Devon and of out of areas placements, outgoing and incoming.
Improving how we triangulate data on process and outcome with feedback from people and qualitative data from practice quality audit and other mechanisms that seek to assess and improve practice quality.
Using the potential richness of complaints information to understand and address themes highlighting where we are deficient which we know is often at transitions into and between services.

Following self-assessment, we aim to improve by:

Embedding the identified learning from the themes of Safeguarding Adults Reviews (including mental health, coercive control, cuckooing, and neglect including self-neglect) in a large rural and organisationally complex area.
Fulfilling the promise of the DCC Disaster and Emergency Management System (DEMS) programme learning from recent emergency incidents to further improve our preparedness and response.
Further developing our Preparing for Adults service to achieve safe transitions between children’s and adult social care.
Working to better join up support to unpaid carers and the people they care for when these assessments and services are delivered by different organisations.
Improving our monitoring of, and operational practice towards, out-of-area placements such that we ensure mutual quality assurance arrangements and regular review to keep people safe.
Improving the commissioning and monitoring of our services to people with mental health needs with staff assigned and responsibilities discharged through a Section 75 agreement with Devon Partnership Trust.
Implementing our revised provider failure policy to give clarity to all stakeholders and consistency for providers.

Self-assessment: ensuring safety – safeguarding

Through self-assessment, we have identified our key strengths as:

The joint commissioning of safeguarding training aligned to the partnership competency framework defining appropriate training based on role within the organisation and across the partnership e.g., 3-tier domestic abuse training package delivered by a partnership of three of Devon’s specialist third sector domestic abuse organisations with a focus on hidden harm.
The partnership development of overarching safeguarding practice guidance including specific guidance on:
- A quick guide for when to raise a safeguarding concern.
- Guidance on safeguarding for organisations that undertake the management of medicines.
- Guidance on the relationship between falls prevention and safeguarding.
Embedding the National Friends Against Scams E-Learning initiative as part of our Level 1 Safeguarding Adult training offer for practitioners to address the noted increase in such scams during the pandemic.
Using data analysis to inform and achieve improvement including through an annual deep dive into published data yielding insights that led to action and improvement, with rates of concern and enquiry now similar to comparators, as are the outcomes achieved under Making Safeguarding Personal.
The quality of regulated services in Devon as assessed by CQC with a greater proportion being rated Good or Outstanding than is typical regionally or nationally and in particular with regard to their safety.
Sound multi-agency policy, guidance, process, and training with a new policy in place to address serious incidents.
A partnership approach to whole service safeguarding incorporating and continuously learning from provider feedback.

Through self-assessment, we have identified our key challenges as:

Reinvigorating our approach to the quality assurance of safeguarding practice to inform our improvement activity.
Ensuring consistent uptake of safeguarding training, including through improved monitoring of learning and development individually and in aggregate.
Exploring our comparatively low conversion rate of concerns into enquiries and differential activity between localities by understanding whether they are driven solely by differences in population, services, and risk or result from inconsistent application of the Section 42(1) legal criteria.

Following self-assessment, we aim to use evidence better by:

Building on the use of our Community Reference Group of people with lived experience of safeguarding processes by ensuring those with protected characteristics who may not achieve equality of access, experience or outcomes are represented.
Embedding our Safeguarding Practice Governance Group and ensuring that through reinvigorating practice quality assurance it is informed by qualitative as well as quantitative information.

Following self-assessment, we aim to improve by:

Focussing on the strategic priorities determined by our Safeguarding Adults Board i.e.
- To embed the learning from Safeguarding Adults Reviews (SARs) into organisational practice.
- To work with partners to better understand and reduce the risk of ‘hidden harm’, especially in the context of COVID-19.
- To improve outcomes for people with needs for care and support by finding the right solution for them.
- Improving involvement and engagement with people in receipt of safeguarding services.
Improving internal safeguarding operational guidance by building on the published partnership guidance.
Reinvigorating our assurance of safeguarding practice through a review of tools, take-up and reporting with consequent improvement planning and delivery.
Implementing a Rapid Improvement Process within our Safeguarding Adult Hubs focussed on waiting list management, risk assessment and triaging, allocation of concerns and enquiries, and recording requirements.

Self-assessment: leadership – governance, management, and sustainability

Through self-assessment, we have identified our key strengths as:

Achieving good outcomes overall, with 19 of 26 indicators of the Adult Social Care Outcomes Framework in the top two quartiles of national performance, especially those associated with promoting independence.
Being stimulated by the fresh ideas and approaches brought in by a new Chief Executive and Director of Adult Social Services who are supported by a stable and experienced senior management structure and team.
Having integrated operational leadership and management directing co-located and co-managed frontline staff.
Having stable and experienced political leadership with a Leader who chairs South West Councils and a Lead Member for Health and Care who chairs our One Devon Integrated Care Partnership Board where they are well respected and enjoy good relationships with local partners, as well as being well connected nationally to influence MPs and government.
Supporting our Health and Care Scrutiny Committee through coordinated agenda setting and report writing across the health and care system, providing regular masterclasses, and funding an independent expert advisor.
Having many senior leaders and managers being active and making a difference at regional and national levels through ADASS and other networks.
Demonstrating consistent success in regional and national awards schemes e.g., Social Worker of the Year.

Through self-assessment, we have identified our key challenges as:

Addressing financial sustainability, with the governance of budget setting in recent years acknowledged as not fully recognising the challenges of increasing demand and increasing costs.
Gaining sufficient and consistent corporate focus on adult social care in a context where our children’s services have been rated less than Good by Ofsted for many years.
Getting wellbeing in general, and adult social care in particular, sufficiently represented in the One Devon strategy and joint forward plan which is mainly NHS focussed.
Progressing from our recent refresh of our vision and strategies into realistic implementation plans in a context of financial and workforce challenges.
Understanding and acting on the comparatively worse outcomes we achieve for carers, including their quality of life being limited by social isolation.

Following self-assessment, we aim to use evidence better by:

Using the insights we gain from our data analysis of trends and benchmarking to inform medium-term financial strategy and change planning.
Finding ways of better using data to evaluate and improve equality in employment and of access, experience, and outcome of services.
Paying more attention in corporate and service level political and officer decision making to the information gathered to support it such as business case, impact assessment, and consultation outcome.
Building on our first stakeholder leadership survey by repeating it at least annually, seeking to improve response rates, and taking the results back to staff, members and providers to better understand their views and how representative they are and what needs to be done to improve where results are less good.
Learning from the latest Local Government Association adult social care employer standards healthcheck.

Following self-assessment, we aim to improve by:

Contributing to and implementing a corporate review of governance, including of budget and performance, initiated by our new Chief Executive.
Embedding the changes we have made to the governance of assurance and change management within adult social care to drive and evidence improvement.
Further developing our change programme to prioritise and schedule activity emerging from financial sustainability, strategy development, and assurance work into a prioritised medium-term plan.
Getting more grip on escalating demand and costs in areas where we know growth is greater than comparator authorities and is a root cause of our financial challenges.
Ensuring our internal and external workforce strategies are fit for the challenges of a changing labour market.

Self-assessment: leadership – learning, improvement, and innovation

Through self-assessment, we have identified our key strengths as:

Maintaining the discipline of a comprehensive annual report that provides a public, evidence-based reflection on our performance, outcomes, activity, cost, spend, markets, workforce, risk etc.
Using data and the data analysis tools and reports that draw insights from it effectively, with best practice in this area recently being highlighted by DHSC and LGA.
Informing budget setting by a comprehensive annual exercise analysing trends and benchmarking in activity, cost and spend.
Exemplifying how the use of data and other evidence can drive improvement e.g., from being an outlier five years ago, our safeguarding activity and performance is now similar to comparator authorities.
Identifying, mitigating, and managing risks in a complex environment, especially strategically but also tactically and operationally.
Using our ‘Unleashing Potential’ programme to grow and develop our own workforce e.g., through apprenticeships at all levels and with defined career pathways supported by a comprehensive learning and development programme for operational staff.
Involving people through a well embedded set of arrangements valued by both the organisation and people who use services and their carers who participate, with best practice in this area highlighted by a recent House of Lords report.

Through self-assessment, we have identified our key challenges as:

Combining strategic performance management and improvement with mechanisms that deliver that at locality and team level, addressing known differences in practice and effectiveness e.g., in safeguarding.
Acting on the insights we gain from data analysis more consistently e.g., LGA recently identified that although we have long highlighted more working age adults with lower-level needs are supported and why we have not successfully addressed the issue.
Turning our strategic intent into delivery and impact e.g., in shifting resources from long-term support to prevention and early intervention when budgets are constrained and under immediate pressure.
Making whole system improvement in a complex partnership environment e.g., working with eight district and city councils on housing, four NHS trusts in improving system flow.

Following self-assessment, we aim to use evidence better by:

Improving our use of qualitative information, especially distilling what we are told by stakeholders into intelligence that can be acted upon.
Reinvigorating practice quality assurance and provider quality assurance post-pandemic to give senior leaders and members clear line of sight to the frontline to drive those improvement cycles.
Making reporting of complaints more contemporary and with more focus on thematic analysis and identifying, monitoring, and evaluating actions taken.
Using our revised assurance arrangements to identify, prioritise and assign actions that address evidence gaps and areas for improvement feeding into a medium term change programme.
Being more consistent in the understanding and use of national research and best practice generated by organisations such as SCIE, NICE and the King’s Fund.

Following self-assessment, we aim to improve by:

Encouraging innovation across the system, including in providers, recognising that good practice is not always easily identified, developed, and sustained in a large rural authority and area.
Accelerating the digitisation of providers and use of Technology Enabled Care Services in a market that is dominated by small/medium sized providers that deliver good quality but not always flexibility.
Being more outward looking in improving services where we know we achieve less than Good outcomes such as providing breaks to unpaid carers, looking to similar councils who do demonstrably better.
Taking the recommendations and agreed actions of CQC assurance, Peer Challenge, Sector Led Improvement, and focussed support and challenge commissioned from LGA and IPC into our change programme.

At the Social Worker of the Year Awards 2022 , Lucy Hunt and Tom Wood won a gold and silver award in the Team Leader of the Year category.

Tom is an Adult Social Care Lead within Devon Partnership NHS Trust mental health services. He has experience working in London and Devon, in a range of adult mental health teams, as an AMHP and also as a social worker in Children’s Services.

Tom’s collaborative approach to being a team leader means his team members feel involved in the decision-making process and the direction the service is moving. He is committed to supporting others with continuous professional development, having co-created a monthly peer-reflective practice group across 2 teams; regularly providing trainees with placements/support in the team; supporting time for staff to do additional training/shadowing with other services, and facilitating a locality Social Work Forum within the Trust.

Lucy had a history of working with adults with learning and physical disabilities before moving into leadership positions in Adult Safeguarding, where she continues to be highly respected. Lucy has been in her current role as a Locality Team Manager since 2021.

Lucy is a trusted leader, whose members are not afraid to turn to her for advice or direction. Her team have advocated for the importance of her personable, honest approach in her leadership role. Her ability to bring humanity to the daily challenges faced when working in this sector is essential to the general wellbeing of her team.

Above all, Lucy is motivated by her passion for driving positive change within social care. She is consistently striving to create new solutions for her team, making their working efficient and organised. Lucy played a significant role in reviewing current practice to find areas to improve, forming a new Urgent Review Model which will influence transformations across the council’s adult social care service.

Congratulations to our colleague, Ana Barbosa, winner in the diversity and equality category at the West Country Women Awards.

Ana is a dedicated social worker, motivated to make a difference to people’s lives, and hugely driven by the values at the heart of her profession, empowering people to contribute to their communities and to be the answer to their own needs.

What makes Ana anything but typical is the leadership she has shown in Devon County Council’s anti-racism initiatives. Ana has been at the heart of the work, shaping and influencing, sharing her own experiences, encouraging others to do the same, and providing mentoring to those leading the organisation including our Chief Executive.

Ana has championed anti-racism and the need to be more than just not racist, but to call it out and to support those who do so, to help people understand what racism looks like, how it is received, and the impact it can have on individuals, communities and organisations.

Ana is bringing her experiences to shape our acceptable behaviour policies. Entering into constructive and positive dialogue with people that interact with Devon County Council, the services we provide and of course our staff to ensure that everyone in every role across the council can work in safe, inclusive and supportive environments, whether in the office, in a community care setting or in someone’s home.

In March 2021 Devon scooped a prestigious care award at the Health Service Journal Awards for a service designed to support unpaid carers, and highlighted as an example of integrated working by NHSE.

The service involves staff from Devon Carers, a service commissioned by Devon County Council and NHS Devon, working closely with hospital teams to identify situations where carers are involved, and where support for those carers is needed for patients to return home safely, or prevent hospital admissions and preventing breakdown.

By supporting carers, they are more able to look after themselves as well as caring for their loved one, neighbour or friend. In turn, that is preventing further hospital admissions, and reducing the length of time that patients are in hospital because they are able to return home sooner. The service has subsequently been delivered in all four acute trusts across Devon.

In June 2022, the Learning Disability Respite Team came second and were highly commended for its work in the small team of the year category of the Local Government Chronicle Awards.

Devon County Council’s residential respite units provide periods of overnight accommodation for the families of younger adults with a learning disability to give the families the essential breaks they need so that they can maintain their caring role. This is often the only break those families get.

The Pandemic challenged these families and services like never before; the response of this team was outstanding. Staff members have gone above and beyond, putting themselves and their families at risk of infection through their work caring for others. Working from home during lockdown has not been an option.

As hard as the pandemic has been for staff, they have grown and developed new skills, supporting older people and people in their final hours. They have learnt to support families through bereavement, and their support for one another has never been more important.

Following the temporary closure of our learning disability respite services when lockdown restrictions came into place, the team switched to become a bridging service to support people being discharged from hospital to home. They provided a supportive environment for people to learn, or relearn, lost skills following a hospital stay, to promote independence, reduce likelihood of readmission and help people to stay where they want to be – in their own home.

Moving with Dignity – Community Health and Social Care Teams shortlisted at the Local Government Chronicle Awards 2023 in the large team of the year category.

Local authorities face increasing difficulties supporting people to meet their needs, due to workforce recruitment and retention challenges, budget pressures, and limited provider capacity.

In Devon we have developed an effective approach to supporting people, improving their independence, and promoting their dignity. An approach that utilises care and support capacity more effectively, improves hospital discharge pressures, and realises savings.

Our approach has given new confidence to staff to see potential in people’s abilities to be more independent, to learn or relearn the skills that can enable then to get more out of live and do the things that matter to them.

The Northam Care Trust won the South West Region Kickstart award in the 2022 National Small and Medium Size business category.

The Kickstart Scheme provides funding to employers to create jobs for 16- to 24-year-olds on Universal Credit. Based in North Devon, Northam Care Trust provide person centred support to individuals with learning and physical disabilities, and older people and individuals with dementia. Services provided include supported living and enabling, residential, domiciliary care and day opportunities.

Westbank Neighbourhood Friends in Exeter won the 2021 Queen’s Award for Voluntary Services for its work during the pandemic to help to keep vulnerable or frail adults out of hospital, or to have shorter hospital stays.

They match volunteers with people who need assistance, so that they’re able to get out of hospital and back home as soon as possible. During the pandemic, their volunteers provided support to over 2,030 patients across the Exeter, East and Mid Devon area.

The Devon County Council team who coordinated our support to care homes and wider response to the pandemic as it affected adult social care in the county was highly regarded by many providers, with some of them inspired to present those involved with an ‘Inspirational Care Award’ recognising the partnership between the council, providers, and their staff that kept fatalities in care settings in Devon to a minimum.

The Devon County Council Reaching for Independence service works with adults and young people from the age of 17 in transition to increase their confidence for and skills in independent living.

A brewing company in Ivybridge is using Innovative Technology to enable people in Devon with learning disabilities and autism to gain and maintain skills essential for independent living and Employment.

Through the AutonoMe App custom content is developed to support individuals in their job and progress towards their outcomes in an individualised manner, and thereby reduce the need for direct support.

Steve has learning disabilities and dyslexia. When we started working with Steve he had high anxiety and low self-esteem impacted by a previous experience of using public transport and getting lost. His goals were to be able to travel independently and to find employment.

After weeks of working with Steve including downloading the Stagecoach app and accompanying him on a bus his confidence has grown.

Steve has subsequently managed to use the app and catch a bus on his own to meet a member of the Team. Steve was so proud and happy he had achieved this alone and has grown his independence. We have supported Steve with producing a CV and we are accompanying him as he gives it out personally to prospective employers.

Claire has learning disabilities and dyslexic. She wanted support in finding a volunteering role in the community and also support with budgeting but did not know where to start and was very anxious. After supporting Claire with using budgeting sheets to keep track of her income and outgoings, Claire decided that with her remaining money she would save for a new pair of trainers.

Claire has subsequently set up a savings account and completed the first week budget sheet. She is so excited to get to the target in her savings, and now she looks at offers and ways to save money when shopping. Claire has also been supported to successfully gain a volunteering role in a local flower shop in her community.

Sue has cerebral palsy and is in a wheelchair, she is also visually impaired and dyslexic. She requires large print on purple paper in order for her to read, however, letters she receives are not always in that format and Sue has been calling a friend to read her post for a long time.

We supported Sue to trial an app that can help her read. She was overjoyed by the impact and this small aid has made a huge difference to her independence.

Sue also wanted to travel on the bus to the beach with her daughter but due to her dyslexia she can only understand the time in a 12-hour format, which means she is reluctant to use public transport. We supported Sue to use the Stagecoach app to plan the journey and to convert times into the 12-hour clock. This has enabled Sue to access the beach independently with her daughter.

David was referred to Adult Social Care for a care and support needs assessment, was an older adult who had physical disabilities and a diagnosis of Dementia; he did not have any care and support in place and his wife had been supporting him at home as his main carer.

David’s person-centred assessment (which involved a social worker, occupational therapist and community psychiatric nurse working together) led to provision a specialist provider which would meet David’s needs at home, and support his wife in her caring role.

Unfortunately, later in the year, David’s health deteriorated, and he was necessarily admitted to hospital during one of the COVID-19 peak periods. His previous views and wishes to be at home at end-of-life were considered in a multi-agency meeting that identified, in partnership, how community resources such as appropriate equipment and specialist care could be used to support David to safely return home in a timely manner where he died in the comfort of his own home, surrounded by his family.

Devon County Council has been using Independent Service Funds (ISFs) to promote independence for people with disabilities.

Derek is a 49-year-old with a learning disability with a keen interest in sport. He and his mum had felt that previous support was not aligned to Derek’s interests and so worked his assessor and provider using a Planning Alternative Tomorrows with Hope (PATH) Tool to map out his hopes and dreams and then co-design his future support leading to a weekly routine that gave him the lifestyle he was seeking.

This included being able to access support online to give him the confidence to do more for himself and evening check-ins to reduce reliance on physical support. In-person support became more focussed on improving his independent living skills, so his ISF was focussed on what mattered most to him.

After six months he was ready to take-up voluntary work and is now able to attend without support with the potential for this arrangement to evolve into paid work in the future. He has also taken up art as a hobby, using the resources of a local community centre, and teams up with others of similar interests to buy shared support, making their money go further.

Jade is a 54-year-old woman who lives in a supported living house with two friends. She had spent most of her adult life receiving care and support but complained she had little influence over what she received and when. She agreed an ISF might help her take more responsibility for her life, working to identify her own goals and how they might best be met with her circle of support.

She planned to stop attending the day centre where she had long been going to, spending her time doing activities more meaningful to her in the community instead. She had limited experience of managing money, but used a Planning Alternative Tomorrows with Hope (PATH) Tool with those she knew and trusted to set goals and develop a new schedule.

She now attends online cookery classes and is able to do her cleaning routine alone by following easy read instructions and prepare snacks and basic meals for herself and her friends using videos and recipes she accesses from her tablet computer. She now uses technology to administer her own medicines without support.

Devon County Council has long believed that being employed is one of the best ways of keeping people as independent as possible, giving them a purpose in life and enabling them to make a difference to the lives of others.

Nina is a woman in her fifties with mild learning disabilities was supported in looking for and applying for suitable job vacancies. She secured an interview for a job as a Bingo caller and when successful was supported in taking up the role which has boosted her self-esteem and extended her social life.

This has led her to become more assertive about how her other needs are met and she is now registered in the Home Choice system as she seeks to live alone and independently rather than in a group setting.

Julie has a mild learning disability and some physical disability. Now she has finished college, she is attending the ‘Ability not Disability’ job club every Thursday and volunteers in a local shop every Friday to build up her work experience.

She uses a direct payment to purchase seven hours of support each week from a personal assistant who is helping her as she becomes used to the responsibilities and opportunities of adulthood and looks forward to achieving her dream of a paid job doing something she enjoys and helps others.

Devon County Council is increasingly encouraging people we work with to make co-production and co-design real by getting involved in changing the way we work to improve it for them.

One group including autistic people and people with learning disabilities has participated in reviewing our web pages, using them for themselves and advising on how navigation and content could be improved from a user perspective. They also selected the photos used on the site that they felt best represented them and checked the language used was plain English and avoided professional jargon.

Another group worked with us on improving our review feedback forms to give us more insight into our care assessment service from a user perspective, including the development of an Easy Read version.

Devon County Council encourages those who use services to feedback on them whether their experiences are good or could be better so that we can spread good practice and make improvements where they are necessary.

Alison has a learning disability which limits her ability to manage money and causes anxiety that others will take financial advantage of her. Enabling support has been commissioned from a local advocacy provider and she is now confident in accessing reliable sources of information and participate in a local ‘speaking up’ group which also reduces her social isolation.

Roger complains that although he should receive daily visits of 30 minutes, his care worker often only stays for 15, and it depends on the carer which tasks they are willing to help with, some being unwilling to assist with things he struggles with like putting out the bins, despite his contributing to his own care costs.

Hamish has been in the wars, breaking his jaw shortly after being diagnosed with schizophrenia and early inset dementia. He complains the six hours of support he receives each week is not enough to help with the things he finds difficult to do now in his home and feels the change in his needs has not been recognised.

Karen has positive and negative things to say about her new enabling provider. Visits are more reliable but who visits changes more often and three way communication between her, the staff, and the agency is variable. She reports some of her carers seem as stressed and unwell as she is.

Carol says her life has improved significantly since her new personal assistant started; she seems to understand what matters to her, are trustworthy, and was willing to adjust her routine to fit with Carol’s support dog.

Maggie rates her home care service highly, saying their carers are polite and helpful, always willing to listen, observing and responding to her changing needs. They go the extra mile, doing her shopping and taking her to medical appointments, giving her the space to enjoy life with family and friends.

Michael has a brain injury and suffers from forgetfulness meaning he needs prompting about things other people take for granted. Not all agency staff understand this and communicate with him as if he will remember previous conversations. This frustrates them and he feels it limits their enthusiasm to taking him out which he enjoys.

Richard attends a gardening project in her home village twice a week.The support workers involved have arranged to take the group to the Eden Project to see the gardens there which they are excited about. Richard donated a vintage tractor to a nearby home farm and his support worker takes him there to see how its restoration is going. Seeing the machine he loves being brought back to life always cheers him up.

Summary: what we are proud of and concerned about

What we can be proud of:

In 2021/22 Devon had 19/26 indicators from the Adult Social Care Outcomes Framework ranked in the top two quartiles, up from 13/26 in 2020/21, and improved on most measures when the national trend was downwards.
Our overall satisfaction ratings for service users and their quality-of-life indicator based on survey questions about their lived experience were among the best in the country, ranking 15/152 and 5/152 respectively.
Our provider quality ratings in Devon judged by the Care Quality Commission exceed the national, regional and comparator authority averages with 79% of community-based services and 89% of care homes in Devon are rated Good or Outstanding.
Our vaccination rates, with 96% of care home residents and 94% of care home staff in Devon receiving two or more doses of a vaccine against Covid-19; the fatality rate in care homes in Devon relative to population from Covid-19 was 27/152, among the lowest in the country.
Our perception of safety indicators, where we exceed all comparator averages, with marked improvement in whether people feel their services keep them safe, ranking 60/152 and 45/152 respectively, a consistent improvement over the last 5 years when we highlighted this as an area of concern.
Our staff and providers have been nominated for and won many national and regional awards in the last year, including gold and silver awards in the National Social Worker of the Year, building on our strong showing in recent years.

What we are concerned about:

Financial sustainability, with the cost-of-living crisis impacting on people who use our services and their carers, people who might become vulnerable, the viability of our providers, and county council budgets.
Market insufficiency, especially regarding regulated personal care where we are currently unable to source up to 2,000 hours each week with contingencies in place to keep people safe, but in some places at some times also residential and nursing care.
Hospital discharge and system flow, with delays sometimes due to lack of capacity in community-based health and care services, which can mean people don’t get the right care at the right place at the right time to optimise their recovery.
Operational waiting lists for assessments and reviews, with our own capacity constrained, demand increasing, and people’s circumstances changing more frequently.
Replacement care and short breaks for unpaid carers, with their social isolation and its impact on their wellbeing highlighted in recent surveys as being of particular concern, especially in rural areas.
Demand pressures from those aged 18-64, with activity levels higher in Devon than elsewhere, and market costs rising more rapidly than is typical, especially for services to older people, both residential and community-based.

The challenges ahead:

Delivering on our ‘Promoting Independence’ vision and ‘Living Well’, ‘Ageing Well’, and ‘Caring Well’ strategies including maintaining people at home and not in hospital or a care home wherever possible.
Living up to the vision that people should be supported to live their best possible life in the place they call home, with the people and things they love, in communities where people look out for each other, doing what matters to them and be independent, informed, secure, and connected.
Managing within a budget that while increasing is under pressure from rising demand, increasing costs, insufficient supply, cost of living pressures, and falling council income.
Implementing the government’s agenda for health and social care reform including regarding integration, assurance, and the currently postponed changes to charging arrangements.
Maintaining flow through the health and care system, especially during winter when we are facing outbreaks of infectious diseases, and pent-up demand for NHS services.
Recruiting, retaining, and developing sufficient staff to deliver on our statutory duties and maintain sufficient, diverse, and high-quality services including working with providers to develop their capacity and innovate new services.
Strengthening our governance in line with a corporate review, and building on the changes we have made to the governance of assurance and change in adult social care, reinvigorating practice quality assurance.

Accessibility

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If you need guidance, or an alternative format, email LGAPeerChallenge@devon.gov.uk with details of any preferred format and the assistive technology you use.

Contents

Introduction – our leadership team

Context – our place and its population

Context – the pandemic, cost of living crisis and recovery

Context – our services and who they serve

Context – our adult social care providers and workforce

How we work – our vision and strategies to promote independence

How we work – our council

How we work – our partners

How we work – our operational services

How we work – our approach to safeguarding

How we work – our approach to commissioning

How we work – in partnership with our market of social care providers

How we work – developing the social care workforce

How we work – listening to those we work with and for

How we work – managing change

How we work – ensuring financial sustainability

Analysis – the outcomes we achieve

Analysis – our operational performance

Analysis – our safeguarding performance

Analysis – our activity, cost and spend

Analysis – our provider market quality and sufficiency

Analysis – our risks and how we manage and respond to them

Self-assessment: our approach to assurance and improvement

Self-assessment: working with people – assessing and reviewing needs

Self-assessment: working with People – supporting people to live healthier lives

Self-assessment: working with people – equity in experience and outcomes

Self-assessment: providing support – care provision, integration, and continuity

Self-assessment: providing support – partnerships and communities

Self-assessment: ensuring safety – safe systems, pathways, and transitions

Self-assessment: ensuring safety – safeguarding

Self-assessment: leadership – governance, management, and sustainability

Self-assessment: leadership – learning, improvement, and innovation

Stories: from and about people who work in adult social care in Devon

Stories: from and about adult social care services in Devon

Stories: from and about people who use adult social care services in Devon and their carers

Summary: what we are proud of and concerned about

Accessibility