Bristol City Council: local authority assessment

The local authority understood the risks to people across their care journeys, risks were identified and managed proactively, the effectiveness of these processes in keeping people safe was routinely monitored. The Principal Social Worker (PSW) told us that although the numbers of people waiting for an assessment were falling, the local authority maintained a close scrutiny of risk through both their Waiting Well Strategy and auditing processes. This allowed them to assess risk and address safety for individuals within the system.

A transitions forum was held as a space for informed discussion about cases with practitioners. The forum’s aim was to ensure complex issues related to risk management, mental capacity, safeguarding, housing/commissioning, and other circumstances were discussed in a timely way, with a focus on horizon scanning, early planning and problem solving. Principles were to ensure safety during transitions and continuity of care through structured collaboration. Forum decisions were advisory and requiring management review before implementation, ensuring considered and safe adoption. This approach supported continuity when people were transitioning from children to adult services, ensured safe hospital discharge, and allowed oversight of care when this was provided outside of the local area.

Staff worked with care providers to ensure safety across systems. For example, information was shared between the local authority and care home staff to ensure people's needs were assessed effectively.

Information sharing protocols supported safe, secure and timely sharing of personal information in ways that protected people’s rights and privacy. The Swift Response Team and the Discharge to Assess teams had access to Connecting Care, which is a digital care record system for sharing information in Bristol, North Somerset and South Gloucestershire. If a person consented to sharing their information, this was used to gather additional information to help prioritise responses. For example, staff could understand their most recent GP interventions or hospital admissions.

Health partners were overall positive about arrangements for working with local authority staff. Feedback was some of the senior operational staff were great and worked well across the teams. This impacted positively on people's safety, the flow out of hospital and had enabled stronger working relationships. Partners confirmed using different IT systems could pose some challenges, however work arounds had been created together, and there were shared agreements about using these. Sharing of data was one area which could still be improved however, and both the local authority and health partners wanted to develop this as currently it meant they were talking about different numbers at times (for example of people waiting for care) due to different systems and ways of counting this.

The local authority had recognised they needed to improve pathways and planning for young people transitioning to adult services from children's and education services. Their aims were to improve their understanding of young people, commission appropriate housing and support provision, and enable better planning.

The Young Adults Transitions Service included social workers, social care practitioners and occupational therapists, working with young people from age 14 to 25, with a focus on ensuring prevention, early planning and promoting independence, and positive outcomes for young people. The service was formed in 2023 from a merger of two other teams and the Transitions Project was set up in 2023 creating a new direction for the future of the service.

The local authority emergency duty team (EDT) was employed by a neighbouring local authority as part of an agreement with Bristol and covered 4 local authority areas in total. This team worked out of office hours and was described as stable and knowledgeable. Staff could access local authority crisis teams when needed and told us availability was ‘good’. The team worked autonomously with most of their calls coming from professionals. Practitioners supported them on an 'on call' basis such as Approved Mental Health Practitioners (AMHP's). Handovers of information were given to them as needed to ensure continuity of information. Staff were supported with regular supervision and a manager was available if they needed support. Feedback was this work was busy, but embedded processes were in place and staff could access the various local authority IT systems as needed. A lack of resources for people in the community was deemed to be their biggest challenge plus they would like other teams to have a better understanding of their role. The rota for the local authority at Bristol could also be improved, for example contact numbers sometimes needed updating, however support could be obtained from their own service managers when needed.

The majority of people we spoke with were positive about their experiences of moving between services. For example, people told us they felt listened to, with options and choices being provided. Case recording information was clear, concise and timely, reflecting good communication with families, and teams working well together. Some transitions were done over a period of time to enable people to adjust gradually to changes and gain confidence. One person told us there were no delays in transition processes for them and everything felt smooth. Another person told us they were well supported in their transition from hospital to live back at home. Some people told us of good experiences of partners working together, for example, sharing information to ensure they had the right equipment in place to support them in returning home. Feedback from some people, however, was they did not like having no named social worker in terms of continuity of care and one person had not had a good experience moving from children to adult services. Some people felt the partnerships between agencies could be better as well as sharing of information, which could cause confusion at times.

Staff working in relation to hospital discharge and reablement worked with several partners when someone was ready to leave hospital. Most of their referrals came from the community health provider. Referrals were triaged to ensure they went to the right local authority teams and reablement was used where possible. The views of people who use services, partners and staff were listened to and considered.

The Multi-agency Safeguarding Hub (MASH) was a partnership which included the local authority, Housing, NHS partners, Police, domestic abuse services and the Fire and Rescue Service. Staff in the MASH told us the Integrated Care Board were close partners, positively attending calls with them and they were keen to work with health colleagues further to develop these relationships. However, staff acknowledged there had already been some examples of joint working to ensure people's safety.

In April 2024, the local authority adopted a systemwide prioritisation tool for Transitions services to better manage the numbers of young people waiting for a response and to support better monitoring, assessment of risk and timely allocation. Referral numbers had increased as partners were referring people in a timely way from age 14. However, the waiting list for transitions had reduced significantly and that the waiting list for young people who had turned 17, was now 20 people. Staff told us when moving young people from the transition service to adult locality teams, this was done on a case-by-case basis, considering the needs of the person and the support network they had around them. They gave the example of those with complex needs who would stay with them longer so the right care could be placed around them.

Staff had recently started working with a clearer criterion for those who would be eligible for the transitions team, including being diagnosed with an impairment and having a transitional need. Young people could be brought forward from 14 years old with the team starting conversations with them and signposting. At 16, young people had the support conversation with staff, and this is when more formal support started. They explained the team did a lot of work with the special educational needs’ coordinator and transitional lead at special needs schools, so they could also pick up people from here that might not already be known in the local authority.

For those young people awaiting allocation to practitioners, risk was managed jointly with Education Services. Young people had support conversations with staff, then following this were contacted with signposting information and duty contact information in case they need to speak with someone whilst waiting for further support. Staff worked closely with other partners to support young people through the transition process including other agencies such as employment and training.

Staff felt the direction of travel for transitions work was very positive. Positive plans were in place to have occupational therapists in the team. Although there was a potential gap in service provision for those people who had more complex needs, so more evolving was needed in that area. Choices for young people and the range of options available to them could also improve as there was a lack of accessible accommodation, and provision of supported living was difficult to source in Bristol.

The Quality Assurance Team took a proactive role in ensuring safe transitions of care when contracts were terminated due to quality issues or provider failure. For example, with one short notice home care closure, staff coordinated internal meetings and external meetings, sending pen pictures to providers with availability to ascertain if they could meet people’s needs. In another example of a care home closure, the team arranged a relatives meeting to provide reassurance, held regular meetings with other local authorities who had people placed there and worked with care management teams to identify suitable new placements. This involved looking at people’s friendship groups in services, working maintain these where possible.

Hospital admissions in Bristol were higher than the England Average. For example, in 2021/22 there were 1,610 female emergency hospital admissions due to falls in people aged 65 and over. The Bristol rate was 2,573 per 100,000 population which was significantly higher than the England average of 2,099 per 100,000. Local authority teams worked closely with NHS colleagues to support discharges from hospital, improve flow through the acute hospitals and discharge pathways, and ensure people received ‘the right care in the right place’.

Discharge to Assess Transfer of Care (ToC) hubs had been in place for 15 months. These changed the way people left hospital with multi-disciplinary teams working within acute hospitals to support discharges with NHS partners, social work, occupational therapy, and VCSE professionals working together in co-located office spaces. Feedback was this model of working aided creative conversations about discharge. The focus of conversations was on the ‘Home First’ principles to ensure more people were able to return home.

Partners confirmed a new Transfer of Care Hub was being introduced in early February 2025 for people with mental health needs and they felt this would be an improvement to the way they currently worked as having social workers as part of that team would allow for more co-ordinated care. The new Mental Health Integrated Network Teams aimed to address inequalities in accessing mental health services and support individuals who have been unable to access secondary mental health services. Partners explained patient flow especially for those with complex needs was difficult. They saw a high number of clinically ready for discharge people not moving on and trying to unblock this was challenging. Feedback from leaders was that individual staff were excellent, but the system was ‘clunky’. They felt there needed to be more mental health social workers as they did not see there was parity with acute services who had more social workers supporting their teams. Although the MINT were in their infancy, work was progressing, the plan being to address some of the issues identified.

Other partners told us the local authority had experienced a high turnover of staff which they felt had impacted on outcomes for people and could extend times, for example, when supporting a move from hospital to a permanent bed in a care setting. Some care providers told us some improvements had been made with transitions between services however it could still be better, for example, they were not always informed if someone had moved to a new provider following a hospital stay.

Plans were in place to cover unexpected events for people. An unpaid carer told us the social worker had spoken with them about contingency planning and had increased their contingency hours from 4 weeks to 6 weeks should they need extra support at short notice which had given them peace of mind in case they became unwell. Some people told us they had the contact information for the local authority should their needs change in the future. However, other people were less sure of who to contact if they needed further support. Feedback from partners was the biggest challenge unpaid carers faced was the lack of respite provision and difficulty in being granted respite.

Engagement and monitoring arrangements enabled the local authority to get early warnings of potential service disruption or provider failure and contingency plans were in place to ensure people had continuity of care provision in this event. Different scenarios were planned for and information sharing arrangements were set up in advance with partner agencies and neighbouring authorities to minimise the risks to people’s safety and wellbeing. Directorate Management Teams were made aware of emerging new high risks of care providers for business continuity planning.

The local authority provider failure/service interruptions process meant staff with the relevant skills were able to support with closures, suspensions or major service interruption where needed. Learning plans from provider concerns documentation evidenced the local authority quality team undertook audits with care services following concerns being raised. Incorporated in quality assurance reports was a section on business continuity which was reviewed by staff as required. This covered whether risk assessment processes were in place which identified, recorded and mitigated service-wide risks and risks to business continuity, and if the service business continuity plan had been reviewed within the last 12 months.