Bristol City Council: local authority assessment

Data for people using services in Bristol indicated a positive picture. For example, national data from the Adult Social Care Survey for 2023/24 showed 65.11% of people said help and support helps them think and feel better about themselves. This was somewhat better than the England average (62.48%). Additionally, 71.08% of people reported that they spend their time doing things they value or enjoy. This was the same as the England average (69.09%). National data from the Adult Social Care Outcomes Framework for 2024 showed 78.08% of people who have received short term support who no longer require support which was the same as the England average (79.39%).

In terms of unpaid carers, data was more mixed. National data from the Survey of Adult Carers in England for 2023/24 showed 11.80% of carers were able to spend time doing things they enjoy. This was somewhat worse than the England average (15.97%). However, 88.60% of carers said they found information and advice helpful, which was somewhat better than the England average (85.22%).

In the Bristol Joint Strategic Needs Assessment 2023/24, the considerable health disparities were documented within and across Bristol between those living in the most deprived and least deprived areas. Locality partnership health profiles had been developed for each of the three Bristol localities, Inner City and East Bristol, North & West Bristol, and South Bristol. These combined with ward data, helped the local authority identify hotspots of higher demand.

Senior staff explained in Bristol there was one city but many communities who were each very different. Life expectancies had really wide divisions. In the inner city and east there were high levels of deprivation. Northwest Clifton and Henbury had more care homes. In the south there was more deprivation and higher rates of safeguarding referrals. Historically Bristol has had high smoking rates (linked to being a centre for cigarette manufacture) which had an associated impact on people’s health.

The local authority worked with people, partners and the local community to make available a range of services and resources to promote independence, and to prevent, delay or reduce the need for care and support. Feedback from people was overall positive, however unpaid carers feedback less, mirroring the data. People told us about their positive use of technology to support them and success learning new skills. Another person liked the flexibility of the support they received. Unpaid carers feedback related to wanting to take a break from their caring role but not feeling able to do this, and a need for an increase in the availability of respite care which was a recurrent theme.

Staff teams were positive about the ways they were able to support people around prevention and OTs did a lot of preventative work, for example, social prescribing which could prevent the need for a formal package of care. Examples included an electronic falls detector for a person with epilepsy and a vibrating watch to remind someone to take their medication. Equipment was funded through the disabled facilities grant. Some staff reflected pressures could prohibit preventative working at times when risk was their primary focus.

Senior leaders told us plans were to develop a much more preventative approach to stop as much crisis driven work and to develop their reablement offer. They were aware earlier interventions could resolve issues for people.

Preventative services were having a positive impact on well-being outcomes for people. There was a strong cohort of providers working to prevent needs escalating, which included a VCSE sector. There was a number of specific projects that prevented, reduced or delayed needs. This included work being done with the ICB and other local authorities to create a support register that would identify at an early-stage people with a learning disability who also had a mental health risk, to enable earlier intervention and prevent escalation. Other teams such as the sensory impairment team supported people in a variety of ways to prevent the escalation of needs.

A local authority partnership with a development trust co-ordinated local community volunteers to meet people’s low-level care needs as well as offering a befriending service. The focus was on preventative work to avoid longer term provisioned services. The local authority provided initial financial support to launch the project, and an evaluation of the service was carried out by a local university in January 2024, confirming it demonstrated an effective social return and financial savings.

Partners were able to tell us about a range of services in Bristol to prevent, delay or reduce the need for care and support. For example, a carers centre provided social and financial support to unpaid carers as well as connecting unpaid carers to other community groups supported by local authority. Another preventative service who received grant funding from the local authority supported people with mental health needs offering peer support with walk in and online sessions. Feedback was most people felt the service had prevented them from needing acute mental health services.

Another partner said that whilst the local authority focused on prevention and early-intervention strategies, they feel more could be done to address the health and wellbeing of people in more holistic way. For example, the local authority worked on reducing falls and hospital admissions but other aspects of wellbeing, such as occupational and social aspects, needed a greater focus. Common feedback from partners was the local authority were less able to do preventative work due to the pressures they were under.

National data from the Adult Social Care Outcomes Framework for 2024 showed 2.48% of people aged 65+ receive reablement/rehabilitation services after discharge from hospital. This was the same as the England average (3.00%). National data from the Short and Long-Term Support for 2023/24 showed 92.31% of people aged 65+ were still at home 91 days after discharge from hospital into reablement/rehab. This was better than the England average (83.70%).

The majority of feedback we received from people using services was positive. Comments included the support provided by the local authority enabled one person to live as they wished and their safety was enhanced by having a falls alarm. Assessment documents clearly evidenced a strength based approach by staff, fully taking into account the wishes of the people to remain as independent as possible. Adaptations and interventions by the OT involved, showed careful consideration of the person's needs with adaptations being specially made.

As part of the initial conversation with the person, the duty worker could signpost to community services (including the Technology Enabled Care service) or make a referral to reablement. Some staff said they had experienced some capacity issues with the reablement team at times where they had been unable to accept more referrals, resulting in a package of care being commissioned instead.

The Reablement Service provided a city-wide community-based service for people over the age of 18, delivering short term (up to 6 weeks) support at home from 3 locality-based teams. This was following an injury, stay in hospital or a period of poor health at home and was free. The local authority worked with partners to deliver intermediate care and reablement services that enabled people to return to their optimal independence. Reablement was a key part of the local authority work following hospital discharge, supporting flow, promoting independence and reducing the demand for long term support.

Senior Reablement Workers were trained as Trusted Assessors so were able to support people with lower level needs, assess and arrange for smaller, basic pieces of equipment, enabling OT services to focus on people who had more complex needs. A trusted assessor is a suitably qualified person who carries out assessments of health and/or social care needs to facilitate speedy and safe transfers from hospital. A short-term domiciliary care bridging service with a promoting independence approach was available at the end of reablement and intermediate care services, if required, whilst waiting for the completion of a Care Act assessment.

Feedback was the reablement service was good overall at supporting people to be as independent as possible. However, some staff told us referrals were not always accepted when the person had a mental health need, as the preference of the service seemed to be on providing reablement to people whose needs were physical.

A hospital avoidance project for ‘step up’ beds was underway working with the ICB, colleagues from reablement and the hospital social work team. People at risk of hospital admission were provided with up to 6 weeks bed-based rehabilitation support to stabilise their needs. The project was in the pilot stage and yet to be fully evaluated, but data from the first 7 people using the service showed that positively 60% returned home without the need to go into hospital.

Waiting lists for OT assessment and major adaptations were decreasing. This was due to there now being a full complement of OTs and Occupational Therapy Aides (OTAs) in post. External OT agency support was also in place until June 2025 to ensure they were equipped to deal with the back log of people waiting.

Data provided by the local authority for January 2025 showed a rise in numbers of referrals for OT assessments, however progress had been made in reducing waiting times. The median waiting time for the last 12 months had reduced by 58%. Approximately 70% of referrals to OT in adult social care over the last 12 months had been for people who did not have a commissioned service at the time of referral. In total 903 Technology Enabled Care assessments had been completed from May 2024 to January 2025 with the average days to assessment of 11.06. The major adaptations waiting list as of 20 January 2025 was 457 in December 2024 from 685 in July 2024, so reduced by 33%.

Referrals for assessment were triaged by an OT to ensure any immediate risks were mitigated. A lot of OT work related to short term prevention and preventing hospital admissions. Staff told us the biggest challenge for them remained waiting lists, as by the time they got to work with someone who had been waiting, it could be difficult to build a rapport if they were unhappy about the delay, however this was improving. A continuous improvement plan for adaptations was in place was in place governed by the Adult Social Care Quality, Improvement and Performance Board (QUIP) to ensure oversight of this work.

A new framework for contractors was being procured. Improvement plans were in place to reduce waiting times to 6 weeks for teams primarily involved in assessment for equipment and 8 weeks for the Accessible Homes Team which is responsible for major adaptations.

The Adaptations Continuous Improvement plan set out the local authority's action plan under four key objectives: reduce waiting times for assessment, demand management strategy, measuring outcomes/impact, reducing times for completion of work. Some actions on the plan had been completed already.

People could access equipment and minor home adaptations to maintain their independence and continue living in their own homes. People gave us some mixed feedback about access to equipment and home adaptations. For example, for one person there had been some confusion across teams which they felt delayed the adaptations they were waiting for. However, other people told us the OT support was very good, and they were happy with the equipment they received. Partners gave us positive feedback in relation to the OT service too, feeling this was something the local authority did well.

The longer-term specialist OT team worked with a large proportion of people who did not have commissioned support. Occupational Therapy was primarily provided via the Independent Living Team (equipment and minor adaptations) and Accessible Homes Team (major adaptations). Both teams accepted referrals from the public and professionals. New referrals were triaged by the Swift Response Team and directed to the most appropriate service. OT's were also based in the front door of the local authority, in transitions services for young people and hospital discharge services. The outcomes data collected by the local authority showed that OT intervention led to reduced risk of falls and hospital admissions.

Staff in the Accessible Homes Team told us about the 'Making Best Use of Stock' Team. If a person's home was not suitable to meet their needs and could not easily be adapted, this team helped to identify an alternative suitable property from existing housing stock. This could be a property that was already appropriately adapted, or one that was suitable for the required adaptation. There was sometimes a delay in adaptations taking place following an OT assessment because of capacity issues with surveyors and contractors that carry out the work. This was particularly the case with more complex adaptations, which they said were increasing in frequency. They told us whilst someone was waiting, they would remain involved and supply any interim equipment or liaise with social work teams to try and manage risk and promote independence.

There was a wait for adaptations of around 18 months. Staff would always try to source the most cost-effective option to assist. For those who were still waiting for adaptations they would try to find an interim plan. They gave an example of supporting people to access washing facilities in other ways whilst waiting for a wet room to be fitted.

Staff told us it was an easy process to refer for OT support. For more minor equipment this could be sourced relatively quickly. Staff told us that often small changes were those that made the biggest difference to people's lives. For example, one person had purchased their own bath stool but slipped off it and this had knocked their confidence, impacting on their wellbeing. The OT Aide carried out a bathing assessment and arranged for a standard shower chair to be delivered so they could now bathe with confidence.

The Technology Enabled Care (TEC) Hub explained that as well as considering any new equipment, they asked people about their current devices to maximise their potential. For example, a helpful app that could be downloaded onto a smart phone, or a smart speaker function could be utilised. This approach could avoid the need to introduce new, unfamiliar equipment unnecessarily. There were TEC Champions in some teams and the hub lead met with champions to update them on new technology.

The external equipment provider service was jointly commissioned by Bristol City Council, North Somerset Council, South Gloucestershire Councils, in the area known as BNSSG with the Integrated Care Board (NHS). Staff told us the local authority equipment supplier was good, with no issues around stock availability or timeliness of deliveries. Most items were delivered within 5 days but could be delivered sooner if urgent. The local authority gave staff scope and autonomy to research and test out specialist equipment if they felt standard equipment stock items were not suitable.

The Accessible Homes and Technology Enabled Care team assessed individuals across all housing tenures to determine their eligibility for assistance and enable the installation of aids, adaptations, or equipment to help people to remain living independently at home or ensure quick discharge from hospital. The team worked across the Integrated Care System (ICS) to improve hospital discharge pathways and provide technology enabled care as soon as the need for preventative support was identified.

People could access information and advice of their rights under the Care Act and of ways to meet their care and support needs. This included unpaid carers and people who fund or arrange their own care and support. National data from the Adult Social Care Survey for 2023/24 showed 67.87% of people who use services found it easy to find information about support. This was the same as the England average of 67.12%. Also, national data from the Survey of Adult Carers in England for 2023/24 showed 61.61% of carers found it easy to access information and advice. This was the same as the England average (59.06%).

Unpaid carers were complimentary about the carers support services offered in Bristol, feeling able to access these for advice and support. Other people told us information had been sent to them by the local authority, for example, in relation to groups for people living with dementia.

Some staff and partners felt the online information and advice offered by the local authority was difficult to navigate and could be improved, and they did not routinely use it when providing information and signposting for people. Instead, they had developed their own list of local community services details, which was a working document they updated regularly. A review of the existing Adult Social Care Directory of Services was now underway to make improvements. The local authority was working with another local authority to develop a new directory of services. The new directory would provide information and guidance to meet the requirements under the Care Act, it was anticipated this would be available in April 2025. The information portal people accessed was being improved, along with the self-referral form, professional referral form, advice and guidance. The local authority had developed easy read versions of charging leaflets for care in the community, residential care and direct payments, each were translated into various languages as well as being available on the website.

Staff working with people with sensory impairments explained there had been a recent redraft of the accessible communications policy. Some other staff felt there was a lack of accessible information around assessments for young people, there previously was a film with young people explaining what to expect of the service, but this was not relevant now. Access to interpreters and the internal translation services were described as good.

Some partners were engaged in conversations with the local authority about how they could make information sharing easier. They were also in discussion with commissioners around a piece of work to give promotional information to people when they first accessed social care services.

National data from the Adult Social Care Outcomes Framework for 2024 showed 20.17% of people received direct payments. This was lower than England average (25.48%). Also, 26.22% of people aged 18-64 received direct payments. This was significantly lower than England average (37.12%). Finally, 97.53% of carers received direct payments, this was lower than expected. However, national data from the Adult Social Care Outcomes Framework for 2024 showed 11.95% of people aged 65 and over received direct payments which was similar to the England average (14.32%).

Data provided by the local authority in July 2024 provided further detail about the use of direct payments. Ninety-nine direct payments were ended in the year prior to 30 June 2024, 90 were people using services and 9 were unpaid carers. This represented an 18.2% decrease on the same period in the previous year. Most direct payment users were female at 63.6%, with males at 36.4%. Of these 73% were white, with 20% black, Asian or other ethnic minority background. More younger people used direct payments, with only 20% being over the age of 70, and 71% were identified as having a long-term condition.  

Several unpaid carers told us they were aware of direct payments or in receipt of these. Other feedback was there could be better information provided about what direct payments were and how they could be used.

Senior staff told us there had been a national decline in the uptake of direct payments which was also reflected in the local authority's figures for the past 12 months. Action was being taken to increase the uptake of direct payments and was one of the local authority transformation projects. For example, the local authority were piloting a direct payment support hub, simplifying their internal processes and refreshing their staff training around direct payments, making this mandatory. Contractual agreements with providers ensuring expectations of roles and processes were being aligned with the local authority vision for direct payments. In the past 12 months and since the actions had started there had been a 0.6% increase in direct payments usage indicating an improving trend, although small. 

The Direct Payment Support Hub team was being piloted for 12 months. Staff told us they hoped this would become permanent, as they were excellent. The Hub had practitioners who had had specialised training to support the set up and initial review of all new direct payments. The purpose of the pilot was to increase the uptake of direct payments by streamlining the process and improving information provided to people. The local authority were in the process of reviewing the success of the pilot by reviewing data on the uptake, practitioners’ confidence and finance data. Further support was provided through a virtual direct payments café which provided practitioners with a place to share learning, seek advice and support, leading to increased confidence and competence. Feedback from staff demonstrated the success of the cafes.

Staff felt direct payments encouraged people to be more creative around their care and support. Some barriers were due to the complexity around managing direct payments. Adult Social Care Policy Committee Members explained direct payments had been an area raised to them by constituents, and they were aware uptake was lower in Bristol. They understood the price of direct payments had not yet caught up with homecare prices and local authority senior leaders were keen to develop this further.

Partners told us in response to challenges facing the direct payments process, they had worked with the local authority to trial the specialist direct payment hub. Other partners said the local authority had undertaken a lot of work in trying to address challenges and make the system work more effectively. For example, they had created a network of all local authorities across Southwest England with the aim of working collaboratively in finding solutions to overcoming the barriers to usage. This work was strategic, looked at practical solutions for improving the system and they saw the local authority as a leader in this area. Partners reported anxiety surrounding financial pressures and administration were barriers for some people.