Preparation for Assurance Peer Challenge Report - London Borough of Merton

The London Borough of Merton (LBM) asked the Local Government Association to undertake an Adult Social Care Preparation for Assurance Peer Challenge at the council and with partners. The work was commissioned by the executive director of adult social care, integrated care and public health at LBM. He was seeking an external view from a team of peers about the experience of people receiving support from adult social care and comment on the council’s preparations for Care Quality Commission (CQC) up-coming assessments.

A peer challenge is designed to help an authority and its partners assess current achievements, areas for development and capacity to change. Peer challenges are improvement focused and are not an inspection. The peer team used their experience and knowledge of local government and adult social care to reflect on the information presented to them by people they met, and material that they read. As the LGA Preparation for Assurance Peer Challenge team spent three days onsite conducting the challenge, this process should be seen as a snapshot of the adult social care department’s work rather than being wholly comprehensive. All information was collected on a non-attributable basis to promote an open and honest dialogue and findings were arrived at after triangulating the evidence presented.  

The members of the peer challenge team were: 

• Hazel Summers, Director of Improvement, Partners in Care and Health, Local Government Association
• Cllr Jim Dickson, (Labour) Joint Cabinet Member for Healthier Communities, Lambeth Council and Chair of Lambeth Health and Wellbeing Board
• Victoria Lawrence, Director of Adults and Health (DASS), North Lincolnshire Council
• Judith Westcott, Head of Commissioning, Health and Care Transformation, Bath & North East Somerset Council and Bath, Swindon and Wiltshire Integrated Care Board
• Damian Nolan, MBE, Assistant Director, Commissioning and Provision, Halton Borough Council
• Fiona Havord, Principal Social Worker, Oxfordshire County Council
• Megan Belcher, Expert by Experience, Bristol City Council
• Marcus Coulson, Peer Challenge Manager, Local Government Association 

The team were in Merton for three days between Wednesday 5 to Friday 7 June 2024. In arriving at their findings, the peer team: 

• Held interviews and discussions with those with a lived experience and carers, councillors, managers, practitioners, team leaders and front-facing staff and partners.
• Read a range of documents provided by LBM including a self-assessment and completed a case file audit of nine cases. 

Specifically, the peer team’s work was focused on the Care Quality Commission (CQC) framework of four assessment themes for their up-coming adult social care assurance inspections. They are:  

The peer team were given access to at least 144 documents including a self-assessment. Throughout the peer challenge the team had more than 38 meetings with at least 154 different people. The peer challenge team spent over 250 hours with LBM’s adult social care department the equivalent of 35 working days.

Initial feedback was presented to the council on the last day of the peer challenge which gave an overview of the key messages. This report builds on the presentation and gives a more detailed account of the findings of the peer team. 

There are a number of observations and suggestions within the main section of the report. The following are the peer team’s key messages to the council: 

Strengths

Strong and engaged political leadership with clear corporate support for adult social care: Merton Council benefits from political leadership that prioritises adult social care, ensuring sufficient resources and attention are allocated to this vital service area. In 2022/23 adult social care in Merton provided social care services to over 2500 people aged 18+. 

Member officer relationships. Those with whom we spoke, both members and officers at different levels described relationships between members and officers as respectful and with trust at its core. This strong foundation of trust and respect facilitates effective communication and collaboration, enabling the council to implement policies and initiatives smoothly. It also contributes to a positive organisational culture which the peer team also saw. 

Director of Adult Social Services (DASS). The council demonstrates strong leadership with a visible and approachable director of adult social services (DASS) who actively engages with staff and is open to suggestions and ideas. This approachability and openness promotes a culture of inclusivity and continuous improvement, encouraging staff to share ideas and feedback, which can lead to innovative solutions and enhanced service delivery. 

The staff we met are a real asset for Merton. The peer team had the privilege of meeting a wide variety of staff in the adult social care department at Merton Council. They were typically experienced, committed, hardworking and supportive who demonstrated a culture of caring for people:  Merton's assessment teams are dedicated professionals who embody a strong culture of care, ensuring high-quality, person-centred support for people with lived experience.  The peer team felt that the staff are a real asset for the council and a key foundation that it builds upon to deliver good services to people. 

Frontline staff see their team managers as very supportive.  From the frontline staff that the peer team met they were clear that they see their team managers in a positive light. Team managers provide crucial guidance and resources, creating a positive working environment and enhancing service delivery through collaborative problem-solving. 

Principal Social Worker (PSW). The PSW is a member of the adult social care Directorate Management Team with direct line of sight to the DASS. The peer team heard very clearly expressed views from a number of teams that she is highly respected by the staff who value the direction they received form her. 

There is a strong and effective strategic safeguarding partnership and Safeguarding Adults Board (SAB) and good connectivity with the Children’s Safeguarding Board and the Community Safety Partnership and Think Family.  Merton Council’s integrated safeguarding framework enhances protection for vulnerable individuals which is supported by effective partnerships. 

Well managed adult social care finances. The council’s prudent financial management ensures the sustainability and strategic allocation of resources for adult social care. A recent review by Grant Thornton mentioned that “Merton is performing well compared to its statistical neighbours in managing increasing demand and inflationary pressures in adult social care”. The department has managed it’s budget well in the past five years with a small overspend predicted this year and limited underspends for the four years previous to that. Based on this evident it is fair to say that adult social care has managed the budget well despite of all the pressures and challenges in the system. 

Relationships with health. There are good relationships between adult social care senior leaders and their colleague’s in the Integrated Care Board (ICB). Together they are developing a sense of Place. This has supported decisions and actions on shared roles, emergency planning and public health initiatives. 

Relationships with providers. When speaking with providers the peer team were struck by the descriptions of positive and effective relationships. The peer team were impressed by this. These collaborative and respectful relationships is supported by the fact that currently Merton has 32 care homes 91.4 per cent rated as good or outstanding (the London borough average is 82.4 per cent and the national average is 77.4 per cent). There are zero care homes that are rated inadequate by the CQC. This refers to services provided externally and by the council. 

People’s Voice. There are some good examples of the council effectively integrating the People’s Voice being heard from feedback, which is included into service planning, which demonstrates a commitment to person-centred care. 

There is an extensive community offer provided by both the council and the Voluntary and Community Sector (VCS) that staff describe using in their practice and is linked to the approach to prevention. It is clear that Merton Council invests time and resources into this offer. Merton’s extensive community services, supported by the council and the VCS, are integral to its preventative strategy, reflecting significant investment in community-based care solutions. 

The Learning Disability service is well integrated and there are numerous examples of positive outcomes for people. These included health screening, addressing such issues as breast cancer and menopause as well as issues of inequality offering genuinely integrated approaches to prevention and wellbeing. Merton’s well-integrated Learning Disability service delivers positive outcomes for people with lived experience, highlighting the council’s commitment to tailored support.

There are good examples relating to Equality, Diversity, and Inclusion (EDI) through the teaching partnership and the Human Resources and Organisational Development activity. Furthermore the council has been a pilot for the Race Equality Standards and there is a full council approach to this which is to be commended. 

Deprivation of Liberty Safeguards (DoLS) success.  The reduction in the Deprivation of Liberty Safeguards (DoLS) waiting list a success story. The council’s effective management of Deprivation of Liberty Safeguards (DoLS) has significantly reduced waiting lists, showcasing its operational responsiveness through an investment in resources to clear the backlog. In January 2023 the DoLS waiting list was 218 waiting for a s.12 doctor assessment and 244 waiting for a Best Interest Assessment (BIA). An external provider was engaged to complete assessments and Independent BIA’s and S12 doctors were recruited as well as an increase in internal resources in the DoLS team. As a result of this work at the end of March 2024 there were three waiting for S12 doctor assessment and zero waiting for a BIA assessment. 

The Public Health and Learning Disability health promotion work was fantastic. Merton’s proactive Public Health and Learning Disability health promotion efforts to improve health outcomes were really impressive to the peer team. They demonstrate a clear commitment to holistic well-being. 

Safeguarding processes. The focus and investment in safeguarding processes has improved responsiveness, reduced the safeguarding waiting list and supported an increased consistency of practice and approach. Creating additional staffing capacity in the safeguarding adults team has increased the majority of safeguarding concerns being received and responded to by this specialist team in a timely manner, usually on the same day. Where there is concern about the person’s current safety the peer team heard that a visit takes place the same day and appropriate actions are taken. 

Developing data systems. The adult social care is working to develop the department’s data systems to improve practice process and outcomes. Real time PowerBI dashboards are being developed and consistently utilised across the leadership and management team. This seeks to facilitate informed decision-making and continuous improvement. Examples given included business cases for additional and different staff (Occupational Therapists) to meet increases in need and the release of home care capacity, identifying workforce training needs such as the Mental Capacity Act (MCA) and being able to project the future resources required for young adults with disabilities. 

Emergency planning and resilience. There are robust systems at corporate and adult social care department level for emergency planning and resilience that are tried and tested This ensures preparedness and service continuity in emergencies. 

Risk registers. There are risk registers are place at a corporate and adult social care level which are reviewed quarterly. The comprehensive nature of the risk registers that are frequently reviewed enable the council to proactively identify and mitigate potential issues such as safeguarding service delivery. 

Contract management of providers. The peer team were impressed by the contract management of providers as it is undertaken regularly through what were described by those involved as supportive and productive relationships. It includes reviews of processes and systems and is very comprehensive in all aspects of safety. This supports and promotes high standards of safety and quality in service delivery. 

Considerations

Clearer strategic approach. There is the need for a clearer strategic approach and direction of travel described by the adult social care department that should be outcome focused and evidence based and then communicated and understood throughout the department. This would be most obviously seen in an amended self-assessment for the regulator so that the reader could easily grasp the political priorities, the needs of people and the resulting vision and priorities of the department and the supporting evidence for this. 

Strategies and plans. The peer team recommend that the department complete the strategies and plans that are outstanding or have lapsed in order to give clarity to the clarified strategic narrative. Whilst the peer team appreciate that having strategies can have limited use if they are not connected to specific work plans it would be helpful for the regulator to see how strategic intent is linked to plans and activity. This would make it easier to follow a golden thread narrative through the department from political priorities to effective frontline service delivery.  It would also give a clearer narrative for staff to see where they fit into the overall story and for them to demonstrate and describe their role in the overall work of the department. 

Voice of the People. The peer team recommend that the council introduce the Voice of the People with Lived Experience into the strategic and operational narrative.  There are good examples of this across the department in the Carer’s strategy, the Dementia Feel good folders, the work around the Big Conversation, the re-design of the Customer Satisfaction Survey and the involvement of families in Safeguarding Adults Reviews. This wealth of evidence and examples could be used as evidence of good outcomes being achieved with people. These could then be used by staff when speaking to their understanding of people’s lived experience and describe how they meet their needs and the impact they are having on people’s lives.  This is also a significant focus by the regulator.  

Waiting lists. The peer team recommend that the adult social care department clarify the waiting list narrative and ensure it is based on evidence from across the department and fully embed it with all teams. At present the understanding of waiting lists held by different teams is not a shared understanding. This is because the PowerBI system is in the process of being introduced and has not yet progressed to all staff at the time of the peer team’s visit. As it is rolled out and staff are trained on how to use it a shared narrative should become evident as it becomes fully socialised. The senior leadership recognise this and are aware of its importance and are working towards it, not least because the regulator has a clear focus upon this. 

Co-produce a Practice Model. The department should consider how to co-produce a Practice Model that includes a clear description of the department’s approach to strengths-based practice. This approach should empower staff to be better able to describe their interventions and the difference it makes to people’s lives. The peer team met staff who are able to describe the good work they do with people which was impressive. A Practice Model would seek to include this good work in a coherent strategic framework that would then support the ongoing data and quality assurance work.  

Continue to strengthen assurance of practice including supervision: The council should continue strengthening practice assurance, including supervision, to maintain high standards and support professional development. 

Co-production. There is the need to develop a clearly stated strategic intention for the department around co-production including a definition, process and the plans to embed co-production in practice. The senior leadership are self-aware about the status of the co-production work in adult social care and what needs to change and see the peer challenge work as an opportunity to address the issue throughout adult social care. 

User and Carers Experience. The department should consider developing a narrative and action plan to improve the current ASCOF position in relation to the indicators based on the surveys of people’s experiences and perception. An aspect of the need to address this is that recent CQC reports reference these indicators as evidence of users of services and Carer’s voice and experience. But addressing recent survey results is something that should be seen as central to the department’s improvement work as a whole. The council should develop a narrative and action plan to improve people with lived experience’ and carers’ experiences and perceptions. 

Increase capacity in commissioning. There is a lack of capacity to deliver the commissioning function which causes a focus on day-to-day activity rather than the staff involved having the opportunity to focus on strategy and engagement.  Addressing the lack of capacity in the commissioning function will enable the council to better develop the department’s strategic commissioning, planning and engagement. Linking these strategies to the well-articulated aims of the ICB would create a compelling shared narrative. 

Guide the Section 75 (s.75) narrative. The narrative around the planned disaggregation of the s.75 agreement with the Mental Health Trust needs to be communicated again to demonstrate the benefits for both people who access those services and the staff who deliver them. This would also seek to ensure that those with mental ill health access their rights to Care Act assessments and related support. 

Staff engagement. The peer team support the department’s commitment to staff engagement which is commendable and should be maintained to continue to foster a motivated and empowered workforce. The peer team saw evidence of a commitment to communication with the workforce through the Director’s Blogs and posters and emails regarding Merton United and the new value. As well as the personal visibility of senior staff with front facing colleagues. 

Resources. The department may want to re-visit the issue of resources that comes up as an issue for staff in the self-assessment for this work. Resource constraints are identified by the adult social care staff as important in the self-assessment for this work, however there was little explanation of the recognition of this. Further attention could be focused upon it to ensure that staff feel they have the necessary resources to perform effectively.  

Recruitment remains an issue. As with very many adult social care departments across the country recruitment of staff is a pressing issue. The council should continue to address the ongoing recruitment challenges by further exploring innovative strategies to attract and retain skilled professionals, ensuring continuity and quality in service provision. 

Prior to the peer team being onsite five individuals were asked by a member of the team about their experience of their adult social care service. Amongst other things, they were asked if they felt safe, if they knew who to contact and what the council did well and where it could improve in the delivery of services. Further interviews took place whilst the peer team were onsite. 

Strengths

• Carer representation in decision making spaces is a consistent practice with their voices embedded for the most part in different pockets of work.
• People with lived experience describe staff/officers as “kind”, “respectful”, “great” and there has been a description of the goodwill of officers being widely agreed upon.
• There have been opportunities for thoughts and opinions of people with lived experience to be heard such as with the ‘Big Conversation’.
• There is some future planning to see how to embed the voice of people with lived experience such as in the re-designing of Jan Malinowski Centre (JMC).

Considerations

• The current narrative appears to be focused on staff’s experience of working (which is consistently reported as being great, i.e. collaborative, supportive) and there isn’t yet a visible presence of people with lived experience’s voice from staff or otherwise. Staff need to be able speak to an understanding of people’s experience of drawing upon services.
• There appears to be limited opportunities for people with lived experience to directly speak about their own experiences. There is a tendency to rely on family member or carer stories rather than finding ways for the person to speak about their own experience themselves.
• There is a gap currently with local information and opportunities being communicated to parent carers and people with lived experience. A lot of resource and information sharing seems to be happening ad-hoc rather than being a consistent component of workers practice. Filling this gap will mean people will be informed of ways to have their voice heard.
• Further develop the relationship with user led organisations to widen the membership of people they support.
• Feedback loop – raise the awareness of the need to have the lived experience’s voice present in services. There is some collection of feedback but it is ad-hoc and minimal and workers aren’t aware of where it goes to or how it will inform future practice. There is an added gap that when people with lived experience do input thoughts and opinions, outcomes are not then reported to them so they can see the impact of their input (notably the Big Conversation).
• As part of the assurance process of a newly introduced Practise Model for front facing staff seek to ensure the service seeks the direct experience of people when auditing cases. 

Co-production: 

• There is the need to develop a clearly stated strategic intention for the department around co-production including a definition, process and the plans to embed it in practice.
• The senior leadership are self-aware about the status of co-production work in adult social care and what needs to change.
• There are useful frameworks already in place for example the Merton Compact and “Working with Communities” which could be referenced in terms of participation.
• There are pockets of good work to embed the voice of people with lived experience and practice but this is not centrally captured and would be a quick and easy fix for the department to do this using the following areas as a starting point:
  • Carer’s strategy
  • Dementia Feel good folders
  • The Big Conversation
  • Re-design of the Customer Satisfaction Survey
  • Involvement of family in Safeguarding Adults Reviews
  • Involvement in the re-design of day opportunities. 

The peer team considered nine cases in the audit. 

Strengths

1. Where a Carer was involved their needs were appropriately considered and recorded.
2. The Voice of the Person was evident in the majority of recordings, across various forms (assessment, mental capacity assessments, safeguarding). Some evidence of practitioner skills at conveying the person's story, describing what is important to them and identifying their strengths.
3. Care Act Assessments clearly outline the advice and information provided and consideration of other options.
4. Within the detail of the records practitioners are making reference to people's individual characteristics and cultures.
5. There was some evidence of creative approaches to support and solutions.
6. There was good communication with other agencies and authorities evidenced in recording and evidence of working well together to achieve good outcomes for people.
7. Recordings refer appropriately to Making Safeguarding Personal, the six Principles and the eligibility test for s.42. decision making and action plans are well evidenced and recording is mostly person-centred. 

Considerations

1. The Support Plans and reviews were less strength-based than other documents and the outcomes do not appear to be from the perspective of the person, often service-focused and lacking evidence of collaboration with the person. Some language could be revised and consideration of the Think Local Act Personal (TLAP) I/We statements could be helpful.
2. There were some instances of deficit-focused language in assessment recordings. Care Act Assessments are inconsistent in approach; it is unclear whether recording should be from the perspective of the person or the professional. Some examples included recommendations for long-term care at the outset of the assessment, which is contrary to a strength-based, collaborative approach to support planning and undermines professional curiosity and assessment.
3. Consideration should be given to how this can be better represented within the Care Act Assessment template to ensure it is considered in all cases.
4. Risk assessments are not always evidenced but would enhance the recording and understanding of the person’s experience and outcomes.
5. Recording is at times unnecessarily repetitive, using the same information multiple times across a record.
6. Actions were not always outcome-focused or person-led. Some instances indicated a lack of interaction with the person. 

This relates to assessing needs (including that of unpaid carers), supporting people to live healthier lives, prevention, well-being, and information and advice.

Supportive culture. From the evidence the peer team read beforehand and what was heard and seen whilst onsite the adult social care department at Merton Council excels in fostering a supportive staff culture, promoting a healthy work/life balance, and offering robust training opportunities.  There was positive feedback highlighting the supportive environment and work/life balance, and staff described access to various training programs and professional development opportunities that they welcomed. Whilst working in adult social care can be a stressful experience at times the peer team met staff who supported each other and had good morale that resulted in a stable workforce with low turnover. 

Outcomes forum. The adult social care department uses an Outcomes Forum that staff submit assessments to in order to reach organisational agreement of services to people. This is a tool that seeks to promote a consistency of practice and creative practice, thereby supporting continuous improvement and innovation in practice with the aim of leading to better outcomes for people. Whilst this appears to be the case the peer team also heard of some anxieties about inconsistent decisions experienced by frontline staff who submit work to it that the department may want to look at again in order to address. 

Use of PowerBi. The council is beginning to introduce the PowerBi data system to monitor performance data, enhance oversight of assessments, support planning and service user journeys. At the time of the peer team’s visit it had been rolled out to senior staff and there are plans to compete this with all adult social care staff. This increased ability to track key performance indicators and metrics should develop the department’s quality assurance processes and enhance transparency of activity. 

Carer’s First contract.  In 2022/23 the council supported over 1000 carers and has successfully integrated the Carer's First contract into the MOSAIC system giving enhanced oversight of carers' assessments allowing comprehensive tracking and management within adult social care. 

Prevention offer. The peer team heard and saw evidence of the good relationships between adult social care and the Voluntary, Community, and Social Enterprise (VCSE) sector. These collaborative initiatives and partnerships offer a diverse array of preventative services offered to the community.  

Social prescribing. There has been the successful implementation of social prescribing programs in partnership with VCSE organisations and Primary Care Networks. These are built upon good relationships with the ability to work together effectively through joint ownership of issues and the ability to effectively problem solve.  

Occupational Therapy (OT) clinics. The department has developed innovative uses of OT clinics to enhance access to support. These clinics provide targeted support and interventions, enhanced accessibility to essential services, ensuring timely and appropriate support for individuals in need. 

In-house translation service. The department’s in-house translation service is well used, well-resourced, and well regarded. The high usage rates and positive feedback from users are evidenced through the speed of turnaround times for accessible formatting and their quality. Everyone to whom the peer team spoke about this work heard that this quick provision of accessible formats ensures that all residents, including those with disabilities, can access information promptly, enhancing their ability to engage with services and support.  

EDI projects. The council is actively involved in corporate Equality, Diversity, and Inclusion (EDI) projects, including the participation of staff networks. This demonstrates the council’s commitment to fostering an inclusive workplace and community.   

Population representation. The adult social care workforce, the council in general, providers and schools represent well the increasingly diverse population of Merton in terms of diversity, ethnicity, and culture.  

Considerations

Practice Model. The council would benefit from implementing a practice model to help practitioners articulate their practice and outcomes. Whilst onsite it was difficult for the peer team to grasp what approach practitioners were working to. A practice model will provide a common framework for practitioners, improving consistency and clarity in service delivery. It will also enable better documentation and communication of outcomes, enhancing transparency and accountability in adult social care services.  

Share performance data with teams. The department is in the process of introducing Power BI across the service. As it does this there is recognition that it would be beneficial to share performance data with teams to celebrate progress, particularly in relation to the waiting list position. When this is achieved it will be easier to create a consistently held narrative and the evidence of how the department understands the levels of those waiting and how this issue being addressed in different areas and teams. At the present time there is a level of inconsistency here.  

Unpaid carers. The information for unpaid carers needs to be revised. The department recognises the need to enhance its approach to how the resources for and information about the options to unpaid carers is shared. The aim should be to increase their knowledge about what is available and how to access it to better support them.  

Unmet need. The council needs to develop a systematic approach to capturing unmet need and integrating this information into commissioning and planning processes. The current processes do not adequately capture and utilise data on unmet need and using this information in commissioning and planning would ensure that services are responsive to all community needs.  

Waiting lists. The peer team recommend that the adult social care department clarify the waiting list narrative and ensure it is based on evidence from across the department and fully embed it with all teams.  At present the understanding of waiting lists held by different teams is not a shared understanding. This is because the PowerBI system is being introduced and has not progressed to all staff at the time of the peer team’s visit. As it is rolled out and staff are trained on how to use it a shared narrative should become evident as it becomes fully socialised. The senior leadership recognise this and are aware of its importance, not least because the regulator has a clear focus upon this.  

Roles and responsibilities of advocates. There is clarity needed on the roles and responsibilities of advocates and how social workers understand what they can bring to a situation with people who use services. The aim should be to emphasise the opportunities for collaboration.  

Evidence the prevention agenda. This report has previously stated that the VCSE and the council work well together and offer a variety of opportunities for people to promote their wellbeing and thereby prevent, reduce and delay their presentation for support.  An area of improvement would be for this positive work to be evidenced and this story shared with people who use the services – to inform and widen their choice, but also to ensure frontline staff have an increased awareness and understanding of the offer.  This could include greater clarity on the evidenced outcomes that can be achieved by different opportunities. 

Enhancing the visibility of intermediate care pathways.  The peer team heard feedback indicating a lack of clear information on intermediate care pathways. Therefore, in coordination with the ICB, the department could investigate this further to improve the visibility and clarity of pathways into, through, and out of intermediate care. Enhancing the visibility of these pathways would ensure that people with lived experience and their families are better informed, facilitating smoother transitions and more coordinated care. 

Direct Payments.  In Merton 25.2 per cent of adults in receipt of a service from adult social care purchase their service using a direct payment. As an aspect of this the department should articulate a clearer approach to the use of direct payments to promote choice and control for people with lived experience. There is presently some ambiguity in current policies and practices regarding direct payments.  Staff and people in receipt, or likely to be in receipt of direct payments would benefit from greater clarity.  

EDI. The council needs to more explicitly integrate Equality, Diversity, and Inclusion (EDI) considerations into case examples and practice documentation. At present EDI is not overtly discussed or evidenced in relation to case examples, although there is evidence of staff knowledge and awareness. Making EDI considerations more explicit in practice and strategy would ensure that services are equitable and inclusive, addressing the diverse needs of all people with lived experience effectively.  

Use of language. Whilst onsite listening to staff and when reading the self-assessment and supporting documentation for this work the peer team noticed a variety of language was being used such as ‘client’, ‘customer’ and ‘service user’. The department may want to consider updating the terminology used to refer to people and seek to adopt a more current, consistent and respectful language. Doing so would reflect a more person-centred approach, enhancing dignity and engagement. 

This relates to assessing needs (including that of unpaid carers), supporting people to live healthier lives, prevention, well-being, and information and advice.

Strengths

Learning Disability Forum. The work with the Learning Disability Forum is a good example of where individuals' voices are heard and significantly influence the work being done. The staff in the adult social care department who have made this happen demonstrate that they understand how to incorporate the voices of people with lived experiences into decision-making. 

Integration of Public Health. The council effectively integrates Public Health in its commissioning processes. It was evident to the peer team and appears effective as shown by collaborative initiatives and the inclusion of public health priorities in commissioning decisions. This supports a more holistic approach to health and social care, addressing wider determinants of health and improving overall population well-being. 

Contract monitoring and quality assurance. The council maintains regular contract monitoring and quality assurance processes. Members of the peer team were impressed by these processes which were engaged, open, transparent, and focused on outcomes to ensure high standards of care.  The outcome that has been achieved here is that service providers remain accountable and that the quality of care is consistently high, leading to better outcomes for people with lived experience. Inspection outcomes by CQC of local providers support this. 

Requests for Social Worker / specialist input.  When requests are made by providers for input or support from social workers or other specialist input it was evident that the council responds quickly.  Their requests are met with engaged, focused, and facilitative responses which means that service providers receive timely support, enhancing their capacity to deliver high-quality care and addressing issues promptly. 

Commissioners relationships. The adult social care commissioners have strong relationships with providers based on good contract management. The peer team heard about effective and collaborative contract management practices that build strong relationships. This leads to better coordination and cooperation between commissioners and providers, ensuring that care services are responsive and aligned with strategic goals. 

Considerations

Co-production. As had been referenced elsewhere in this report there is the need to develop a clearly stated strategic intention for the department around co-production including a definition, process and the plans to embed it in practice. The senior leadership are self-aware about the status of co-production work in adult social care and what needs to change. There is currently no formal strategy or plan in place for this. Developing this strategy would enhance the involvement of people with lived experience and other stakeholders in designing and delivering services, ensuring that they are more effective and user centred.  

Market Position Statement. The council needs to update its Market Position Statement (including Fair Cost of Care) as it is presently out of date. Updating these documents would provide a clearer and more accurate picture of market needs and costs, helping to inform better commissioning decisions and ensure fair pricing. 

Commissioning across Place. The council needs to develop a strategic approach to commissioning across the place as at present there is a lack of a cohesive, strategic approach to commissioning. While the Towards Outstanding Programme (TOP) is well run and monitored it needs a strategic and visionary “home” in the department to set out objectives and outcomes for the residents of Merton. Developing this approach would ensure that the strategic intent of the department is better understood, efficient, and aligned with commissioned activity and broader community needs and priorities. 

Equity. The council should consider how to address geographical equity in service provision. An example would be better evidence of how the Core 20 plus five is being outworked and impacting on the people of Merton. This would ensure that all areas receive equitable service provision, addressing disparities and improving overall access to care. 

People with Lived Experience (PLE).  The council needs a systematic approach to understanding people with lived experience’ experiences. Currently there is no systematic approach to capturing the quality of experiences from the perspective of people with lived experience. Implementing such an approach would provide valuable insights into the effectiveness and quality of services, informing continuous improvement efforts. 

Quality Statement – Partnerships and Communities

Strengths

Integration of Public Health. The council effectively integrates Public Health in its commissioning processes. It was evident to the peer team and appears effective as shown by collaborative initiatives and the inclusion of public health priorities in commissioning decisions. This supports a more holistic approach to health and social care, addressing wider determinants of health and improving overall population well-being. 

Relationship with the Integrated Care Board (ICB). It was evident from the discussions the peer team had with key senior leaders across adult social care and health that there are strong working relationships with the Integrated Care Board (ICB). These relationships are prepared to tackle difficult issues through relationship governance, as evidenced by effective responses to recent incidents such as the local gas explosion, the work on the Better Care Fund (BCF), Adult Social Care Discharge Grants (ASCDG) and winter pressures. This results in a more resilient and responsive health and social care system capable of addressing complex and emergent issues effectively. 

Mencap. The department has been able to ensure the representation of Mencap in major partnership boards. Representatives stated that they feel represented and involved in major partnership boards. This ensures that the needs and perspectives of people with learning disabilities are considered in strategic decision-making, leading to more inclusive and supportive services. 

Borough Committee. The Borough Committee delivers effective strategic engagement for LBM, the Integrated Care Board (ICB) and the rest of the NHS. There is agreed joint analysis of need, planning functions and clear governance arrangements. This suggests that the partnership is better able to address community health needs effectively and fosters strong inter-organisational relationships. This is a real success and can be added to the adult social care narrative. 

Community groups.  It was interesting to note for the peer team that independently set up and run local community groups engage with adult social care. They are not financially dependent on adult social care but engage effectively nonetheless. This suggests a positive view of the Council by these groups as well as offering the residents of Merton a wide range of opportunities to support wellbeing and enabling them to flourish.  

Considerations

PLE and partnership boards. The service recognises the need to develop the representation of the voice of people with lived experience on major local partnership boards. This will ensure that the perspectives and experiences of people with lived experience are adequately represented in strategic decisions, leading to more user-cantered policies and practices. 

Strategic approach to commissioning. Elsewhere in this report there is reference to the need to increase the capacity in commissioning. This would enable a more strategy focus and positive engagement with colleagues. When this is done it should then be possible to develop a strategic approach to commissioning across place, roles, and responsibilities.  Clarity about the relationship between the TOP team and the commissioning role within the department would support sustained improvement and attainment of departmental vision. Developing this approach would also improve coherence and efficiency in developing the Merton offer, ensuring that services are well-coordinated and meet the diverse needs of the community. 

Discharge pathways. The council works well to deliver a good reablement service. A high proportion of people (79 per cent) do not require long term support following a period of reablement and there is proactive support for people moving from hospital back into the community. There is a need however for the council to have clearer discharge team pathways and better links to other teams as at the present time they are not clearly defined, and links to other teams can be unclear. Clarifying these pathways would improve coordination and communication, leading to smoother transitions and better outcomes for people with lived experience. The peer team recognised that working across multiple hospitals necessitates flexibility of approach, but discharge and reablement teams should be supported by both the council and ICB to have a shared understanding of goals and outcomes for people in Merton going through discharge pathways. This would also extend to further discussion around preventative or community reablement offers.

Disabled Facilities Grant (DFG) pathway. The council needs to address disconnects in the Disabled Facilities Grant (DFG) pathway. There was evidence to suggest that there is a disconnect to the environmental health function which makes it difficult to effectively deliver the service. Addressing this supports the maintenance of independence for people with lived experience as they receive timely adaptations. 

Voice of People with Lived Experience. The council should create a safe space for user-led organisations to speak openly. There is a need for a safe space for user-led organisations to discuss their members' experiences, even if negative. Providing this space would foster honest feedback and constructive dialogue, leading to improved services and better outcomes for people with lived experience. 

Merton Compact. The Merton Compact is a partnership agreement between local public bodies and the VCSE sector to improve their relationships and provide a framework within which the sectors can understand what to expect from each other. Whilst the Merton Compact has been meeting for some time it needs to be refreshed and integrated into adult social care conversations. 

This area relates to safeguarding, safe systems, and continuity of care.

Quality Statement – Safe Pathways, Transitions and Systems

Strengths

Emergency planning and resilience. There are robust systems at corporate and adult social care department level for emergency planning and resilience that are tried and tested. This ensures preparedness and service continuity in emergencies. 

Risk registers. There are risk registers in place at a corporate and adult social care level which are reviewed quarterly.  The comprehensive nature of the frequently reviewed risk registers enable the council to proactively identify and mitigate potential issues such as safeguarding service delivery. 

Contract management of providers. The peer team were impressed by the contract management of providers as it is undertaken regularly. It includes reviews of processes and systems and is very comprehensive in all aspects of safety.  This supports and promotes high standards of safety and quality in service delivery. 

Out-of-area placements. The council effectively manages it adult social care out-of-area placements, ensuring continuity of care. This is evident from the strong and effective relationships with neighbouring authorities, which facilitate seamless transitions for people moving from Merton. This results in uninterrupted and consistent care for individuals, reducing the stress and potential risks associated with moving between different care systems. 

Preparation for Adulthood. The council is investing in the Preparation for Adulthood team which is leading to better transitions. Investment is starting to show positive results with more timely and coordinated transitions, supported by effective relationships with the Children’s and Education departments and a growing focus on employment. This means that young people with disabilities should experience smoother transitions into adulthood, with increased opportunities for employment and independent living.  

Community Navigators. The council’s community navigators are improving outcomes for young people with disabilities. Community navigators are actively engaged and are making a noticeable impact on the outcomes for this demographic. This pilot, while in its early stages, evidenced case examples which described improved support networks and resources for young people with disabilities, enhancing their quality of life and promoting greater independence. 

Considerations

Carers and transitions. The department could consider the effectiveness of communication with carers through the transitions process which the peer team heard needs improvement. Whilst it was a small sample, the carers spoken to reported insufficient communication and a lack of attention to their own needs during transitions which suggests a gap in support that could lead to carers feeling undervalued and stressed, potentially affecting the quality of care they provide. Addressing this issue by using the new provider to enhance communication should ensure carers are well-informed and supported. 

Young adults’ needs. There was evidence that some young adults' needs are not being fully met, resulting in them falling through the gaps. This was during their transition from Children’s to Adults Services. This results in unmet needs and potential negative outcomes for these young adults. Targeting community and prevention offers to these groups can ensure more inclusive and effective support, preventing individuals from falling through the gaps. 

Quality Statement – Safeguarding

Strengths

There is a strong and effective strategic safeguarding partnership and SAB with ambition and a positive direction of travel. There is an experienced and respected Independent Chair and an established governance structure with leadership and contributions from across the partnership. There is also good connectivity with the Children’s Safeguarding Board and the Community Safety Partnership and Think Family, which enables a focus on cross cutting issues including domestic abuse and transitional safeguarding, sharing intelligence and delivering joint conferences and training.  Merton Council’s integrated safeguarding framework enhances protection for vulnerable individuals which is supported by effective partnerships. 

Diverse assurance and learning mechanisms.  The council has managed to successfully embed diverse assurance and learning mechanisms across the system.  These are well-integrated and operational within the system.  Safeguarding Adults Review (SARs) appeared to be robust and take a person centred and partnership approach including involving people’s families. There is a focus on learning and improvement with action plans being developed and implemented in line with recommendations with learning loops followed up. Examples were given regarding multi-agency training on the Mental Capacity Act and Substance Use, with positive feedback and a commitment to determining impact. 

The SAB and the voice of people. The Safeguarding Adults Board is increasingly active in seeking the voice of people with lived experience (PLE) is heard. The initiatives such as the Community Safeguarding Champions and plans to enhance PLE involvement are in place. This results in more person-centred safeguarding practices that are informed by the real experiences and needs of people with lived experience, enhancing the effectiveness and relevance of safeguarding measures. 

Investment. The senior leadership of adult social care and the SAB recognised that there needed to be improvements in safeguarding that included reducing response times to concerns and the recording of decision making. Creating additional staffing capacity in the safeguarding adults team has facilitated the majority of safeguarding concerns being received and responded to by this specialist team in a timely manner, usually the same day. Where there is concern about the person’s current safety a visit takes place the same day and appropriate actions taken. There has also been an improved consistency of practice and approach thereby reducing the risk of harm and improving overall safeguarding outcomes.  

Making Safeguarding Personal.  In the judgement of the peer team the department effectively implements Making Safeguarding Personal (MSP) in practice and case discussions.  The Council has strengthened the Safeguarding Team following a review.  Making Safeguarding Personal data was recorded for 95 per cent of concluded enquiries, where outcomes were expressed and they were fully or partially achieved in 94 per cent of cases.  The Peer team found that staff demonstrate a good understanding of MSP, as evidenced in their practice and discussions.  This ensures that safeguarding interventions are tailored to the individual's needs and preferences, promoting more effective and respectful outcomes. 

Considerations

Making Safeguarding Personal principles. Whilst the peer team make the positive comment above, there was evidence that the principles of MSP were not always consistently applied. This was reflected in the case file audit for this peer challenge and suggests a potential gap in practice that could lead to safeguarding interventions that are not fully person centred. Strengthening MSP consistency can enhance the relevance and effectiveness of safeguarding efforts.  

Practice not always outcome focused. There was evidence to suggest that safeguarding practices were sometimes focused on the process of safeguarding rather than the desired outcomes of the person with lived experience. This can result in interventions that do not fully address the needs and goals of individuals, potentially reducing the effectiveness of safeguarding measures.  Emphasising outcome-focused practices can ensure that safeguarding efforts lead to meaningful improvements in individuals' lives. 

People’s perception of feeling safe. The proportion of people with lived experience who feel safe reported through the annual survey has been comparatively low in recent years. Consideration and exploration could be given as to why people are reporting that they do not feel safe and planning what actions can be taken. 

Quality assurance and oversight of operational safeguarding.  Whilst there has been an investment in safeguarding resources and a reduction in wait times and increased consistency there is the need to complete the project cycle by including a stronger quality assurance and oversight of this operational safeguarding activity. The data shared with the peer team indicated some variation in decision making regarding the progression to enquiries over the last year. The directorate management team are aware of this and monitoring it and are confident that the new operational arrangements are leading to increased consistency.  This current use of the blended model requires further development to enhance quality assurance and oversight. 

This relates to capable and compassionate leaders, learning, improvement, and innovation. 

Political comments 

Cabinet Member. The cabinet member for health and social care is closely engaged in adult social care policy development and giving political direction to the department. Member ownership of key departmental initiatives is demonstrated through engagement in key projects such as the Joint Management Committee (JMC) project, hospital discharge processes, and reablement initiatives. This level of engagement ensures that adult social care policies are aligned with political priorities, leading to cohesive and well-supported initiatives. It also fosters accountability and ensures that the department's key projects receive the necessary political backing and resources for successful implementation. 

Member officer relationships. Those with whom we spoke, both members and officers at different levels described relationships between members and officers as respectful and with trust at the core. This strong foundation of trust and respect facilitates effective communication and collaboration, enabling the council to implement policies and initiatives smoothly. It also contributes to a positive organisational culture which the peer team also witnessed.  

Political oversight. The leader and cabinet member receive regular updates of departmental financial and performance information in a corporate format. This practice ensures that senior political figures are well-informed about the department's performance and financial health, enabling them to make informed decisions and provide effective oversight. 

The 2023/24 adult social care budget was £67,987m with the biggest area of expenditure of £29.1m on supporting people aged 65+, followed by £20.9m on people with a learning disability (18-64), £4.6m on people needing support with their mental health (18-64) and £3.9m on people with a physical disability (18-64). In Merton there are increasing pressures on adults services as there are on all adult social care budgets across the country. The main reasons are typically an increased complexity of individuals receiving services, which leads to higher overall placement costs, particularly in Learning Disability and Mental Health services and increased activity at hospital discharge. The adult social care department’s overspend last year £1.7m overspend compares favourably with other London Boroughs with the same pressures leading the Peer Team to conclude that the adult social care department is good at manging its finances and has been over recent years. In the present financial climate this is an achievement worth noting. 

Wellbeing and prevention.  The council has successfully integrated the wellbeing and prevention agenda across various departments, with strong support from cabinet colleagues such as Children’s and Leisure who are very focused on promoting people’s activity and exercise through being the Borough of Sport and the use of Libraries as Hubs. They see strong relationships with the Voluntary, and Community Sector as key as they are essential to delivery of this work.  One example amongst many the peer team saw included the creative arts work with Workshop305 which typically goes beyond day activity and also celebrates the skill and artistry of its members with learning disabilities and autism. 

Strengths

Director of Adult Social Services (DASS).  The council demonstrates strong leadership with a visible and approachable director of adult social services (DASS) who actively engages with staff and is open to suggestions and ideas. This approachability and openness promotes a culture of inclusivity and continuous improvement, encouraging staff to share ideas and feedback, which can lead to innovative solutions and enhanced service delivery. 

Corporate Support. The DASS and the adult social care department is well supported by the Corporate Team who recognise the role it plays to deliver political priorities and cross council initiatives. Colleagues could readily describe their understanding and activities.  

Self-assessment and frontline staff. When speaking with frontline staff the peer team heard the views outlined in the self-assessment for this work in that there are teams of experienced staff delivering good outcomes for people through effective working practices and with high morale. This alignment between the self-assessment and staff feedback indicates a well-managed and supportive work environment. 

Principal Social Worker (PSW).  The PSW is a member of the adult social care Directorate Management Team with direct line of sight to the DASS. The peer team heard very clearly expressed views from a number of teams that she is highly respected by the staff. 

NB:  The evolving role of the Principal Social Worker. As CQC roll out their assessments it is becoming clearer of their increasing focus on the evolving role of the Principal Social Worker (PSW).  CQC are explicitly asking to speak with the post holder in their onsite work.  The expectations of the role are changing and as a result Councils are moving towards a PSW role that holds a senior position providing strategic direction to the quality of operational activity for adult social care. This means they monitor, provide guidance and clarity at a senior level of the lived expertise, that of carers and the related activity of front-facing adult social care staff. This role will be an important feature of the Council’s internal processes to assure itself that local people are receiving good support.  The service should ensure that it uses the understanding of practice and the management of the associated risk that the LB Merton PSW brings to the role which would then be reflected in the priorities of the service and its plans for mitigation of risk.

Workforce Strategy.  There is a newly developed workforce strategy in place with the team who developed it working closely with Kingston University and a training partnership to develop new tactics to recruit and retain staff. 

Quality Assurance Model (QAM).  A refreshed QAM is in place and there are plans for a more robust case file audit practice to be developed that is focused on data and performance information utilising new dashboards. The aim is to create more rigorous and data-driven quality assurance processes to enhance service delivery quality and accountability. 

Manager communication with DMT.  The peer team heard evidence that communication between managers in the adult social care and the Directorate Management Team (DMT) was positive and respectful in both directions.  This culture of respectful communication supports effective collaboration and decision-making and overall organisational efficiency and morale. 

Manager support. Managers clearly articulated how they support staff via supervision, caseload management, wellbeing and frequent communication. This was corroborated through speaking to the staff involved in this activity. 

Borough Committee. The Borough Committee delivers effective strategic engagement for LBM the Integrated Care Board (ICB) and the rest of the NHS. There is agreed joint analysis of need, planning functions and clear governance arrangements. This suggests that the partnership is better able to address community health needs effectively and fosters strong inter-organisational relationships.  This is a real success and can be added to the adult social care narrative. 

Considerations

Clearer strategic approach. There is the need for a clearer strategic approach and direction of travel described by the adult social care department which is outcome and evidence based, communicated and understood throughout the department. This would be most obviously seen in an amended self-assessment for the regulator so that the reader could easily grasp the political priorities, the needs of people and the resulting priorities of the department and the supporting evidence for this. 

TOP Programme evidenced narrative. The department has £1.752m savings to achieve across the next three years as part of the Medium Term Financial Plan. Savings proposal implementation and benefit tracking is done through the Towards Outstanding Programme (TOP) Board. The council could enhance the narrative of the TOP work by focusing on a revised adult social care narrative vision and use clearly evidenced outcomes to illustrate the changes it is making. When speaking to the TOP team the peer team heard of numerous examples that evidence the positive changes that are being made in the different workstreams of the programme. Those in the TOP programme recognise that using the outcomes achieved would drive the narrative of the work and is an obvious quick win. This evidence could be added to the self-assessment. 

Staff training focused on cultural awareness.  The council should consider implementing staff training focused on cultural awareness specific to Merton’s diverse communities. Cultural awareness training will equip staff to better understand and meet the needs of Merton’s diverse population, improving service accessibility and effectiveness. This should enhance community trust and satisfaction with council services. 

Work Force. The workforce plan needs to be widely shared and embedded with staff to ensure that the cultural significance and practice of this narrative is impacting on their work life. Further work is also needed to extend this cultural and practical commitment and vision with the ICB and onwards into the wider adult social care workforce amongst providers in Merton. 

Practice governance.  The department recognises that practice governance needs strengthening through an audit framework and the related outcomes to be achieved. The peer team suggest involving managers to take responsibility for audit practice and feedback in teams. This would integrate feedback effectively into service improvement processes, leading to better outcomes for people with lived experience. 

On behalf of the Adult Social Care Preparation for Assurance Peer Challenge team for the London Borough of Merton, June 2024. 

Marcus Coulson

Senior Advisor – Adults Peer Challenge Programme

Local Government Association

Email: [email protected]

Tel: 07766 252 853

For more information on the Adult Social Care Preparation for Assurance Peer Challenges please see our website: Adult social care peer challenges | Local Government Association

We appreciate the senior political and managerial leadership will want to reflect on these findings and suggestions to determine how the council wishes to take things forward. 

As part of the peer challenge process, there is an offer of further activity to support this. The LGA is well placed to provide additional support, advice, and guidance on a number of the areas for development and improvement and we would be happy to discuss this. 

Kate Herbert is the main contact between your authority and the Local Government Association. Her contact details are: 

Email: [email protected]

Telephone: 07867 632404

Web: Home | Local Government Association

Steve Tingle is the LGA Care and Health Improvement Adviser for London and your main contact to the LGA Partners in Care and Health Programme.  His contact details are: 

Email: [email protected]

Telephone: 07853 100778

Web: Partners in Care and Health | Local Government Association

In the meantime, we are keen to continue the relationship we have formed with the council throughout the peer challenge. We will endeavour to provide signposting to examples of practice and further information and guidance about the issues we have raised in this report to help inform ongoing consideration. 

Councils need an authentic narrative for their adult social care service driven by data and personal experience.

The narrative needs to be shared with those with a lived experience, carers, front-facing staff, team leaders, middle managers, senior staff, corporate centre, politicians, partners in health, third sector and elsewhere.

Ideally this story is told consistently and is supported by data and personal experience - do not hide poor services.

This will probably take the form of:

• What are staff proud to deliver, and what outcomes can they point to?
• What needs to improve?
• What are the plans to improve services?

In the preparation phases, consider putting it on all team agendas asking staff what they do well, what is not so good and to comment on the plans to improve. Collate the information from this process and add to the self-assessment. Ensure the self-assessment is a living document that is regularly updated.

Immediately prior to CQC arriving, ask staff what they are going to tell the regulator. How is their experience rooted in observable data and adds to the overall departmental narrative? These stories drive the understanding of yourselves and others. 

The regulator is interested in outcomes and impact from activity. The self-assessment needs to reflect this as do other documents.

The conversation with the regulator is not a chat. For those interviewed it should be a description of what they are proud of delivering, the impact they have had and the evidence they can point to. Case examples written in the authentic voice of those with a lived experience bring this alive.