Older people and vulnerable adults are supported to lead fulfilled and independent lives

Are we achieving our targets?

Green – 5; Amber – 2; Red – 4; M – 6

Are we getting better?


Improved performance


Stayed the same


Requires improvement


Further information is needed or the latest measure is unavailable

Analysis and issues

The Older People and Vulnerable Adults Outcome Plan key performance indicators are reporting challenging performance, with one measure at Green, two at Amber, and three at Red status. The picture in terms of direction of travel is more positive, with four measures improving and two declining.

The Green measure related to the proportion of adults with a learning disability who live in their own home or with their family, which reports in at 89% compared to mid-year performance of 85.8%. This measure has therefore switched to Green, as has surpassed its target of 88.3%, and the latest performance is the highest since Quarter Two 2017-18.

One Amber measure concerns performance regarding the proportion of adults receiving community-based social care services who receive self-directed services, which has improved on prior performance of 99.8%, now standing at 99.9% against the target of 100%. The second Amber measure concerns the number of Adult Social Care attributable Delayed Transfers of Care, which has experienced significantly improved performance compared to last year.

Three key performance indicators have a Red status. One of these indicators relate to delayed transfers of care, looking at both overall Cheshire West numbers and those in particular attributable to Adult Social Care. Two measures are included relating to Delayed Transfers of Care in recognition of this as a significant performance issue locally and nationally.

In 2017/18 the Council and its partners were set challenging targets as part of the Better Care Fund submission by the Department of Health. These targets were agreed by the Cheshire West and Chester Council Health and Wellbeing Board.
(Total delays target – 11,302. Social care delays target – 5,014.)

New Targets for 2018/19 have only recently been released by the Department of Health and Social Care and subsequently approved by the Health and Wellbeing Board. The expectations are further challenging compared to last year’s target, and emphasis for the reduction is weighted to social care delays.
(Total delays target – 8,667. Social care delays target – 2,554.)

This is an even bigger challenge for local partners in 2018/19 in further reducing the delays against a backdrop of funding pressures and growing demand. In essence the new targets mean that adult social care can only have 7 delays per day across any hospital location for Cheshire West and Chester Council residents awaiting a discharge.

At the time of writing the latest published data was for January 2019 activity therefore narrative below is based on January 2019 delayed transfer data.

Over the past 12 months the number of delayed days have fluctuated monthly, with the past quarter peaking at an average of over 1,000 days each month; however, the result in January 2019 is the 2nd lowest (best performing) over the past 12 months, showing a positive downward trend. This means that the overall system, the NHS and Adult Social Care all hit the centrally set targets. This is even more positive when considered within the context of winter pressures. Winter funding schemes have been mobilised and flexed to meeting the ongoing and changing demand over the winter period.

Operational changes have been made to the teams based in both Countess of Chester and Leighton Hospital hubs. These changes involve engaging earlier in the patient journey through the “red to green” ward meetings, meaning discharge can be facilitated more efficiently once the person is ready to leave hospital; there is also daily Delayed Transfers of Care performance monitoring in the teams so all staff are aware of current performance and targets.

As part of the Better Care Fund, health and social care partners agreed to ring-fence a Delayed Transfers of Care investment fund to pilot new schemes, or expand on ones that are known to be making a difference over the winter period.

Given the pressures experienced over winter these schemes were carried forward and continued from April 2018. Whilst this has had a positive impact on delayed transfers for some months of the period, it only shows part of the picture as each organisation funds services and schemes outside of this in support of timely discharges. An initial review allowed partners on the Steering Group to ensure that only the effective schemes were being continued, this includes;

  • Additional elderly mentally inform nursing bed capacity
  • Additional Social Worker resource to support seven day and bank holiday working
  • Social Care assessor support for intermediate care facilities
  • Mental health input into community assessment units and Mental health liaison support at home
  • Enhanced transport services for timely discharges

Further information is available in Appendix Four.

The second red key performance indicator looks at the total number of carers given advice, information or signposted has significantly missed the target set for the year of 965, having reached 291. This is also significantly below the overall figure achieved in 2017/18 of 469, which was itself under the 17-18 target of 931. A detailed set of actions has been agreed to improve performance on this measure, including:

  • Data cleansing. An extensive exercise is in progress identifying and correcting errors in the recording and loading of over 4,000 individual records. This will be an ongoing exercise. Around a third of these records have now been cleansed and corrected, with the remaining records to be completed in the coming months. Current Carer records, as identified in Liquidlogic, will be prioritised and completed by end April 2019.
  • This exercise has highlighted a larger number of carers who the Council have already supported and signposted to appropriate support. Community Access Team have been briefed on what they are required to load in order to capture carer activity in reports.
  • Clear and updated user guides have been re-issued to all teams to address the inconsistent loading. These user guides have been issued and full briefings will take place with all teams throughout Quarter Two and Quarter Three.
  • Adult Social Care Performance Team and Carer liaison Support delivered team, team rep and team manager briefings and training on carer recording on Liquidlogic between Aug 18 and Jan 2019.
  • A new i-Learn module ‘carer awareness training’ has been created and is live.
  • Carers Dashboard to be completed by end July 2019.
  • Identification of carers is included in the revised case file audit, which will identify correct data loading and capture. This will contribute to identifying any further training needs. Revised file audits are now in place and ongoing.

The third red key performance indicator measures the number of older people who have a permanent admission to a residential or nursing care home. Performance on this measure has declined, with 497 admissions to care in 18-19, contrasted to 419 admissions during the same period in 17-18, and is Red compared to the full-year target of 435 admissions.

An extensive review of the quality of the data that is used to calculate this indicator has been undertaken. Some of the issues identified included some temporary placements mistakenly being recorded as permanent, and some historic code removed from the report that compiles the base data that was dropping some of the placements.

Data quality is improving in the service and awareness of the correct categories means that fewer respite placements will be incorrectly loaded.

The current population is forecast to increase by about 10% to 367,000 by 2035. Older age groups will see the biggest increase, with the number of residents aged 65 plus expected to increase by 28% and the numbers of people aged 85 and over forecast to more than double. The shift to a more elderly population with more complex need has contributed to increased admissions to residential and nursing care homes.

Additional actions to reduce admissions to residential care and improve the recording of admissions include:

  • Further data quality work is being carried out with teams to raise awareness of the importance of correct recording, and a summary of the main recording issues have been provided to senior managers to communicate to teams.
  • Operational and commissioning teams are improving work with Extra Care Housing providers with the intention for them to accept more complex cases at the higher bands of need, thus not requiring permanent admissions to care homes.
  • Work is being undertaken with carers council-wide to improve support for long-term main carers of service users. Predictive analytic work is being reviewed with the intention in preventing temporary or permanent carer breakdown, to alert ahead of time where carers may be reaching the limits of their ability to cope. This should have the effect of removing some preventable admissions through carer support.
  • Further investment is being made in domiciliary care services to help providers and care workers support more vulnerable and complex people at home.

Wider Performance Indicators

Looking at the wider performance indicators in this Outcome Plan, six measures report as Green, compared to five which report as Red. Positive performance has been achieved on measures such as supporting residents in need of reablement, with 69.4% of residents requiring no ongoing support against a target of 70.5%. The number of people receiving telecare has performed well, with 3,520 people in receipt compared to the mid-year figures of 2,867.


Analysis and issues

Over 75% of actions have been delivered or are on-track for delivery. In terms of examples of actions which have been delivered or where progress is being made to deliver to timescale, key areas of progress to highlight include:

  • Wellbeing Coordinators as well as Pathfinder (Early Intervention and Prevention) staff are working closely with the Cheshire West Community Access Team (previously Gateway) to encourage signposting and low level support to enquirers who may not need statutory social care support from the Council.
  • The multi-agency Falls Prevention Group chaired by Public Health has continued to meet to progress the Falls Prevention agenda across west Cheshire. The group has recently reviewed both its Action Plan and rated current falls prevention performance against the Public Health England ‘Falls and fracture consensus statement: resource pack'(PHE, 2017). Some of the actions undertaken in 2018-19 include:
    • The Falls Operational Group, chaired by NHS West Cheshire CCG has continued to meet allowing practitioners to share and reflect on current practice, a similar approach is in place within NHS Vale Royal.
    • Falls Prevention is also a priority of the Integrated Care Partnership (ICP). Members of the Falls Prevention Group have been working with the Integrated Care Partnership Programme Manager to map existing falls pathways across acute and community settings. Following receipt of transformation funding, a number of bids have been approved to support the Falls Prevention work stream, notably:
      • Delivery of a Falls Prevention Summit
      • Production and delivery of a falls prevention training package for care homes
         Falls Prevention Leaflets
      • As recommended in the Falls Prevention Strategy, evidence-based, strength and balance falls prevention classes are now being held in community settings in Cheshire West and Chester. Brio Leisure has been commissioned to deliver the new service which commenced in June 2018. The service offers wide reaching community-based classes, to enable greater scale and impact of falls prevention. Referral is via GP or healthcare professional and is aimed at residents aged 65+ identified as being at risk of a fall.
    • Currently, eight classes per week are being delivered from the following venues:
      • Wharton Library – Winsford
      • Northwich Memorial Court;
      • Ellesmere Port (This is now the second course, as the first was completed in December);
      • Frodsham.
    • By June 2019, classes will extend to a further additional eight settings in areas that have been identified as having the highest falls prevalence.
    • Since 1 February 2017 the Cheshire and Merseyside Fire and Rescue Service have been undertaking falls risk assessments as part of their Safe and Well visits to householders over 65. Between 1st April 2018 and 22nd March 2019, there were 181 Falls Referrals made within Cheshire West and Chester.
    • Work is ongoing to develop a Cheshire wide Joint Strategic Needs Assessment.
  • An interim review of Community Mental Health services including the Council’s in-house community provision was completed in March 2019. A new service performance framework for the in-house provision will be in place by summer 2019 to improve oversight of the service and provide a baseline for a more in-depth review of the service which will commence in April 2020.
  • Scoping work with partners is underway regarding further integration with health services, multidisciplinary team meetings with health colleagues and GP practices are already established. Further work is now being undertaken to develop Care Communities. The transformation plans for the Integrated Care Partnership focus on 4 priority areas of the care model: Healthy Lives, Care Communities, Intermediate Care and Long Term Care, underpinned by enabling workstreams such as Digital. These programmes are in turn supported by an integrated resource plan and integration agreement which governs the work of the partnership. A diagnostic review of Community Care Teams within the 9 Care Communities will complete in Summer 2019 and provide clear opportunities for the integration of health and social care services.

Regarding actions that have been re-phased, the West Cheshire Offer Phase Two is now progressing into implementation. A staff consultation took place between January and February 2019 regarding the new ways of working and redesigned team structures. The full roll-out of new ways of working is expected in July 19.

Next Reporting Period

The following are examples of tasks and milestones expected to be completed in 2019-2020:

  • Further implementation of Falls Strategy priorities.
  • Development of outcome-based care plans, and rolling these out across domiciliary care services, in-line with the re-commissioning of domiciliary care services in the 2019-2020.