EMBARGOED TO 1901 Thursday 13th of January 2022
ADASS Winter Contingencies Survey
13th January 2022
ADASS responded to concerns from members, DHSC, providers and others relating to staff shortages, social care fragility and the impact of winter and the omicron variant on social care by conducting a member survey between 24th December and 5th January. The survey was based on a list of potential emergency contingency measures drawn up by experienced Directors of Adult Social Services (DASSs). These were shared first to assist DASSs across the country in reviewing their contingency plans and then to assess whether, in the period specified above, any of the measures were being taken. We are clear from responses that sharing the list of actions has been useful. One respondent said:
“We are using the contingency survey as a checklist at our twice weekly Gold planning meetings to ensure that we have worked through every possible scenario prior to consideration of re-prioritising support. It has been a useful tool for us.”
It was clear in sharing the list and in conducting the survey that whilst these were possible actions to manage rising levels of demand in the face of acute workforce shortages, there was no suggestion that these were desirable or acceptable, though clearly some were unavoidable. There was a narrow window of time for survey completion, mainly during a holiday period. Despite this difficulty, and the acute operational pressures being faced by Local Authorities, we received 94 responses.
Not all DASSs answered all questions though the vast majority answered nearly all.
Outcome of the Survey: summary
The clear messages from the survey are that of the Councils that responded:
- All 94 are implementing at least some contingency actions in the current circumstances. The responses made clear that these are actions which councils judge to be essential, but these are by no means actions which they wish to take. Even the most experienced directors are being forced to implement actions that they find unacceptable – e.g. staff are being redeployed to cover shortages but this is clearly undesirable as the redeployment is strategically and tactically into the wrong places – e.g. library staff to care roles or reablement staff to regular long term care at home. There is a real challenge in ensuring that responses remain personalised to meet the needs of individuals
- 49 Councils are, for at least some of the time, taking at least one of the measures needed to prioritise care and assess risk that Directors regard as least acceptable g. prioritising life sustaining care such as supporting someone to eat, and remain hydrated over supporting someone to get out of bed or complete other activities; being unable to undertake reviews of risk at all or to rely for this on the views of providers, family carers or people using services themselves; and leaving people with dementia, learning disabilities or poor mental health isolated or alone for longer periods than usual.
In reviewing the results of the survey it is important to remember that it represents a snapshot of what was happening on the ground at the precise time of the survey. It is clear from discussions with ADASS’s Regional Chairs that the position is serious across the country but also extremely volatile. A DASS who might have responded on Christmas Eve stating that they were having to take some extreme measures to manage pressures might have felt able to cope without them now, even though they still face serious challenges in eking out the care available. Equally, a DASS who felt able to cope before Christmas by implementing some contingency actions, and have responded to say so, might be in a much more challenging position now. As one respondent said in terms of the seriousness of the situation and the volatility:
“Our position is very fluid as I am sure most areas are, in terms of life and limb I would say we are prepared for this and are having isolated incidents with providers being unable to fulfil care home runs, or cover shifts in care homes these change and seem to resolve daily, it feels difficult but we are currently managing. We are supporting business continuity and taking a risk approach on a case by case basis….”
The situation is volatile and it is clear that a very significant number of Councils are having to make extremely difficult choices about who receives care and support, and what level of care they can expect given the increasing constraints.
Follow up to the survey
ADASS has followed up with DASSs where their responses indicated that the plans being implemented are posing particular concerns, in order to understand better the position they were in. These were the DASSs who indicated that at that particular time they were having to make the most difficult choices around providing the most basic levels of care, leaving people with dementia, a learning disability or mental illness alone for longer periods of time than usual, being unable to assess risk or leaving carers or providers to raise concerns. These actions would have been taken temporarily and in response to shortages and, the fact that they were needed at all is very concerning. In each case, the DASS has confirmed that a) the risk to the Council has been identified, shared and accepted and b) there is active support or available support to them from that DASS’s region. It was important to establish that the DASS was not shouldering the burden alone.
As far as possible DASSs are being supported across the Council and their regions. Examples of comments include:
“The corporate management team and the politicians are well briefed on the risk in both older people LD and MH. I feel as a DASS well supported by our approach to manage and mitigate the risk. I have to say these are extremely risky situations we are dealing with because of the lack of staff and now the period of staff absence due to isolations” and
“We have excellent support from region and sub region ADASS … regional chair is fully briefed and we are working across the piece on mutual aid …and sharing best practice etc”.
Issues to escalate to Government
DASSs were invited to raise issues for escalation to Government. Responses show a number of common issues of concern:
- Short term fixes being used (and failing) to address long term problems. Staff pay and progression are critically important and need to be addressed if the workforce is to become resilient. While additional funding is welcome, grants at short notice and in the thick of the emergency are difficult to use to best effect and short-term funding will not attract new staff to working in the sector. It cannot substitute for a more realistic long-term settlement.
- Respondents also flagged difficulties accessing sufficient therapists and physios from community services to support recovery and reablement.
- Respondents also noted the pressures on staff, speaking of a tired and stressed workforce.
The survey responses bring home the reality of ‘riding out’ the OMICRON surge. It is having a serious impact on the health and well-being of older, disabled and poorer people, and paid and unpaid carers across the country. Councils are making extraordinary efforts to offer the right support in a fast-changing and volatile situation. They are looking for Government to recognise the seriousness of their situation, which reflects not only the immediate crisis but the long-term, underlying fragility and under-funding of the sector – which has been raised repeatedly over many months and years.
It is also clear that once the surge of Omicron has abated, there will remain a very high number of people waiting for care and support or who are in interim arrangements with a depleted and exhausted workforce.
Detailed survey results
The survey looked at three main areas of contingency measures: service supply and provision; need and risk; and assessment. Where percentages are quoted these relate to the percentage of those who responded.
A. Survey supply and provision
1. Rewards, incentives and recruitment
- Many Councils are taking measures to improve recruitment and retention with staff incentive payments (81%) and rolling recruitment campaigns (91%). 58% of respondents are supporting fast-track on-boarding of staff e.g. through shortening induction and using the basic rather than enhanced DBS processes.
- Other measures raised by respondents included setting up an in-house domiciliary care provider arm, setting up a social care cadet scheme (a bank of supply staff for the provider market), shortened application processes and increased use of telephone interviews, parallel recruitment of drivers and exploring staff loans for driving lessons or vehicle purchase.
- Issues raised for government included a perception that the national recruitment campaign had ‘gone silent’ and that there was the risk of a ‘cliff edge’ when the Workforce Recruitment and Retention Fund ends in March. Changes to the immigration rules were welcomed, but government was urged to go further. DBS checks were reported to be slow.
- Contracts, purchasing and commissioning
- In normal circumstances, councils select providers ‘on contract’ - meaning that they have been through a competitive process to select providers based on quality and value. In the current crisis, the vast majority of local authorities are needing to change their procedures and are going off-contract to spot purchase home care from good or outstanding providers (88%), while about half this number are going off contract to purchase home care from providers who are Requiring Improvement, with less than one year of experience, following due diligence around risk (46%). This has longer term cost implications and the risk that councils will not be able to afford to support as many people in the future. Respondents are also having to go off-contract to spot purchase care home capacity from Requiring Improvement providers (55%). This involves risk to the quality of care if providers are struggling to adequately care for the people they already support. Collaboration is a crucial strategy for most councils. 81% are co-commissioning more rehab places in care homes or at home and/or more step-down beds with therapy input, and 77% are commissioning or co-commissioning rehab / reablement in care homes (in line with recent guidance). Around half are taking at least some provision in-house as a provider of last resort (52%), and a substantial minority are commissioning new accommodation like hotels, use of sheltered and extra housing (39%). The extent of support to existing providers is shown in 57% of respondents moving to payment on plan for some of their providers, and 73% of councils providing further support for providers to access LFTs.
- Other measures raised by respondents included offering 'family payments' to hold interim care arrangements (which might enable a family member to take some unpaid leave, or get in child-care arrangements to enable them to care for a family member as well), developing designated setting places in care homes or community hospitals for people who are Covid positive) with system partners, co-commissioning interim residential places with no therapy and looking at enhancing delivery of community meals to release domiciliary care capacity.
- Issues raised for government included a Lack of Occupational Therapists and physiotherapists is challenge, with a lack of therapy capacity across health and social care reducing the system’s ability to offer reablement at home or in care homes, providers handing back packages of care for both staff shortages, and latterly for more money, and little or no interest from the provider market to engage in designated premises provision.
- Staffing and redeployment
- Many councils are facilitating or requiring mutual aid between providers (73%), and a substantial majority are getting home care providers to collaborate, e.g. on best deployment for routes and areas (59%). Over half of councils are redeploying staff from non-essential or non-critical services to meet more urgent needs in social care roles. Only a quarter have introduced flexible deployment across the statutory and independent sector, with access to each other’s staff banks (24%). Volunteering is an important resource for many councils. 92% have updated their volunteer schemes and strengthened links with local volunteering networks. 75% are using volunteering for non-personal care tasks, though only 21% are using volunteers and / or redeployed staff in second carer, double-up visits.
- Other measures raised by respondents included stepping up trusted assessor schemes to allow providers to flex packages up/down and enabling VCS social prescribers to support people whose care packages are not in place.
- Issues raised for government included the ongoing stress on the social care workforce – ‘people are tired’ – and the possibility of incentivising the use of IT/e-scheduling between providers.
B. Need and risk
- Prioritising and risk assessment
- The great majority of councils are continuing to meet people’s core assessed needs but asking people using services accept that there will be flexibility in this, for example changes in their usual staffing, times of visits may differ, or visits may be shortened once core needs are met (82%). However, pressures are acute. 43% of councils are re-prioritising support to those most at risk and essential activities only, and 42% are reviewing risk on a reduced and essential basis, including accepting provider view, relying on people drawing on services and carers or providers to flag issues, and responding only to demands rather than regular review. 38% are moving to welfare calls for some. A small but significant number of councils have had to go further, at least for a short time and in respect of particular services. Some councils report moving to ‘life and limb’ care only – e.g. help limited to helping to eat, hydration, toileting, and changing continence laundry (13%) in at least some of their area for at least some of the time. A similar number report pausing support for facilitated social contact – leaving people with dementia / learning disabilities / mental ill health isolated or alone for longer periods (11%).
- Other measures raised by respondents include providers identifying care packages that can be reduced, risk rating all care activity by the person using services (working with providers to do so) and devising local a legally compliant model of easement of the Care Act
- Issues raised for government included the question of easements in national policy, and the need for government to appreciate the significant number of people who are waiting longer for assessment, care or reviews that are building up.
- The majority of councils are introducing measures to support unpaid carers (71%), with an increased offer of short breaks from 36% of respondents. Nevertheless, 33% of councils say that they are having to ask carers to provide more support.
- Other measures raised by respondents include providing a carers network virtually to listen to and respond to pressures, and a range of hospital discharge carers grant schemes.
- Issues raised for government include councils’ limited resources to intervene in support of carers, something which they acknowledge to be ‘counter productive’ but which is not in their gift to correct. Stress on carers is also being compounded by a ‘fear factor’, with some people scared of going back to day care.
- Just over half of councils are making more use of ‘trusted assessments’ for areas like equipment, freeing up assessment capacity for what only councils can do (52%). Just under half of councils are prioritising assessment capacity to core and obvious safeguarding where life and limb safety are immediately threatened, those currently at most immediate risk in life and limb safety, and for maintaining flow out of reablement or hospital (46%). In a smaller number of cases, assessments have been scaled back, consistent with the prioritisation principles outline above. In 20% of councils, referrals are being triaged, but visits (opportunities to gain what can be critical information about circumstances) are being omitted. 27% of councils are reducing DOLS assessments and 24% are delegating some assessments and reviews to providers within a clear framework. A small minority have suspended CHC assessments, and redeployed staff (11%).
- Other measures raised by respondents include looking at DOLS and CHC and Mind doing Care Act work, introducing overtime for OTs to accelerate / avoid blockages in equipment, handling etc and trialling trusted assessment within bridging home care agency.
- Issues raised for government include whether Care Act flexibility is sufficient to meet current risks, and the fact that annual review performance is deteriorating as staffing resources are focused on new assessments and changes in circumstances.
In summary, the need for these measures illustrates the fact that these are unprecedented times: none of the actions described is ideal or desirable and this evidence shows why we describe the current position as a national emergency in Adult Social Care.