The Scrutiny Performance Panel – Adult Services met to discuss collaborative working between health and social care to support hospital discharges, and to review the Director of Social Services Annual Report 2024-25. Councillors shared their views on the collaborative work and considered the report as part of their scrutiny function. The panel also agreed its work plan for 2025-26.

Discharges from Hospital

The panel received a report on how health and social care services are working together to facilitate timely discharges from hospital, focusing on the Home First model, which prioritises getting people safely home from hospital for recovery, with assessment for any longer-term needs taking place in the community.

The report outlined the work of the Adult Services Home First Social Work Team (HFSWT), which supports Swansea residents who are patients in several hospitals, including Singleton Hospital, Morriston Hospital, and Neath and Port Talbot Hospital. The team works alongside Adult Services Therapies teams, Swansea Bay University Health Board, and third sector colleagues.

A key element of the Home First approach is the Discharge to Recover then Assess (D2RA) model, also known as Discharge to Assess (D2A). Andrea Preddy, Adult Services Principal Officer for Community Integrated Services, explained that D2RA is designed to ensure that people are discharged from hospital as soon as they are 'clinically optimised'.

The D2RA model comprises four patient pathways:

• Pathway 0: No additional support required for discharge.
• Pathway 1: Supported Home First - short-term support provided at home.
• Pathway 2: Short-term supported facility - rehabilitation/reablement in a non-acute bed.
• Pathway 3: Complex support - transfer to a long-term bed, assessment bed, or usual residence with complex support.

The report also highlighted the role of the Integrated Discharge Hub (IDH) based in Morriston Hospital, which brings together health board staff, social workers, and the third sector. The IDH's Multi-Agency Triage Team (MATT) ensures the right services are in place to support patients returning home or going to a placement.

The report noted that reducing Pathways of Care Delays (POCD) is a Ministerial and Regional priority, and that Swansea has seen a reduction in POCD as a result of the effective collaboration and implementation of the D2RA model.

As a result of the effective collaboration, effective implementation of the D2RA model and initiatives such as the IDH all detailed in this report, in Swansea our POCD have decreased over the past six months.

The report also identified ongoing challenges, including demand pressures and workforce sustainability.

Director of Social Services Annual Report 2024-25

The panel received the Director of Social Services Annual Report 2024-25 for information. The report sets out the local authority's improvement journey in providing services to people, those who access information, advice and assistance, and those individuals and carers in receipt of care and support. The report demonstrates how Swansea Council has promoted well-being and accounted for the delivery of well-being standards, as required by the Social Services and Well-being (Wales) Act 2014.

The report included a summary from David Howes, Director of Social Services, highlighting the hard work of social work, social care, and other colleagues within the council and across partner organisations. It also noted Swansea Council's strong reputation for innovation and the strong, resilient, and adaptable leadership provided by the Heads of Service and their senior management teams.

The report framed the analysis of the past year's performance in the context of future delivery against statutory requirements, considering how to meet the needs of an aging population, more children and families with more complex needs, the rising costs of care, and potentially constrained public service funding.

The report also provided evidence of how the council continues to place people at the centre of everything, work with people's strengths, focus on prevention and early help, build strong strategic alliances with partner organisations, and build resilience within communities to help safeguard the most vulnerable and promote well-being.

The report included a performance assessment section, with self-assessment of performance under the four headings: People, Prevention, Partnership and Integration, and Well-being. It also included other information, such as inspections and reviews, complaints and representations, and other sources of information.

The report concluded with a glossary of terms and a summary of improvement actions.

Work Plan 2025-26

The panel agreed its work plan for 2025-26, which includes the following items:

• Performance Monitoring
• Early Help Update (includes Area Coordination)
• Briefing on Deprivation of Liberty Safeguards (DoLS)
• Internal Day Opportunities (includes Fforestfach ATC)
• Update on Adult Services Transformation and Improvement Programme
• Briefing on Transport for Day Centres
• Draft Budget Proposals for Adult Services / Child and Family Services
• Update on West Glamorgan Transformation Programme (including progress with Mental Health Strategy)
• Update on Inspections from the last year
• Delivery of Corporate Priorities / Policy Commitments in relation to Adult Services
• Panel Review of the Year

The work plan also includes future work programme items such as a briefing on the Annual Review of Charges (Social Services) 2025-26, the Adult Services/Child and Family Services Complaints Annual Report 2024-25, Wales Audit Office / CIW Reports, and a combined report on Annual Performance and Annual Census.