Bristol City Council: local authority assessment

The local authority worked with local people and stakeholders and used available data to understand the care and support needs of people and communities. Commissioners had access to live data on both activity and spend for all people receiving long term care. This was drawn from care management and provider payments systems and allowed commissioners to better understand trends.

Staff explained data and intelligence from across the health and social care systems were critical to understanding and meeting current care and support needs, and in planning for the future. Data helped them to make better decisions, evidence what was working and capture the impact of pilots and projects.

Bristol’s commissioning team was split across two service areas, Accommodation and Complex Care, and Community Based Care and Support. Their goal was to enable people to optimise their independence in their own home and thrive within communities of their choice. The commissioning teams included a dedicated housing specialist expert who collaborated with care commissioners and the housing department, reflecting the local authority focus on this particular area.

The local authority had developed a comprehensive understanding of local care and support needs for 2024/25 by analysing 2023/24 data and applying growth forecasts. From this, efforts had been made to improve areas such as patient discharge pathways from hospital. It was noted that despite increased demand for community reablement and rehabilitation, capacity gaps persisted, leading to longer wait times. Actions taken in response to this included introducing a bridging domiciliary care service so people could be supported leaving hospital or a care setting quickly, whilst an ongoing package of care was arranged.

Brokerage staff worked with care providers to ensure people received suitable care. For example, staff sent pen pictures to providers detailing people's specific needs to ensure potential placements would be suitable, meeting with practitioners in complex cases. Staff gave one example of where they wanted to support a person who was HIV positive, and they faced difficulty in finding services to support them due to a lack of understanding around HIV. Staff arranged for further training to be provided to educate some care providers which resulted in HIV being destigmatised and subsequently care provided.

Partners told us the local authority had actively tried to diversify the services available in the adult social care market. For example, the local authority had utilised the expertise and voices of people from ethnically diverse groups to inform commissioning choices.

One care provider told us a strategic partner group used to be held however, this was ended around 18 months ago due to procurement considerations and had not been reinstated. This meant there was an increased risk of partners being unable to share information, concerns and ideas they had or be involved in the development of policies and strategies. However, there had been conversations more recently between care providers and local authority leaders about how to improve areas identified and these meetings went well.

National data from the Survey of Adult Carers in England for 2023/24 showed 10.19% of carers accessed support or services allowing them to take a break from caring at short notice or in an emergency. This was the same as the England average (12.08%). Additionally, from the same data source, 18.87% of carers accessed support or services allowing them to take a break from caring for more than 24 hours. This was the same as the England average (16.14%) and 21.52% of carers accessed support or services allowing them to take a break from caring for 1-24 hours. This was also the same as the England average (21.73%).

National data from the Adult Social Care Survey for 2023/24 showed 72.64% of people who used services felt they had a choice over services. This was the same as the England average (70.28%). However, data from the Short and Long Term Support for 2023/24 showed 74.29% of adults with a learning disability lived in their own home or with their family. This was worse than the England average (81.66%).

Commissioning staff supported new and innovative approaches to care provision, which led to better outcomes for people. The Commissioning Strategy (2022-2025), which was also the Market Position Statement, was updated every financial year and included the local authority's strategic vision, operating principles and data, and tendering intentions, so the local care market was aware of the commissioning priorities for the year ahead. This provided the ‘golden thread’ for team objectives and commissioning project priority areas for the coming year. The Commissioning Strategy 2024/25 iteration set out the strategic direction for commissioning which was to enable the shift away from the use of longer-term care providers with plans to increase the direct payment rate for personal assistants and encourage the VCSE markets to support and work directly with people who received a direct payment. The Commissioning Forward Plan set out all the active projects across both complex and community-based commissioning for managing the local care market and facilitating strong, ‘value for money’ care services that offered choice and continued to be high quality.

Senior staff told us the need to refocus commissioning around prevention and other service alternatives was challenging in the context of budget pressures and as existing long-term funding was tied into traditional care home and domiciliary care services. The local authority continued to work towards a reduction in the number of bedded care placements and an increase in community-based and domiciliary support. There was a commitment to prevention which was supported by the leadership.

Staff confirmed the new local authority Adult Social Care Single Framework had enabled them to set clear expectations with care providers, for example around being person-centred in their approach, working in an enabling way, meeting cultural needs and being flexible. The framework had one set of terms and conditions, one quality assurance framework and one forward plan for tenders. Innovation was also built into the framework. Staff generally felt relationships with care providers were good and open lines of communication enabled issues to be raised and addressed proactively.

A number of market shaping projects had either taken place, were underway or were planned. Different members of the Commissioning Team were involved in different project areas, including learning disability and autism, community-based services and supported accommodation and extra care. Person centred commissioning supported people’s needs. For example, through the use of specialised supported housing, one person with complex needs had been able to move from a secure mental health setting where they had lived for long time into bespoke accommodation in Bristol, near to their family and community. The local authority told us this work had generated government interest and interest more widely across the health and social care sector.

An integrated Learning Disability and Autism Commissioning Team had been established within the local authority. The joint commissioning with the Learning Disability and Autism team, working alongside the ICB to develop plans and address areas where supply was hard to find both in terms of quality and price. The purpose of the team was to deliver system priorities, having a better understanding of the growth in demand, housing needs and types of services people with a learning disability wanted and needed. The local authority planned to relieve pressure on adult social care budgets by developing more supported housing, providing a wider choice of community-based accommodation options, and meeting people’s needs in a better and less costly way than existing residential settings. The increased provision of supported housing was part of the supply management workstream within the Adult Social Care Transformation Programme.

The Provider Forum helped commissioners have conversations with providers around market shaping and they told us they wanted to support smaller providers to develop and thrive. An example was provided of working with a small, supported living provider to enable them to remodel their building so more complex needs could be met. Staff were involved with work with community providers in their localities to develop pathways for people with mental health needs stepping down from complex bed based care.

Partner feedback included that more work could have been done with commissioning with the involvement of health to improve outcomes for Autistic people. However, other partners had opportunities to interact with the local authority at a strategic level but felt it would be helpful to have more feedback following initial discussions, for example, they were involved in some work around extra care housing but had not heard back about this. Feedback from the local authority was discussion around extra care housing had been paused due to the procurement and implementation of the single framework. With the framework now in place, the local authority planned to re-start monthly meetings with providers to further refine models. More positively one partner had regular meetings with the commissioning team and felt members of the team were very open to listening to ideas and suggestions and the co-production work done with the local authority was good. They went on to say there had been very good team work with the commissioning manager. Partners told us the local authority had a social care housing policy which defined best practice. This focused on landlords and relationships which helped inform the market. Feedback was the local authority wanted to do work to a high standard.

Information from the local authority submitted as part of their information return in July 2024 explained that Bristol had struggled over the years for quality market supply for more complex care, for example, for people with a learning disability and mental health. Also, for emergency respite which had been feedback from people, unpaid carers, and partners. Feedback included there was a gap in respite provision for young people. There were alternative services such as shared lives services (where someone was matched to an approved carer to stay in that person's home) although they found a lot of the young people they supported had needs that were too high to access this.

Staff told us about the lack of provision for those people experiencing mental health issues and felt this could be improved with better communication between them and commissioning to better understand the issues. There was a need for more mental health specialist provision to meet the needs of people, particularly following the Covid-19 pandemic and increased levels of mental ill health.

However, the local authority were starting to see some changes which they hoped would be accelerated by the implementation of the Learning Disability and Autism commissioning team, created last year, and the teams work programme which included a specialist housing policy and aligning strategic providers on the new single framework. Both of which the local authority felt would start to create the right quality supply of housing and care within the city to meet people’s complex needs.

Data provided by the local authority in January 2025, showed the average wait for homecare for people at end of June 2024 was 6.4 days on average compared to December 2024 when it was 4.6 days. For December 2024 supported living and residential care showed improved performance of 7.3 days.

In terms of people placed outside of Bristol for care (either through capacity or choice) there was a steady reduction in numbers. For example, in July 2019, 835 (out of 5,287) people were placed outside the city (16%). That figure fell to 701 despite the total number of people using services going up to 5,564. Overall, this was a fall across the past 5 years of 144 people being placed outside of the city, bringing the out of area placements down to 12.6%. The local authority acknowledged there was still a long way to go, however the trend was positive. Of the 701 people placed out of the city, 62% of them resided within neighbouring local authority areas, with many being just across the border. Of those placed beyond the neighbouring local authorities, 85% were working age adults primarily with a learning disability or mental health as their primary support reason. There were currently 107 people living within specialist residential care homes, outside of the Bristol and neighbouring local authority areas. For most of these people this was due to not having provision to meet their needs in the local area.

Senior staff told us they would like to be able to offer the opportunity to come back to Bristol if people wanted to when building accommodation. They wanted to make a home for life, for people with complex needs including extra room to accommodate carers. The extra care housing offer was good in Bristol and staff gave an example of how this had been arranged for one person who was self-neglecting, and how this support had made a huge difference to their wellbeing and outcomes. The care home market was also strong.

Commissioning strategies included the provision of suitable, local housing with support options for adults with care and support needs. The High Stability Housing Service was an example of effective joint commissioning with housing. It provided an alternative supported accommodation option for people where other options of accommodation had not worked. It could be accessed by people with eligible needs who were experiencing multiple disadvantages. The accommodation provided a stable basis for recovery with support from a complex case worker. The local authority staff told us this service had led to improvements in health and wellbeing for people, such as people re-engaging with their GP’s, hospital or mental health services to build their independent living skills.

There were challenges around costs and availability of property in Bristol. A shortage of suitable housing and accommodation was a key area of focus for the local authority. As part of their 'Policy and Advice on Housing for Adult Social Care Clients' 2024, the local authority stated Bristol was currently facing a significant unmet demand for specialised supported housing to cater for individuals with complex social care needs. At the time of our assessment there were 81 young people receiving care support in either a residential or supported living environment. Young people transitioning into Adult Social Care in Bristol made up a significant amount of the need for accommodation over the next few years which needed to be planned for.

Senior staff said they had additional housing in the pipeline of around 70 to 100 units but ideally it would need 500, there was a rolling programme to try address this including the programme to develop Specialised Supported Housing. The local authority continued to work with providers to involve them.

Housing partners were involved with a local authority surplus assets disposal scheme which was where any surplus properties were triaged between priority services for use, before being sold off. The local authority had sourced 8 properties through this scheme which would see around 20 units of complex housing being built. Senior staff told us care providers liked this idea as they knew they were able to create a bespoke product and they had complete ownership in the development of this.

Partners feedback was that the local authority could not always deliver what they would like to do due to funding restrictions. Some partners also felt there was a lack of services available in the area for people with mild to moderate dementia. For example, when people were diagnosed there was often no support with the diagnosis until a higher level of care was required. This gap in service provision led to higher levels of anxiety and distress in the people they supported, which could translate into greater care needs.

National data from the Adult Social Care Workforce Estimates for 2023/24 showed 7.37% of adult social care job vacancies. This was the same as the England average (8.06%). Additionally, the same data source, showed 54.84% of adult social care staff had a care certificate in progress or partially completed, or completed which again was the same as the England average (55.53%).

National data from the Adult Social Care Workforce Estimates for 2023/24 showed an ASC staff sickness absence rate of 5.17 which was the same as the England average (5.33). and the same data source showed an adult social care staff turnover rate of 0.23. This was the same as the England average (0.25).

The overall ratings of adult social care services in Bristol in January 2025 were positive with 4% of services rated Outstanding, which was the same as the England average. 91% of services were rated Good, which was much better than the England average. 5% of services were rated requires improvement which again was much better than the England average of 16%, and 0% were inadequate which was better than the England average of 1%. Overall, 95% were rated good or better in Bristol compared with 82% England average.

The local authority had clear arrangements to monitor the quality and impact of the care and support services being commissioned for people and it supported improvements where needed. The Quality Assurance team monitored all services commissioned by Adult Social Care whether they were part of the Single Framework or not (whereas the Contract Management Team work with framework providers). Around 75% of the providers on the Single Framework were new providers, not yet known to them.

The Quality Assurance team activity was based on risk. The number of packages or hours was taken into account but also other factors such as risk to people using the service, intelligence gathered from various sources and previous knowledge of the services. Staff feedback was it had been challenging for them having so many new care providers joining the new framework. The quality team worked mainly reactively, driven and guided by the information and intelligence received. This included concerns, compliments and complaints received. It also included Service Monitoring Information Forms (SMIF) completed by adult social care staff when there were concerns about quality or safeguarding, and routine service data gathered by the Contracts Team for example, the number of safeguarding concerns raised. A SMIF tracker was used to look for themes to enable the team to be proactive in addressing concerns on a thematic basis. Further training was planned for frontline teams around the use of the SMIF tracker, which was not always completed correctly by practitioners, for example, not always telling providers they were raising a concern.

The Quality Assurance Team provided a quality monitoring service that covered home care, care homes, extra care and community support services. The team were fully staffed. The team carried out both full assurance visits and thematic visits (that focused on a specific topic or area of concern). The frequency and duration of visits varied based upon the type of visit, the information that had prompted the visit and the size of the provider. The level of contact was determined by the assessments of risk carried out by the team. There were some providers that were well known to the team with regular contact and others that could go for long periods without any communication.

Staff in the Quality Assurance Team did not generally have capacity to carry out quality assurance visits for out-of-area placements. However, there were agreed processes with other local authorities to notify them when an out-of-area placement was arranged which helped to ensure they would be alerted to any current or new concerns relating to that provider. There was also a regional South West Quality Assurance Forum that enabled intelligence to be shared around concerns or service embargos.

Experts by experience were used as part of the quality assurance process for care homes, home care providers and extra care. This involved lay assessors speaking to people using the service (with consent) and providing feedback to the Quality Assurance Team. Staff were hoping to expand their use of experts by experience into supported living and community support service assurance processes.

Staff told us the quality assurance process was flexible to adapt in response to the information being gathered. For example, if a particular issue was being looked at but another one arose, the process could be adapted. If needed, a Service Improvement Plan would be developed. Follow up visits would be carried out to monitor progress towards the actions in the plan. In mid-2024 the local authority had provider learning and improvement plans in place for 8 providers. We found these to be comprehensive. There was evidence of follow up visits and further actions that needed to be taken by providers to make the necessary improvements, with dates for actions.

The Quality Assurance Team aimed for quality assurance to be a supportive process. The service provider would be given feedback and any areas for improvement were discussed. This included offering advice about potential changes that could be implemented and to connect providers with each other and with community resources to support improvements.

The local authority had adopted a new regional quality monitoring tool which provided an assessment and reporting framework for services and was used for all of the quality assurance visits. Staff told us their quality assurance framework was under review. As part of the review, there were also plans to start seeking feedback from providers about their experience of the quality monitoring process.

Partners feedback was polarised about the local authority in relation to ensuring the quality of services. One partner told us told us the local authority had numerous processes in order to evaluate and monitor the quality of care services and quality assurance was a priority for the local authority. Other feedback however was that the local authority focused more on financial considerations and less on quality assurance.

Clear data provided by the local authority in July 2024 showed the reasons why contracts had been handed back early, including financial viability. Seven adult social care locations had been registered as de-activated in the last 12 months in Bristol.

The local authority told us there had been a consistent trend over the past 12 months of a reduction in residential and nursing care and an increase in community-based models of support. For example, nursing care 684 to 666 and residential 779 to 764.Supported accommodation 775 to 824, and homecare 1344 to 1457.

The local authority had tendered a new Adult Social Care Single Framework in September 2023, which included over 160 providers. With domiciliary care agencies the local authority was working on a localised model with the aim of giving more choices for people. Adult Social Care Policy Committee Members told us told us they took steps to protect niche providers particularly to support communities and in supporting more profoundly disabled people.

The Market Analysis Team worked using a national pricing tool and staff gave us positive feedback about this. The aim was to help the team to work with individual providers to better understand the ‘fair cost of care’ and work to national benchmarks and fair and transparent negotiations.

Staff told us about the challenges in relation to funding care and that delays in the process of getting care approved had led to several financial queries they received from care providers due to late payments. Also, when people had been in receipt of continuing healthcare and they were no longer eligible, fees for care were much higher than the local authority funded so it was hard to do the transfer of care. The outcome was in some cases people had to move from a service they had been living in. Further work was being done by the local authority with their health partners in relation to this issue.

The Adult Social Care Commissioning Strategy and Market Position Statement 2024/25 stated the local authority had an open dialogue with providers where they disclosed financial sustainability issues and had an annual contractual uplift mechanism to distribute funds equitably across services. The operational principles included to reduce reliance on institutional care, sustainability in delivering a care market within the set adult social care budget, be co-produced to use lived experience to promote equity in access to services and locally delivered services to support new locality models that build sufficiency of supply within the local market, also more focus on early intervention.

The local authority worked with providers and stakeholders to understand current trading conditions and how providers were coping with them. Some partners told us about the positive support given to them by the local authority. For example, there had been an uplift to grant money they received to account for increases in the cost of living and to consider sustainability. However, other partners felt the local authority needed to do more to ensure local voluntary and community sector organisations were sustainable as receiving only 12 months of funding from the local authority did not allow them to plan ahead. Feedback from the local authority was they understood the views of partners around the limitations imposed by 12 months of funding, as they too had grants only for one year.

Other partners felt it had been difficult to communicate with the local authority until recently however the new interim senior leader in commissioning had effectively improved engagement in the past few months. Some also fed back concerns in relation to the new single framework that it was impractical and presented many challenges. However, other partners felt the local authority staff were genuine and passionate about providing good care and worked hard with what they had but were restrained and limited by systems and limited resources available.