Adult social care operations service plan 2025-28

A. Overview

Organisation chart

Achievements in 2024/25

• Contacts increased 4% 
• Care Act assessments completion increased by 30% 
• Reduction in the median and longest wait for an assessment and review 
• OT assessments have increased by 293% 
• Overdue reviews decreasing from 42% to 37% 
• Numbers of carers DPs have increased 146 to 199 and numbers of carers supported from 899 to 1158 
• Risk RAG rating system in place 
• PowerBI performance system rolled out 
• Successful recruitment into Heads of Service post 
• Good recruitment and retention in SW and OT posts 
• Successful completion of 3 OT apprenticeships  
• 2 OT apprenticeships started and 4 SW apprenticeships in 2024 

Business-as-usual services

The things your service does for residents or to support staff every day.

There are a number of teams involved with the delivery of Adult Social Care across the Service Area Operations. Each work closely together to ensure a seamless experience for an individual who may find themselves requiring support.     

Advice and Well Being Hub:  

 The AWB Hub has been redesigned to reflect the specific needs of residents, this included having specific pathway and interventions for Occupational Therapy and Social Care assessment and support.  

Information and Advice services are provided through initial contact into the Advice and Wellbeing Hub. This team of Social Workers, Care Co-Ordinators and Occupational Therapists will look to find a resolution for the presenting need. The service is underpinned by the Conversation Counts model of working which takes on the following concepts:       

 Stage 1. The initial conversation will be focused on a strength based / asset approach with a focus on abilities and opportunities available to the individual making contact. The emphasis would be on offering advice and guidance and signposting to universal services and where possible maximising a persons own strengths and support network.       

Stage 2. Look at assessing levels of risk to the resident and stabilising, putting in short term services to meet the current care and support needs.        

Stage 3. The 3rd stage involves greater depth of planning and looking at long term outcomes. This brings about a focus on ‘what a good life looks like’ for the individual and the personal and community based assets and support required to maintain this.        

 Discharge to Assess Hospital Team  

The hospital team works with all adults who live in Reading who may require Care Act 2014 eligible support to enable a safe and timely discharge or support immediately after discharge.      

  If people do require an ongoing service, then they will have a more intensive assessment and support planning experience via the appropriate long term team.  

 Learning Disability and Autism Team   

This newly formed team aims to reflect life long support for autistic people and people with a learning disability who may need long term support or remain with the service service. The team would build relationships with those residents and their carers to ensuring needs reviewed and are fully met over the years.   

This team will also work with Children’s Services to support young people in their transitions to adulthood who would require support under the Care Act.  

The team would work in partnership with the NHS Community LD team were people have a health and social care need.  

The Learning Disability and Autism Team would consist of social workers, OTs and Social Care coordinators is dedicated to providing support and advice for autistic adults and adults with a learning disability. The team aims to support people, so that they can take part in community and specialist services and lead healthy and happy lives.  Everyone in the team works together with peoples’ strengths to help them become as independent as possible.  

Mental Health Team:   

A council team of mental health social workers, OTs and Social Care coordinators provide support to adults living in Reading with complex mental health issues who have Care Act care and support needs. They support people in the community whether they have just become ill, have a short-term illness or need on-going support. They give practical help with a person’s social care needs alongside their mental health needs. This may include helping people after they have been discharged from hospital, helping to manage risks, or helping with practical issues like housing and financial problems. The team also support people with MH issues with Hoarding concerns.  They provide reablement to PLE to increase independence to live in the community as long as possible. They also provide general support and advice to people and their carers. Residents who require input for their mental healthcare and therapeutic needs should be referred to GP, MHICS or CMHT. However, the team would work in partnership with the NHS Community MH team were people have a health and social care need.  

  Physical Disability and Older People’s Team  

 PDOP is a multi-disciplinary team comprised of Occupational Therapists, Social Workers and Social Care Co-ordinators we provide the next step in assessment and support planning to people who are 18 years and over and have a long-term physical disability or are over 65 years old who do not have a primary LDA or MH diagnosis.  

The Team Aim to maximise the quality of life of Reading residents who have a long term physical disability or are over 65 years of age and have care act eligible needs using a strengths based and problem solving approach.’   

Review Team  

The Review Team aims to undertake the annual review of service users under the care of the Physical Disability and Older People’s Team, ensuring the care and support plans are appropriate and meets ongoing care and support needs. The team would lead on ensuring community deprivation of liberty applications are completed were residents lack capacity and movements are restricted.  In addition, the team would lead on joint assessments with the NHS on those who need their continuing healthcare (CHC) assessments to be completed.  

B. Key Performance Indicators

The metrics that tell us how well our business-as-usual services are performing and whether we are delivering the objectives set out in section C overleaf. 

You should aim to have a KPI which describes how well each key business-as-usual activity is operating.  This could be the quantity of work (e.g. bins collected) or/and the quality of work (e.g. missed bins).  These should be focused on the main business-as-usual activities that need tracking and are specifically of interest to senior management and Members. They should be within the council’s control and are your ‘normal level’ of activity. 

If you are proposing to improve the service, through a project or initiative that you may be including below, then you should have a target which shows what that improvement/change will bring (e.g. normal number of bins missed is x%, target following project is y%). 

Under “definition” explain how the indicator is defined and the formula used. E.g. recycling rate = household waste recycled in the month / total household waste collected (kg). “Target type” should say whether the target is “flat”, i.e. the same each month/quarter (e.g. 50%), or cumulative, i.e. increasing each month/quarter (e.g. for measuring total library visits in the year to date). If the target has a variable profile/seasonal targets, please detail this. 

Measure	Definition	Unit	Better (bigger or smaller)	Frequency (monthly, quarterly)	Target type (flat or cumulative)	Normal level/ Target 25/26	Normal level/ Target 26/27	Normal level/ Target 27/28	Council Plan KPI (Y/N)	Data provider
Percentage of people with a learning disability in paid employment	People with a learning disability in paid employment compared with the total cohort	%	Bigger	Quarterly	Flat	5.0	5.25	5.5	N	ASC Performance Team
Older People (65+) who were still at home 91 days after discharge from hospital into reablement	Older People (65+) who were still at home 91 days after discharge from hospital into reablement compared with the total cohort	%	Bigger	Monthly	Flat	87	88	88	Y	ASC Performance Team
Average days waiting time for assessments by ASC under the Care Act 2014	The median wait for residents waiting for an assessment to be completed	%	Smaller	Monthly	Flat	35	28	28	N	ASC Performance Team
Percentage of new contacts to the Advice & Wellbeing hub resulting in a successful outcome not requiring an on-going service	People who are supported by ASC front door service do not require long term care and support.	%	Bigger	Monthly	Flat	84	87	87	Y	ASC Performance Team
Percentage of service users supported to live independently in the community	People under ASC who remain to live in their homes, rather than in care settings	%	Bigger	Monthly	Flat	78	79	80	Y	ASC Performance Team
Number of carers supported to maintain their caring role	Number of carers assessments completed	%	Bigger	Monthly	Flat	752	790	830	Y	Carers Partnership

C. Objectives for 2025-28

The most important changes your service is aiming to deliver over the period of this service plan. 

This should include Council Plan objectives and any additional objectives at service level. 

Example: “Prevent the escalation of children’s needs through developing family hubs.” Objectives should: 

• Clearly and concisely state the outcome we are trying to achieve and how we will deliver it. 
• Be realistic given available resources and relevant to the priorities set out in the Council Plan. 
• Have an associated KPI that tells us whether we have achieved the objective. 

See the annex for a full list of Council Plan priorities and objectives. 

Objectives (one objective per row)	Council Plan objective? (Y/N)	Relevant Council Plan priority
To identify and respond to immediate risks to people’s wellbeing, while they are waiting for an assessment or review.	N	Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children
Ensure a seamless pathway for those who require a Care Act assessment who were initially referred to Safeguarding	N	Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children
Assess the delivery and effectiveness of our person-centred approach, learning from case audits, Serious Adults Reviews, complaints etc mapping the customer journey and using the feedback	N	Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children
Ensure that all discharges are reviewed and packages reduced with the ethos of promoting independence through use of TECH etc and where a package is required this is facilitated via a direct payment.	N	Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children
Support those who need social care services to live as independently as possible in a place they call home with improved wellbeing.	Y	Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children
Improve our offer for unpaid Carers, ensuring they are supported to live well and can sustain their caring role.	Y	Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children
Work with our partners in health and the voluntary sector to provide support solutions for those with complex health and social care needs to improve outcomes.	Y	Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children

D. Projects

Projects are mainly being led by Commissioning and Transformation colleagues. 

• Improve the process of discharge from hospital to prevent patients being readmitted 
• Supported Living Tender 
• Home Care Tender 
• MTFS Savings Programme 
• Mosaic Transformation Programme 

Annex: Council Plan priorities and objectives 

Vision: Our Vision is to help Reading realise its potential and to ensure that everyone who lives and works here can share the benefits of its success. 

Priority 1: Promote affordable housing and more equal communities 

• Tackle economic inequality by taking a place-based approach to how we deliver all our services, and enhance access to education, skills, and training opportunities.  
• Deliver new energy efficient council homes and improve tenant satisfaction with social housing.  
• Prevent the escalation of children’s needs through developing Family Hubs.
• Promote best practice across Reading’s schools, helping to improve educational attainment and narrow the gap for disadvantaged and vulnerable children. 
• Prevent and reduce health inequalities within the population of Reading and improve and protect the health and wellbeing of all its communities. 
• Through the community safety partnership, focus on reducing community-based drug activity, knife violence, violence against women and girls and youth reoffending. 
• Work with partners to prevent homelessness, provide value for money accommodation for those that are homeless, and move people onto settled accommodation as quickly as possible. 

Priority 2: Secure Reading’s economic and cultural success 

• Enable the delivery of over 800 high-quality new homes a year in Reading, along with the infrastructure to support new development. 
• Promote the economic success of Reading by working with councils across Berkshire and the wider Thames Valley. 
• Maximise the benefits available for Reading from opportunities arising from the English Devolution White Paper. 
• Continue to deliver quality cultural and leisure services and facilitate exciting improvements to our cultural offer through grant-funded projects. 

Priority 3: Promote a sustainable and healthy environment and reduce Reading’s carbon footprint 

• Make use of central government funding to deliver improvements to public transport, cycling and walking infrastructure in Reading. 
• Keep Reading moving by delivering investment in highways, including roads, bridges, streetlighting and traffic signals. 
• Continue moving towards a net zero, resilient Reading and council by 2030. 
• Further improve the physical environment of Reading by improving air quality, access to green space, and the quality of public spaces. 
• Deliver major changes to our waste and recycling service to ensure compliance with new legislation. 

Priority 4: Safeguard and support the health and wellbeing of Reading’s adults and children 

• Reduce the number of children in care and the number of children in residential care. 
• Improve our local Special Education Needs and Disabilities (SEND) offer and support education settings to develop inclusive practice, so children receive high quality education locally, and achieve their potential. 
• Support those who need social care services to live as independently as possible in a place they call home with improved wellbeing. 
• Improve our offer for unpaid Carers, ensuring they are supported to live well and can sustain their caring role. 
• Work with our partners in health and the voluntary sector to provide support solutions for those with complex health and social care needs to improve outcomes. 

Priority 5: Ensure Reading Borough Council is fit for the future 

• Deliver good, accessible services for our customers. 
• Invest in technology that is secure and helps deliver effective services. 
• Use procurement of goods and services to secure greater social value and spend locally. 
• Bring Brighter Futures for Children (Children’s Services) back to the council. 
• Be a fair employer with an attractive and competitive offer and a workforce that is representative of the local community.