Decision Date: 7th August 2024
Summary
Following an assessment made by a social worker, the Council made a decision to change Mrs X’s care agency, despite recommendations made by a senior mental health nurse about the positive effects that consistency of care would have on Mrs X’s wellbeing. The decision was made in an effort to save costs, which resulted in Mrs X receiving a poor standard of care.
What happened
Ms A is Mrs X’s daughter and holds power of attorney for Mrs X.
Mrs X has dementia and was primarily taken care of by her husband Mr X, until he became ill and unable to provide care.
Following an ‘urgent’ GP referral for a social care assessment in March 2022, Ms A explained that family members were caring for Mrs X.
The social care team responded that as her parents would (separately) be above threshold and thus ‘self-funding’, it might be quicker to arrange private care rather than ask the Council to source it. Ms A agreed to talk again a few weeks later when she had more clarity on the situation with Mr and Mrs X.
The Council closed the case when Ms A said that currently the family was not looking for a long-term care package for Mrs X.
Mr X passed away in May.
In August, Ms A communicated with the Council again, as Mrs X’s wellbeing declined. She had lost weight and was unable to manage her own needs, reluctant to eat and had been forgetting to take her medication. Ms A stated that the family and a care agency were now providing two hours of care every evening to provide company, reassurance, and encourage her to eat.
Ms A stated that once the probate for Mr X’s estate was resolved, then it was likely that Mrs X would self-fund her care, but until then, Mrs X’s assets were below the threshold at which she would be liable to pay for care.
An allocated social worker arranged to carry out a needs assessment of Mrs X on 10 November. During a discussion between the social worker and the care agency prior to her assessment, the agency explained that they had been asked to increase their contact hours with Mrs X. The agency manager also explained that a small group of staff supported Mrs X so she wouldn’t become confused.
Following the assessment, the social worker told Ms A that the agency charged rates that were “well above” what the Council usually paid for direct payments. Ms A argued that the agency carers had supported her mother well and that to change care providers may negatively impact Mrs X’s well-being.
The social worker discussed the option of alternative agencies with the Council’s brokerage team. The note the social worker made outlined the Council’s obligation to meet identified needs but in a way which was cost-effective. Therefore, the Council put a temporary agreement in place to continue funding the current agency for a month until a more cost-effective option was found.
In December, Ms A expressed frustration to the social worker at the delay in organising a care package for Mrs X, despite both Ms A and the GP contacting social care service twice since May.
Mrs X’s previous referrals were marked urgent by the GP but due to an error, this had not been reflected in the social care’s systems. This led to months of deterioration in Mrs X’s health.
The social worker had made two conflicting statements at their last meeting, first suggesting 24-hour residential care, then stating that 4 hours of domiciliary care a day was excessive.
The current care agency was cautious about introducing Mrs X to new carers and maintained a small group of carers familiar to Mrs X. Ms A agreed to try a new agency selected by the Council as long as Mrs X was eased into working with new carers as to not overwhelm her.
On 20 December, the social worker spoke to a new care agency, Compkey, which warned it could not currently provide a small group of workers. However, the social worker encouraged the council’s brokerage team to accept the agency.
That same day, a mental health nurse assessed Mrs X and the following day, informed the social worker that Mrs X needed consistency of care.
The nurse emphasised the importance of routine for Mrs X and that “being supported by the carers she knows well may facilitate (Mrs X) accepting care”.
That day, Ms A contacted the social worker to express her disapproval at all the care calls being replaced, and instead said they would trial one call a day, to which the social worker agreed.
On 29 December, two staff members of Compkey visited Mrs X unannounced to carry out an assessment. Ms A contacted the social worker and said that had Mrs X’s grandson had not been there for reassurance, Mrs X would have been a lot more panicked. Ms A also highlighted that she had not been informed about the new agency. The social worker apologised and stated that the agency manager was also apologetic.
From the beginning of January, Compkey began providing lunchtime care.
Ms A contacted the social worker on 8 January, stating that the carers had been an hour and a half late on the first day. They continued to be late every day and failed to provide required care, such as encouraging Mrs X to eat. The carers engaged in behaviours that upset Mrs X, such as locking the door. Ms A stated that Mrs X’s wellbeing was deteriorating, which was evidently a result of the upheaval.
Ms A continued to contact the social worker about her concerns about the treatment of her mother, especially regarding her food intake. She stated that this was all evidenced on CCTV footage. She also noted that Compkey had only provided care for 656 minutes out of the 900 allocated, which made their cost comparable to the previous agency.
Ms A gave notice to Compkey and enquired about the Council’s complaints procedure. She was taking time off work to care for Mrs X while the Council wished to extend Compkey’s contract and discontinue the previous provider’s services.
In January 2023, Ms A complained to the Council, first about the delay in arranging care, then the imposition of a new care agency on the family, and had done so when only one call a day was in question. She also noted that this change was made despite concerns about the impact that change in carers would have on Mrs X.
She also said that the carers had changed the care plan and did not document medication administration correctly. As a result, Ms A refused to allow them into Mrs X’s home.
The Council apologised for the issues with the agency carers, in particular the documentation errors and communication problems.
Ms A pursued the complaint due to unresolved concerns. The Council then apologised for the delay in initial assessment. Regarding her concern that Mrs X’s care plan did not reflect the mental health nurse’s input, the Council stated it was satisfied that Compkey was sufficiently informed about Mrs X’s needs and emphasised it had followed cost-effective guidelines advised by legislation.
Particularly, it noted that “consistency of carers” was not a formal care need under the Care Act, but that the Council had taken Mrs X’s wellbeing into consideration when agreeing the existing agency could continue for a month.
The Council stated that following Ms A’s complaint, the Council’s quality monitoring service had assessed Compkey, and requested an action plan to address faults.
The Council offered Mrs X £300 and Ms A £100 to acknowledge the anxiety and emotional distress.
Ms A then complained to the LGSCO. She said Mrs X had moved into a care home in April 2023 and her state had improved immensely due to consistent care and regular encouragement to eat.
The Council said that the care and support plan had already been issued to Compkey before the mental health nurse shared her assessment. It acknowledged that Compkey could not guarantee a small number of consistent carers but noted the efforts made to keep the number of carers to a minimum.
What was found
The LGSCO found fault in the delay until November 2022 to allocate a social worker to Mrs X despite the GP’s and family’s view that the case was urgent, and acknowledged the anxiety the fault caused to Ms A.
Both Ms A and the mental health nurse believed that Mrs X needed consistent care from a small team of caregivers, as provided by her existing agency. However, the social care team focused on reducing costs and finding a cheaper agency.
The Council acknowledged it had shared the care plan with Compkey before receiving the nurse’s assessment, despite knowing Compkey could not ensure consistent care.
In response to the LGSCO’s draft decision, the Council emphasised the necessity of balancing the nurse’s recommendations with budgetary constraints and its legal obligations to meet the needs of the entire population. It expressed confidence that Compkey had made efforts to limit the number of caregivers as promised.
The LGSCO found the Council responsible for the care Compkey provided, as the Council insisted on the trial care package from them. The LGSCO noted issues evident from the start, such as the unannounced assessment visit and poor care standards.
The LGSCO recommended the Council reconsider its insistence on using a specific agency, as it went against the family’s wishes and professional advice, which emphasised the importance of consistent care for Mrs. X’s wellbeing.
While the Council emphasised balancing budgetary constraints with Mrs. X’s needs, the LGSCO found that the focus seemed more on cost than on her wellbeing.
To remedy the injustice, the LGSCO recommended that the Council apologise to Mrs X and Ms A for their shortcomings reflected in the case and the distress caused. The Council agreed to offer £500 to Ms A and an additional £500 to be used for Mrs X’s benefit.
The Council agreed and was advised to review the quality of care provided and implement improvements based on the findings. The Council was to provide evidence of its compliance.
Points to note for councils, professionals, people using services and their carers, advocacy groups, members of the public
This Council did well to avoid stronger criticism, in our view.
It is one thing to refuse to accept a professional’s recommendation which is not in absolute terms – this is normal these days. For instance, staff are often asked to soften the language they use, to something like ‘X would benefit from’ or ‘ideally, X should be provided with’ as opposed to ‘X needs this, that, or the other…’ or ‘The only thing that will meet this need appropriately in my professional view is this, that, or the other.’ The Council is still the decision-maker and is allowed the room to disagree, as long as it addresses any concerns and can point to material which justifies its taking of a different view.
But this council was so fixated on cost that it ignored evidence that the cheaper solution did NOT ever work as it should.
Ms A had written thus: “They had been consistently late and failed to provide the care (encouragement with food and drink) which was required, but instead had spent half the visit moving furniture and cleaning. No food or drink had been provided at all on some visits. One carer had insisted on locking the door when she left, leaving Mrs X in a state of panic. On one day 2 carers had stayed 2 hours and tried to give Mrs X her evening meal during that time (before 3.30 in the afternoon)”.
And later she raised concerns about “a consistent failure to encourage fluids. Lack of care/knowledge surrounding medications, inability to accurately record food/fluid intake and in my opinion the serious risk of harm to a woman who barely weighs 6 stone being given medications which must be given with food, on an empty stomach.”
Ms A had said, “it is clear that mum’s wellbeing is already deteriorating as a result of this upheaval and extreme change in services provided. I am gutted to see my mum shaking again after a few weeks of no shakes.”
It seems that the LGSCO investigator regarded the Council’s stance was a deliberately blinkered approach. The investigator summed it thus: “The theme among the social care team discussions was one of reducing the costs of the care package and sourcing a cheaper agency.”
The Council said back that it had to balance the mental health nurse’s views against “supporting evidence, budgetary constraints, and our legal duty to meet the needs of the entire population.”
This is indeed true but that does not mean that any Council can take an irrational view of the appropriateness of what it has spent its money on, nor refuse blindly to address the evidence of the unfitness for the statutory purpose of what it has arranged to deliver. The LGSCO investigator observed that the more “cost-effective” care package turned out the same price as the existing care package arranged privately because of the number of short calls, but resulting in worse care.
The investigator noted the Council’s view that it fulfilled its duty to consider Mrs X’s wellbeing while considering the financial constraints and legal obligations it faced, the overriding impression left by the language used is that it placed more importance on the cost of the care package than on its knowledge of Mrs X’s wellbeing.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Norfolk County Council (23 013 106) report.
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