Agenda and minutes

Health and Adult Social Care Scrutiny Committee
Thursday, 23rd March, 2023 10.00 am

Venue: LB 31-32 - Loxley House, Station Street, Nottingham, NG2 3NG. View directions

Contact: Jane Garrard  Senior Governance Officer

No. Item


Apologies for absence


Councillor Eunice Campbell-Clark - personal

Councillor Kirsty Jones - personal

Councillor Sam Webster - personal



Declarations of interest




Minutes pdf icon PDF 318 KB

To confirm the minutes of the meeting held on 16 February 2023


The minutes of the meeting held on 16 February 2023 were confirmed as an accurate record and signed by the Chair.



Mental Health Service Commissioning pdf icon PDF 106 KB

Additional documents:


Maxine Bunn, System Delivery Director, Mental Health and Children for the Integrated Care Board, led the presentation on Mental Health Service Commissioning, and highlighted the following points:


(a)  2023/24 will be year five of the five-year Mental Health Transformation programme, following the NHS Mental Health Long Term Plan (LTP) published in 2019;


(b)  this has seen £51.7 million of additional funding across Nottinghamshire, plus £18.1 million nationally ring-fenced for specific transformation areas. The total for 2023/24 is £22 million for services across adults and children’s mental health services;


(c)  it is recognised that there are issues across all kinds of healthcare in the transition between children’s and adult’s services, so there is a focus on improvements that help to address gaps in provision in transitions between mental health services;


(d)  improvements have been made in Specialist Community Perinatal Mental Health services, with increased staffing in community teams to make it easier and quicker to access support, an extended period of care to 24 months from 12 months, with care provided to women and their partners, and a Community Engagement Officer post in place to help increase access to support;


(e)  Children and Young People’s (CYP) Mental Health services have been expanded and increased. Mental Health Support Teams have been implemented in schools, with three teams in Nottingham City and an additional two teams coming on board in 2023/24, supporting an additional 29 schools and colleges. Eating disorder services have been increased and an Avoidant Restrictive Food Intake Disorder (AFRID) pathway has been put in place. 24/7 mental health crisis provision has also been implemented;


(f)  Adult Severe Mental Illnesses (SMI) Community Care has been improved, with waiting times reduced, new Mental Health Practitioner roles working between primary and secondary care, and services introduced to improve outcomes around personality disorders and adult eating disorders;


(g)  there will be a new provider of NHS talking therapies from the 1st April with a specific remit of working with ‘place’, involving the voluntary sector and citizens, reducing health inequalities and reaching specific population groups;


(h)  there is a 24/7 Mental Health Crisis Care line in place, alongside Crisis sanctuaries and an expansion in the number of Crisis nurses. The team have worked with EMAS to put mental health professionals in the Emergency Operations Centre and given training to frontline emergency services crews;


(i)  a new Acute Mental Health Inpatient Care unit, Sherwood Oaks, opened in December 2022, providing an additional 14 beds. An independent bed review has been undertaken to determine future bed requirements and the team have been working with local authorities around Supported Living placements, to reduce the need for private and out of area placements for acute inpatient care;


(j)  multi-agency suicide prevention plans have been implemented, alongside targeted support for at-risk groups. The programme has also delivered suicide prevention training for staff and bereavement support;


(k)  a number of new roles have been developed as part of the programme to fill gaps in services. This includes:


  i.  Mental Health Practitioners to address the gap between talking therapies and secondary care mental health services. They are placed in primary care networks and work closely with GP practices, with 21 out of 23 primary care networks having roles in place. This service is due to be expanded as part of the transformation plan, including through making links with the voluntary sector;


  ii.  Peer Support Workers are those with lived experience of accessing mental health services. There are a number of roles embedded across services;


  iii.  Transition Workers are in place to help individuals moving from Children’s to Adult’s services, and are co-producing services for the 18-25 pathway with Mental Health Two Thousand (MH:2K), a youth-led model for engaging in conversations about mental health;


  iv.  a Co-existing Mental Health and Substance Misuse Needs model has been developed to avoid people falling through the gaps. Historically, people have been referred to either mental health services or substance misuse services, while the new approach assists people who need integrated support from both services;


(l)  there are some challenges around recruitment and increasing demand for services, but the ICB are working to adapt the programme to the needs of people in Nottingham and Nottinghamshire.

In the discussion which followed, and in response to questions from the Committee, the following points were made:

(m)the new provision at Sherwood Oaks is in Mansfield, and has a modern, comfortable Section 136 suite with ensuite rooms. Sherwood Oaks will provide a closer acute inpatient unit for Nottingham City residents than Bassetlaw Hospital or Millbrook Mental Health Unit when Highbury Hospital is at capacity;


(n)  the extra provision, alongside strengthened community rehabilitation, will help to reduce reliance on subcontractors and the use of out of area placements. In December, there were zero out of area placements for a few weeks. There are currently nine out of area placements in mental health intensive care, after an increase in demand in the New Year, but beds have been subcontracted in Keyworth from April to address the increase in demand. The team try to repatriate patients when a bed becomes available, but people do remain in out of area placements if it is the right thing for them therapeutically, decided on a case by case basis;


(o)  the expansion of Mental Health Support Teams will deliver 47.8% coverage of schools by January 2025, compared to a national standard of 35%. This is part of a phased programme, and the ultimate aim is to provide full coverage in the future depending on recruitment and investment. The schools supported so far are local authority schools. The ICB agreed to provide specific information on the schools involved;


(p)  it would be useful for the Committee to hear about how mental health services are reaching young people of school age who are not in education, and may have needs that are not being identified. These needs are chiefly identified through collaboration between health and social care;


(q)  part of the tender process for the new provider of NHS talking therapies tested how they will work at ‘place’ level with local communities to reduce health inequalities and reach out to communities who find it more difficult to access support currently, which have been identified through broader health inequalities work;


(r)  concern with health inequalities has been integrated into mental health service plans at all levels, and monitoring of factors like deprivation and demographics is now standard practice. The ICB are working with Healthwatch to understand people’s experience of accessing services, place-based partnerships have been implemented, and the ICB are engaging with the voluntary sector;


(s)  mental health in student communities has been covered in the news recently. There are specific services targeted for the universities, and all students can access routine services. There is a meeting scheduled with Nottingham Trent University on the week of the 27th March 2023 to discuss improving student access to services, and some of the ongoing discussion will be about ensuring continuity of care when students move back and forth between university and home;


(t)  there are specific posts in place to support individuals through the transition from children’s to adult’s services. The aim is to manage that transition in a proactive way, tailored to the needs of that population through co-producing services with organisations like MH:2K;


(u)  demand will be better managed through changes to the way that people can access services, and the way referrals from GPs will be managed. There is a triage so people can get on the right service pathway more quickly, with signposting early on when another service may be more appropriate rather than individuals having to wait for the full assessment. The ambition is to move to a four week wait after triage;


(v)  it is not clear what additional funding will be available in future years after the end of the five year transformation programme, but the funding for existing services delivered through the programme will remain so that changes can be sustained;


(w)in terms of evaluating the impact of the transformation programme, there is a large set of data required to be reported back and the ICB are held accountable to NHS England on a monthly basis. Many of these are access targets, such as how quickly an individual is seen after referral, or the number of posts recruited to. Nottingham is doing well by these measures;


(x)  the ICB are also looking at locally developed outcome measures, and are in the process of working with service users and staff to develop these. The aim is to measure the tangible difference to the individual. There are lots of different routes by which staff and service users can give feedback, for example through Healthwatch;


(y)  in preparation for the meeting, the Chair of the Committee asked for feedback from members of the public on social media about experiences accessing mental health services in Nottingham. The Chair gave accounts of numerous individuals, and charities acting on behalf of individuals, who had made contact to report issues with accessing appropriate mental health services;


(z)  it is important to recognise that individuals accessing mental health services may not find it easy to give feedback through normal formal routes. There is a need to be more nuanced and creative in how that feedback is captured. It is also crucial to seek to learn the experiences of those who may not be patients, who sought to get into a service but were not able to access it;


(aa)  it is important to note that the public are not generally aware of distinctions between organisations in the NHS, and do not necessarily know the role of the ICB in delivering services. Those individuals may have attempted to give feedback by one route offered by the NHS, and would not then look to give feedback directly to the ICB if they did not see progress;


(bb)  when people are unable to access appropriate NHS services, often people will turn to the voluntary sector, which leave them being supported by organisations not appropriate for their level of need, puts pressure on the sector, and leaves voluntary workers unsure of how to make appropriate referrals when individuals approach as a last resort after already being declined by mental health services. Attention needs to be paid from a commissioning point of view to look into this cohort of individuals seeking support;


(cc)  there is a gap in eating disorder services for those diagnosed with mild or moderate ‘eating challenges’. The ICB are working with First Steps in Nottingham to look at how their support can be expanded, with referrals done through GPs. At the moment it is unclear from information available online how this can be accessed in Nottingham by non-students;


(dd)  the ICB are currently developing a single website that will consolidate information on mental health services available in Nottingham, and specific roles are being put in place to aid communications around mental health;


(ee)  Shout Notts has been launched recently as a free, confidential text service that individuals can contact by texting Notts to 85258, and which connects individuals to a trained Shout Volunteer who will provide personalised signposting.


Resolved to:

(1)  request that Nottinghamshire Healthcare NHS Foundation Trust provide information on the schools covered by Mental Health Support Teams and how it engages with children and young people not in formal education;

(2)  request that Nottingham and Nottinghamshire Integrated Care Board confirm whether First Steps is available to City residents other than students and, if so, the referral;

(3)  recommend that if First Steps is available to all City residents then the Nottingham and Nottinghamshire Integrated Care Board work with the provider to ensure that information to that effect and the referral route is included on its website and information about the Service is available to potential patients and referrers in the City;

(4)  recommend that Nottingham and Nottinghamshire Integrated Care Board look into ways to proactively gain feedback from non-users of services and those residents who have sought support but have not been able to access mental health services;

(5)  review what has changed for City residents and patient experience following implementation of mental health transformation in the City during 2023/24.



Adult Social Care Self-Assessment pdf icon PDF 9 KB

Additional documents:


Julie Sanderson, Head of Adult Safeguarding and Quality Assurance, delivered the briefing on the Adult Social Care self-assessment, highlighting the following points:


(a)  this briefing aims to share information about the new CQC inspection regime of Local Authority Adult Social Care functions, and to assure the Committee of work undertaken to prepare for the inspection by sharing the self-assessment and explaining the next steps;


(b)  the Health and Care Act 2022 gave the CQC a new duty to independently review and assess how authorities deliver their Care Act functions. This applies not only to Adult Social Care in terms of its assessments and commissioning, but also the commissioning team and provider services, both internal and external, and the Integrated Care System;


(c)  pilot inspections will take place over the summer, and Nottingham City has volunteered to participate. It is not clear which authorities will be chosen at this stage, as the pilot will need to involve a mixture of authorities according to different criteria. Being selected for the pilot would have benefits, giving a more fluid process with inspectors learning from authorities as well. It would mean information would not be made public initially, as the CQC intend to undertake at least 20-40 inspections before being able to indicate how different ratings are standardised;


(d)  the full programme will be launched in Autumn 2023, and is anticipated to be similar to OFSTED, with focus groups, meetings with stakeholders and partner organisations, and an audit of case files;


(e)  the CQC have set out four assessment themes:


  i.  Working with People;

  ii.  Providing Support;

  iii.  Ensuring Safety;

  iv.  Leadership;


(f)  despite resistance to ratings in the sector, following from criticisms of the ratings system used by OFSTED, the CQC are clear that they do intend to provide ratings. They have made it clear however that they are looking for good practice to be celebrated and shared, not just focusing on faults, and they have a good understanding of the pressures affecting local authorities in delivering Care Act functions;


(g)  it is not yet clear what the consequences would be if the CQC identify significant issues, or if commissioners could be appointed for local authorities with serious faults;


(h)  to aid preparations for the new inspection regime, the Association of Directors of Adult Social Services (ADASS) decided to pilot a self-assessment tool across the East Midlands, involving all regional local authorities. Each authorities’ self-assessment will be submitted to the CQC when they are inspected;


(i)  a dedicated team have been working on Nottingham City’s self-assessment, and Principal Social Workers have been pivotal in gathering evidence.  It is intended as an accessible and user-friendly document, within a limit of 20 pages;


(j)  Nottingham’s self-assessment was completed and submitted to the region in March 2023, meeting the target timeline. When available, the Corporate Director will review the documents submitted by all East Midlands authorities. The self-assessment will be continually reviewed and used to build an evidence library for when the inspection is announced;


(k)  the objectives of the self-assessment are to demonstrate self-awareness of the service’s strengths, risks, challenges, and gaps. It is intended to be useful for the service in its own right, rather than just for the CQC inspection. The exercise has already enabled the team to identify areas for improvement, through improved citizen participation and feedback for instance;


(l)  the self-assessment has allowed the team to identify a number of improvements already delivered. For example:


  i.  there has been a 20% increase in Support Living placements over the last six years, providing an alternative to residential care for people with Whole Life Disability and mental health needs, allowing more independence and delivering savings for the local authority compared with residential care;


  ii.  due to bold decisions in commissioning, the team have been able to reduce waiting lists for Homecare by over 90% between September 2022 and February 2023. This is likely to be a key area of focus for the CQC. From over 200, there are often now under 10 on the waiting list;


  iii.  due to a merger of services, people supported by the Whole Life Disability team can stay in the same service throughout their life, without a gap or transition between children’s and adult’s services;


  iv.  staff retention has improved, with the turnover of registered Social Workers reduce by over 10% between 2021/22 and 2022/23, and the service is attracting experienced Occupational Therapists;


(m)the self-assessment tool also identifies key challenges and efforts taken to mitigate their impact. For instance:


  i.  there are particular challenges associated with Severe Multiple Disadvantage (SMD). Changing Futures has been developed as a multi-agency approach to improving support for this cohort;


  ii.  complexity and system pressures have been identified as a challenge. The transformation programme is addressing that, from prevention work and an early intervention strategy to improvements in homecare waiting times;


  iii.  co-production has been identified as an area the authority needs to improve compared to other local authorities, by development of a participation strategy. The participation strategy will be discussed at the Adults Leadership Team meeting on the week of the 27th March 2023;


  iv.  variations in the quality of practice of interventions are being addressed through the development of a quality assurance framework, to ensure citizens receive a consistent service from all professionals;


  v.  performance reporting is currently not adequate, but the team are recruiting a head of service who will lead on that and produce an improved performance management framework;


(n)  the self-assessment tool has allowed the team to identify key strengths of the service:


  i.  the commissioning approach is positive, with a small but expanding team who deliver good work in terms of co-production to develop services responding to unmet needs. The Carer’s Strategy is a god example of this;


  ii.  there is a strong culture of continuous learning and improvement, with an in-house training and development team, apprenticeship programmes,  and other professional development opportunities;


  iii.  workforce planning is a strength, with the workforce strategy starting to deliver positive outcomes in terms of recruitment, retention, and the development of practitioners as specialists;


  iv.  the transformation programme is a key strength, improving the quality of care and improving outcomes while dealing with increased demand;


(o)  it is anticipated that the team will know within 4-6 weeks whether Nottingham has been selected for the pilot scheme or not;


(p)  the self-assessment is now a public document, and will be shared with stakeholders and partners. It is important to get feedback from external stakeholders and partners, and hear whether they agree with the conclusions or if there are gaps that needs to be addressed;


(q)  the team are working on a forward plan to address identified areas for improvement. It will be important to learn from the other local authorities’ self-assessments and their examples of best practice;


(r)  it is important to continually refresh and review the self-assessment. It may be two years before Nottingham City is inspected, so any new evidence will need to be integrated.


In the discussion which followed, and in response to questions from the Committee, the following points were made:

(s)  the weaknesses and gaps had already been identified through the transformation programme, which is now in its second year. Those priorities have not changed through developing the self-assessment tool, but there is an understanding of the improving trajectory in those areas;


(t)  the finances of care providers in the private sector have never been under more pressure, due to rising energy bills and the cost of living. Interim funding from the government in last October has helped with that.


(u)  it most important to consider the outcome for the individual, and the authority does not set financial targets relating to support for individuals as there is a duty of care. The Council’s pricing regime for social care has been put out to consultation, and is due for submission soon. New care packages will be issued to the private sector following that framework;


(v)  there are no targets for moving individuals into Supported Living, it is based on individual circumstances, taking individual preferences and needs into account. However, the creation of more Supported Living placements has created an alternative option to residential care when most appropriate to meet that individual’s needs. Living independently in Supported Living with a care package is a better option for a number of individuals and happens to be less expensive, but a target would be the wrong way of looking at how to discharge the authority’s duty of care;


(w)waiting lists for homecare were extremely high a couple of years ago, exacerbated by Covid-19. Social workers were undertaking the assessments alongside other duties with increasing demand. As part of the transformation project, a team has been commissioned to complete the care assessments over the phone, which has enabled the authority to deal with the backlog and reduce waiting times. There are substantial quality checks on these assessments;


(x)  the authority has also taken out block contracts of homecare packages, to get them to people once assessed. The increased hospital discharge funding from October 2022 has helped to deliver improvements in getting people out of hospital with appropriate care packages, and it is hoped there will be a second tranche of funding to continue that work;


(y)  the self-assessment tool was constructed around the four themes identified by the CQC. The CQC will not look at Best Value, but they will look at issues of governance and accountability, and at effective commissioning of services;


(z)  the team commissioned to reduce the waiting list for homecare assessments was not in response to notification of the new CQC inspection regime. It has been in place since January 2022, before the new CQC duty to inspect;


(aa)  there was not sufficient time for frontline worker and service user views to be sought for the self-assessment, as the authority only had four weeks to prepare it. The transformation programme has allowed feedback given through that process to be used however, and the self-assessment is an iterative document that will be refreshed and refined as feedback is given;


(bb)  it would useful to increase the focus on educating citizens about what the authority delivers in terms of Adult Social Care, the costs, and the meaningful differences that this support delivers;


(cc)  Healthwatch work closely with the CQC, and have a statutory function to go into care settings and seek feedback from service users to identify improvements. It would be useful to speak to Healthwatch to talk about a strategy of involvement of citizens, in advance of the inspection;


(dd)  nine local authorities participated in the East Midlands region. The team have not seen the self-assessments produced by the other authorities yet, but will once they have been signed off by ADASS;


(ee)  the ADASS Annual Conversation is due to take place around May-June, which will provide a light touch audit around particular lines of enquiry, led by someone nominated by the Local Government Association. The self-assessments will give this some structure;


(ff)  in terms of encouraging feedback and participation from hard to reach groups, like the cohort experiencing Severe Multiple Disadvantage, there are trusted assessors in organisations like Framework and roles with Changing Futures that help with this. There is currently no cohesive plan, however, and this has been identified as a gap that the team need to work to address.

Resolved to recommend to the Portfolio Holder for Adults and Health that:

(1)  Adult Social Care take up the offer from Healthwatch Nottingham and Nottinghamshire to support with developing approaches to participation;

(2)  Adult Social Care create a version of the self-assessment that can be easily understood by service users and their families and carers;

(3)  She promotes the Council’s role in delivering Care Act functions to citizens, what it costs and why it matters.