Working with people
Improving outcomes and tackling inequalities within our communities
This theme covers how we work with people, assessing their needs, maximising their independence, supporting people to live healthier lives ensuring a focus on those who may experience more inequality.
Assessing needs
Developing our carers support offer
The assessment process is one of the most important elements of the care and support system, a key interaction between a local authority and a person, whether an adult needing care or a carer. We recognise the important role carers play in supporting people and continue to take steps to develop the support we provide to carers.
Carers Action Plan 2024 to 2026
Last year we wrote about the commencement of our Carers Action Plan, which outlines our three priorities over the next 2 years and the actions we will be undertaking. This included:
- empower carer with flexible respite options ensuring they can take breaks
- deliver the right support at the right time and in the right place
- maximise the reach of carers assessments to benefit more carers
The progress of the plan has been aided by positive partnership working with University Hospital Coventry and Warwickshire (UHCW), our Accelerated Reform Fund projects (see page 35 for more details) and a number of new initiatives such as working with Transport for West Midlands to introduce a free 9-month bus pass for carers registered with the Carers Trust Heart of England, this lead to over 600 carers receiving a free bus pass between September and March.
Last year we saw a 32% increase in the uptake of Carers Assessments and a small increase in the use of direct payments for carers. We saw much more personalised outcomes being explored with carers direct payments. We also saw greater utilisation of respite and short breaks provision, meaning more carers are receiving well needed breaks across the city.
What next?
The Carers Action Plan is a two-year plan which will conclude in 2026. In the next year we aim to explore access to respite and breaks for carers alongside the recommissioning of carers support services and the continued implementation of Accelerated Reform Fund projects.
Before we get to providing support for Carers, there is a crucial stage in the work we do, which is identification. It takes on average 2 years to recognise yourself as a carer when a caring role commences, which often means access to information and support is delayed.
In Coventry we use a range of different activities and campaigns to identify unpaid carers, taking a proactive whole system approach. We know that often, by the time someone requires support through Adult Social Care, they have often been caring for a long time, so our approach to identification is trying to identify unpaid carers early on in their caring journey, such as in health care settings, through work and within local communities.
We work primarily with the Carers Trust Heart of England to achieve this but come together as multi-agency group bi-monthly to drive this work forward and in the last year many of our partners have committed to undertaking their own identification campaigns, which has been wholly positive.
Carers told us that the most likely place they access is the GP surgery, so since 2019 we have commissioned a GP carer identification project. The project has worked with every GP surgery across the city (60 surgeries) to increase carer awareness, this might be by having information within the surgery such as leaflets or a board or on screens, the project has also set up surgeries within several practices so carers can receive direct support at the surgery.
Other examples of working to identify carers include:
- work with UHCW to produce a carer identification card and a carers passport for staff
- promoting Digital technology such as Bridgit (online support for carers)
- incentives and support, such as the West Midlands Bus pass and a Go CV+ Card (leisure and recreational facilities discounts)
- work being undertaken by Coventry and Warwickshire Partnership Trust (CWPT) to implement the Triangle of Care (a national initiative that recognises the nuances of caring for someone with a mental health condition and the importance of carer involvement in the care of their loved one)
- working with employers, with a Working Carers Development officer that supports work places, increasing awareness of caring and ‘The Carer Friendly Employer Program’
- Young Carer Identification, working with schools, school nurses and family hubs
- drop-in sessions and events across the city with targeted campaigns with the support of Carers Trust Equality, Diversity and Inclusion Officers
A Carer's Assessment is an opportunity for someone with caring responsibilities to talk about their caring role, the impact that is has on their life, planning for the future and what they would like to achieve.
A Carer's wellbeing assessment
A Carer's Wellbeing Assessment is a good opportunity to talk about your needs as a carer, the impact caring has had on you, what you’d like to achieve and explore any support you think that might help, this might include the use of a carers direct payment to support you in your caring role.
Muthu’s example demonstrates the holistic support that can be offered and the continuation of that support when needed. Anyone with caring responsibilities can receive an assessment of their needs, it doesn’t matter how much care you're giving or how long you have been a carer, we work in partnership with Carers Trust Heart of England to deliver Carers Wellbeing Assessments.
Kirstin Clarke Assistant Director Adult Social Care said: ‘unpaid carers are the unsung heroes who dedicate time, energy, and compassion to support loved ones without financial reward. Caring for those who care for others is not just kindness— it's the foundation of a compassionate society’.
Muthu's Story
Having a Carer's assessment
Muthu was first put in touch with the Carers Trust when the receptionist at her GP surgery recognised her caring role. Muthu at that time felt overwhelmed with her caring responsibilities, her husband had been recently diagnosed with Alzheimer’s. She was supported to apply for attendance allowance and apply for a legal power of attorney.
“Since registering, if I ever needed to talk to anyone, they (Carers Trust) were there for me to talk me through how or where to get help. Everything I have learnt in my caring role is because of Carers Trust”
Muthu continued attending groups and activities over the years. In August 2024 it was clear that Muthu was struggling with the overwhelming responsibilities she had. She was supported to access the Carers Trust counselling project, which helped implement some coping strategies and gave Muthu a safe space to talk about her own wellbeing.
“Had counselling when I was really, really down. It was SO helpful ! And gave me some strategies and exercises to do to help”.
She also explained that the counselling helped her understand:
"I need to ask for help when I need it, from family and services”.
Muthu also agreed that now was right time to have a Carers Wellbeing Assessment and it was undertaken by a Wellbeing Advisor and a student social worker at the Carers Trust.
The assessment explored Muthu’s caring role and that she was not only looking after her husband but other family members too. Muthu also had her own health needs, including asthma and was waiting for an operation. Muthu still very much wanted to remain caring for her husband.
“I found the process (assessment and direct payment) GREAT ! you were both very friendly, I had no problem understanding the process and could tell that you had really understood my circumstances. You were very pleasant and helpful".
The Wellbeing Advisor made a number of recommendations including utilising a Carers Direct Payment. The Carers Trust helped Muthu look at options, such as cleaning services but it became apparent that Muthu needed the house to be deep cleaned as mould had built up in the bedroom and bathroom and this was impacting everyone’s health. The Direct Payment was used to pay for the deep clean and to remove the mould. Muthu was provided with information about the several schemes in Coventry that can support with insulation and preventing the mould from returning and she received further advice about ventilating the house and a de-humidifier.
“I can sleep so much better in my bedroom I feel happier that it is not going to affect my breathing (Muthu has asthma). I have had ventilation fitted in the house and have peace of mind that my health will not get any worse than it is.”
Muthu was also referred to the #CovConnects programme provided by the Council, a scheme which helps address digital exclusion with Coventry residents, where she received a laptop. The laptop means that Muthu can attend Zoom meetings and keep in touch with friends and family, reducing the isolation she was experiencing. This was Muthu’s preferred way to take part in activities and keep in touch due to her caring responsibilities.
Muthu continues to receive support from the Carers Trust Heart of England, accessing their activities and groups. As part of having a Carers Wellbeing Assessment regular reviews can take place and on an annual basis.
Supporting people to live healthier lives
Alva's road to recovery
What was the situation? Alva is an 82-year-old woman, who lives with her husband Phil. Alva has macular degeneration, an eye disease that can blur your central vision and is registered blind. Alva had previously received rehabilitation support from the Councils Visual and Hearing Impairment Team but no care and support from Adult Social Care being independent with her social care needs.
Alva was originally born in Staffordshire; she moved to Sunderland to attend the teacher training college. She met Phil in Sunderland; they married in 1963 and moved to Coventry. They had a son named Martyn and 5 years later she started working for the Department of Health and Social Security in Coventry where she stayed for 7 years before moving to the Job Centre and stayed there for over 30 years before eventually retiring. Alva had a fall coming into the house from the back garden and fractured her ‘Neck of Femur’ (sometimes known as a broken hip). Alva was admitted and a needed operation to resolve the fracture. Alva was in hospital for two weeks, at University Hospitals Coventry and Warwickshire (UHCW) and then Rugby St Cross and then was discharged home with the support from 1 of the 3 Local Integrated Teams (LITs) in the south of the city.
What did we do?
Alva was experiencing problems with her mobility, it not being what it was before the accident. Alva needed to use a wheeled walking frame and was lacking in confidence and nervous. Alva was discharged with 2 home support calls a day, aimed at helping her to regain independence.
Caroline an Adult Social Care Occupational Therapy Assistant (OTA) completed an initial assessment to establish what she wanted to achieve in terms of her independence and identified the need for some aids and equipment which included grab rails in the shower. A physiotherapist from the team ‘Declan’ got involved with the aim of improving Alva’s mobility and eventually to achieve her aim of being able to use a stick to walk with, indoors and outdoors. This included having a home exercise programme to increase strength and balance.
Lisa an ‘Assistant Practitioner’, worked closely with Alva supporting her with this physio programme. Alva received support for up to 6 weeks and during this time the care and support she received reduced as she improved and gained confidence in getting dressed and showered.
What difference did it make and how are things now?
Alva regained her confidence and no longer needed any care, support or the input of professionals returning to her previous level of independence
Alva said:
“I have no fault with anything, everyone was great. All the carers were very helpful. Declan and Lisa were great and thank you to Caroline for all her help”.
Caroline said:
"It was pleasure, supporting Alva to achieve her goals and become independent again, which is what the service is all about."
Since going live in June 2024, 3 Local Integrated Teams (LITs) - comprising of health and care professionals from Coventry City Council and University Hospital Coventry and Warwickshire and Coventry City Council in a single integrated team to support the whole urgent and emergency care pathway - have provided support for over 6,000 people.
Over the year, LITs have meant that 840 people have avoided an unnecessary hospital admission, fewer people with an urgent care need required a long stay in a care home and over 2,000 people were supported for a short while in their home, or close to where they live. The teams are based in Newfield House, the Opal Centre and Tile Hill Primary Care Centre.
Lead for One Coventry Integrated Team (OCIT), Jodie Storrow said:
"What we’ve achieved in a year is truly astonishing. I would like to thank each and every member of the LITs for their compassion and dedication to working differently to deliver improved outcomes for the people of Coventry."
"Day in, day out, you are working as a single integrated team which is fundamentally changing the way we support people with an urgent need."
Aideen Staunton Head of Service, Partnerships and Social Care Operations said:
‘‘What a lovely story that illustrates how working in an integrated way, with a variety of other professionals to promote someone’s independence achieves amazing outcomes for people. It is wonderful to see how Alva has regained her confidence and independence with support from a great team".
What’s next?
We are now just passed our 1-year anniversary of our Local Integrated Teams. While we have achieved a lot within that timeframe, we continue to work collectively to embed new ways of working and work creatively to find the best outcomes for the people we support.
We continue to work with NHS colleagues within University Hospital Coventry and Warwickshire and in the community to support hospital discharge and also how we avoid people needing to be admitted to hospital in the first instance. We are also embracing new technologies and excited to see how we develop this approach further in the next year to further support people’s independence and ability to remain at home.
How do we want our services to be arranged?
We will start to break down the barriers between services by initially focussing on the highlighted areas:
- we will improve flow, simplify discharges and ED outcomes by working on processes in the hospital which don't rely on the wider system
- we will be building local integrated teams with single operational management across Coventry. These teams will handle all urgent health and social care needs for residents, either directly providing the support or coordinating specialist teams. The resident will be on one caseload
- these teams will be connected through human and digital interfaces to a wide range of people from care providers to WMAS, to those working in discharge and the front door
Equity in experiences and outcomes
We continue to seek understanding of how accessible our services are and the barriers and inequalities in the way in which we offer support and care. To do this we access a wide range of information, data and feedback from our staff and the people we support. We recognise that people can be at risk of having unmet needs or poor outcomes due to their protected characteristics.
"Seldom-heard groups" refers to individuals who are under-represented. Mental health stigma can contribute to this "seldom-heard" status, as it discourages individuals from seeking help and sharing their experiences. This lack of voice can result in inadequate support and services for those who need them most.
Supporting and engaging with migrant communities
Coventry has a history of welcoming migrants and refugees, with a diverse population that includes many individuals outside the city. We already have an existing Migration Team in Coventry that supports migrants, refugees, asylum seekers, and individuals with No Recourse to Public Funds (NRPF).
What have we done?
We appointed a full time Social Worker, who has been in post since April 2024. The Social Worker plays a vital role providing support under Care Act 2014 (for adults with eligible needs), Section 117 aftercare (for those discharged from mental health hospitals) and safeguarding duties. A role being key in advocating for migrant rights and fair access to support where eligibility exists.
What difference has this made?
Supporting Mohammed
Mohammed is a 31-year old asylum seeker from Bangladesh. He has one sister and is currently residing in the UK with his mother after the passing of his father in 2013. He entered the UK on a 5-year skilled worker visa in May 2022, having a professional background in civil engineering. However, his employment history in the UK has largely been limited to the role authorised to work.
Mohammed has longstanding psychiatric issues exacerbated by experiences of displacement and trauma. He was admitted to Hospital for a few months and discharge planning was coordinated through extensive multi-agency collaboration, involving the Home Office, police, and mental health services.
A safe discharge pathway was arranged, including accommodation and consistent mental health follow-up. Family involvement, particularly the role of his mother, was central to the discharge plan, recognising the importance of familial support in his recovery. Mohammed is now settled in Home Office accommodation, near his family network, and he is now attending Adult Education classes. Support from mental health services and the migration Team is on an ongoing basis, and he hasn’t had any other admissions for a number of months.
Preventing Homelessness
Matthew's story - regaining control
What was the situation?
Having spent most of his life experiencing mental health issues mainly centred around depression, Matthew had found himself homeless and all personal relationships left in tatters.
He approached Coventry City Council and placed in temporary accommodation for 7 months before being offered a one bedroomed flat with Citizen Housing. At this point, he felt he was given the chance to rebuild his life, achieve some sort of stability, and hope to rebuild a relationship with his siblings.
However, over the next 2 years, Matthew struggled to stay in employment due to his mental health and felt overwhelmed with the pressures of trying to maintain the flat. With debts piling up and a repossession Court Order on the flat, he became more and more isolated with suicidal thoughts. Matthew decided to phone the Mental Health Crisis Line, anticipating that after having the flat repossessed, he would need some sort of support whilst trying to begin the process again of rebuilding his life again.
Matthew had an initial assessment at the Caludon Centre, Coventry, where several referrals were made for him, one being to the Pod Cafe, Coventry.
“I have to admit, I held out no hope of my housing situation being resolved, thinking really that in a matter of days I would have an eviction date and would need all the advice I could find on how to prevent myself being back on the streets.”
What happened, what support was provided?
He walked into the Pod extremely emotional, and was introduced to Social Advocate/Development Worker, Tamsin. Matthew reflects on this point, stating:
“And that’s where the magic happened!! I cannot understate how impressive the next few weeks proved to be. Tamsin and the overall atmosphere in the Pod came across as very empathetic, obviously very interested and supportive as I explained the situation, after that first initial appointment whilst still feeling hopeless I had a feeling that I had found somebody I could trust and open up to, had I not felt that way, it's pretty undeniable that I would not have returned and would be in a totally different situation. I left that appointment still with very little hope but with the belief that I had found someone who would at the very least be supportive once I had lost the flat".
On his second appointment, Matthew learned that Tamsin had spent time researching and planning the options available to him with an enthusiasm to help. Having contacted Citizen Housing on his behalf, she had managed to get an adjournment on the repossession order for four weeks which would give some time to try and find other solutions and support.
“It's almost impossible to put into words the feeling of confidence she instilled in me that day.”
An equitable approach demands that we have continue to focus on what we can do to highlight inclusivity in our practice and develop our own cultural competence (the ability to communicate and support people across cultures through positive behaviours and attitudes). Training for staff has taken place to build understanding, awareness and confidence in having conversations, including sessions on; Religion, Belief and Spirituality and Older LGBTQ+ people, Gypsy, Roma and Traveller people and neurodiversity.
A programme of Social GGRRAAACESSS training (for senior managers, front line managers and staff) commenced in October 2024. This is an acronym highlighting Gender, Geography, Race, Religion, Age, Ability, Appearance, Class, Culture, Ethnicity, Education, Employment, Sexuality, Sexual Orientation and Spirituality.
Promoting Social Graces upholds individuals’ rights, encourages inclusivity and celebrates diversity. It can help staff to be holistic in their approach with people, connect meaningfully with those they are supporting, remove barriers to engagement and ensure that strengths-based practice is meaningful.
Tracey Denny, Head of Service Localities and Social Care Operations said:
"Equity is so important to pay attention to in Adult Social Care, we need to ensure everyone regardless of their background or circumstances has access to the support that they need, it’s about recognising that people have different needs and that providing the same service or support to everyone doesn’t lead to equal outcomes."