Decision Date: 5th September 2024
Summary
The Ombudsman found fault with the care and support provided by the Council to Mr Y and his family who was caring for him. The Council failed properly to assess Mr Y’s needs in the community due to delay in allocating a social worker, [or any other member of staff] causing distress to his daughter, (Mrs X) and his wife.
What happened
Mr Y was living at home with his wife, Mrs Y. He was receiving daily care visits each morning to help him get up and washed. Mrs X, their daughter, contacted the Council in July 2023 to report that her mother was struggling to cope with Mr Y’s increasing needs.
Mrs X felt that Mr Y needed additional equipment at home too. The Council arranged an Occupational Therapy (OT) assessment to occur the next day. As a result, it was arranged for Mr Y to have some equipment. Mr Y’s family also arranged for additional equipment.
Mrs X reported that Mr Y’s condition had stabilised slightly after he recovered from an infection. She also reported that he did not have a formal care plan.
On 31 July, Mrs X reported that Mrs Y was satisfied with one care visit per day, but that flexibility would be helpful.
On 4 August, Mr Y was admitted to hospital with pneumonia on 4 August. Three days later On 7 August, Mrs X informed the Council that the hospital had discharged Mr Y, and that Mrs Y was again struggling to cope adequately care for with Mr Y.
Mrs X suggested that Mrs Y needed help during the nights to take care of Mr Y who would wake during the night, so that she could rest.
On 22 August, Mrs X contacted the Council explaining that Mr Y was weak, malnourished, and was experiencing increasing continence issues. Mrs X felt that nothing was being done and was unhappy that a social worker had not been allocated to Mr Y. The duty officer made a further OT referral. Mrs X called the following day, to say stating that the care provider could not offer any support after 8pm.
On 11 September, the Council allocated Mr Y’s case to a social worker. Mrs X reported to a duty worker that Mr Y had entered a respite placement [the report does not say how, if no social work staff had yet been allocated – it may have been a private placement], but had been admitted to hospital due to experiencing two unwitnessed falls resulting in injury on the first day. The respite care home would not take him back due to his dementia care needs.
On 15 September, the Council reallocated Mr Y’s case to the hospital social work team. The referral noted that he would need 24- hour access to care and that he may be eligible for CHC funding. On 21 September, Mr Y was assessed by the Trust which concluded that he would not be suitable for a D2A Pathway 3 placement (‘for people with complex care needs who need ongoing 24-hour, bed-based care’). [The report does not address any rationale or say whether there was one.]
The clinical records showed that Mr Y had dementia and heart failure. The Trust took X-rays of Mr Y’s lungs as part of their clinical investigations. This revealed lesions consistent with a lung cancer diagnosis. However, it was decided by the clinical team that Mr Y was too frail to undergo further invasive investigations. Despite this, Mr Y’s condition remained relatively stable, as he engaged well with physiotherapy, exercise sessions and was generally eating and drinking well with assistance.
On 25 September, a Care Act Assessment was completed. The assessment noted that Mrs Y felt unable to cope with Mr Y at home due to his increased care needs. The Council’s practitioner recommended a short-term residential placement so Mr Y’s needs could be considered in further detail.
On 6 October, nothing still having been done, a capacity assessment was completed for Mr Y that concluded that he lacked capacity to make decisions about his care. It was also noted by a Council practitioner that Mr Y’s family had arranged a self-funded placement at a care home. On 9 October, The Trust discharged Mr Y to a permanent bed at the care home. This ‘short term residential placement’ [this is how that arrangement is described without any clarity in the report as to who was responsible for it and how it fitted under D2A policy] would allow for further assessment of his long term care needs. The main health need for which Mr Y required active treatment was his constipation. The clinical team prescribed medication for this.
It having been decided that he was not regarded as having complex needs at that point, and the family having found a self funded placement, which effectively solved the Council’s obligation to act under the Care Act upon discharge, the discharge to the permanent bed appears to have been to THAT bed, self funded.
[We cannot understand why it was referred to as a short term placement; but if the family had not pre-empted it themselves, we think that it should have been under arrangements by the Council under the Care Act as reablement or intermediate care, pending assessment, or by the Trust as interim step down D2A pathway 2 or 3 arrangements.]
On 7 November, Mrs X contacted the Council to report that Mr Y had not been assessed since his transfer to the care home. In subsequent communications, Mrs X grew increasingly frustrated at the expressed frustration at the lack of support as she felt as though she was being passed back and forth between the hospital and the adult social care team.
On 1 December, Mr Y’s case was allocated to a social worker. The social worker visited Mr Y at the care home on 6 December where Mrs X was also present. Mr Y was experiencing an erratic pulse and breathlessness, so an ambulance was called and he was admitted to hospital. Mrs X asked the social worker about CHC funding, to which the social worker responded that a CHC checklist could be completed once Mr Y’s condition had was stable stabilised. Mrs X was also advised that if Mr Y was at the end of his life, a fast track assessment would need to be completed.
On 8 December, Mrs X informed the social worker that Mr Y was being treated as being at the end of life. A fast track assessment by a GP was arranged by the social worker. The local Integrated Care Board (ICB) accepted the fast track CHC application later that day.
Mr Y died on 9 December.
What was found
Lack of support
The Care and Support Statutory Guidance states that assessments must be completed in a timely fashion which is dependent on the individual’s unique circumstances. The Care Act also places a duty on Councils to complete a carer’s assessment when someone is in the position of carer and may require support of their own. Mrs X expressed concern for Mrs Y who was struggling to cope with Mr Y’s increased level of need. The Council allocated a social worker to Mr X’s case on 11 September, despite having been asked to by Mrs X in July 2023. Due to delays from the Council and his admission to hospital, the Care Act assessment was only completed on 25 September. The delayed allocation meant the Council was unable to complete a Care Act Assessment for Mr Y before he had to be admitted to hospital. Similarly, the Council did not offer Mrs Y a carer’s assessment during this period. This was contrary to breaches the requirements of the Care Act and thus represented fault by the Council is at fault.
Hospital discharge
Mrs X complained that the Council and Trust discharged Mr Y from hospital without providing putting appropriate palliative care services in place for him.
When assessed in hospital after his admission, the Trust stated that upon discharge, Mr Y’s condition was stable at the point of discharge and that he did not have complex nursing needs and was not at imminent risk of dying. and Ttherefore, Mr Y did not meet the criteria for a D2A3 placement.
Following his Care Act assessment by the Council in hospital on 25 September, it was found that Mr Y’s dementia meant he was found to have had extensive social care needs due to his dementia. This would be provided in the residential placement so he could be provided with 24- hour care.
Therefore, the LGSCO concluded that the evidence was consistent with a view that Mr Y would not have been eligible for fast track CHC funding or end of life care services at that time. There was a plan to review Mr Y in the community. The Ombudsman investigator found no fault here and that the Trust and Council handled Mr Y’s discharge appropriately as, despite having serious underlying health conditions, he was not at risk of imminent death (which would have triggered CHC fast track obligations).
Delayed allocation and CHC assessment
Mrs X complained that there was a delay in the Council’sl delayed allocationng of Mr Y’s case to a social worker. She also complained and that thethey CHC checklist was not completed in an adequate time frame despite the fact that his condition was deteriorating. also failed to complete a timely CHC checklist for Mr Y, despite his rapidly deteriorating condition. The Trust said that as Mr Y did not have complex nursing needs nor was he at imminent risk of dying, his health conditions were not sufficient enough to warrant eligibility for fast track CHC funding. When Mr Y was discharged to the care home on 9 October, the Council’s care notes state that he “[w]ill require a review in the community.” The care records delineate that Mrs X consistently repeatedly raised the issue of CHC funding with the Council. She also made the Council aware that it clear that Mr Y’s condition was decliningdeteriorating. The Council did not allocate Mr Y’s case to a social worker until 1 December, and it was not until 6 December that the social worker visited Mr Y. At that point he had to be readmitted to hospital.
There was a significant delay by the Council in allocating Mr Y’s case to a social worker. Fault was described as contrary to the Care Act.
The investigator noted that the Council should not bear the full responsibility as checklisting could have been undertaken by any suitably trained professional and that there was no evidence that the delay did not have a significant impact on Mr Y’s day to day care as he was under 24- hour support in the care home. However, It was accepted that the delay caused Mrs X significant uncertainty and stress, however.
The reference to other people potentially having been able to do a checklist is referring to the section in the Framework as follows although the investigator does not seem to have determined who should have been prompted to do this or responsible for doing it whilst Mr Y was in the care home.
‘Who can complete the Checklist Tool?
The Checklist can be completed by a variety of health and social care practitioners, who have been trained in its use. This could include, for example: registered nurses employed by the NHS, GPs, other clinicians or local authority staff such as social workers, care managers, or social care assistants.’
Agreed actions
Within one month of the final decision the Council was to send a written apology to Mrs X regarding its failure properly to assess Mr Y’s care needs in the community properly. She was to be paid £500 in recognition of her distress and uncertainty. Within three months the Council needed to write to the Ombudsman to explain what actions it would take to improve its case allocations process so that people can receive timely assessments of their care needs. Additionally, evidence was required to be provided to the Ombudsman that it had complied with the above requirements.
Points to note for councils, professionals, people using services and their carers, advocacy groups, members of the public
Mr Y was awarded Fast Track CHC on the last day of his life, which is a potentially appalling outcome for the family’s finances, The complaint report said that the family had incurred a large fee for care home services. There was no certainty as to when he would have been likely to have qualified, however, even if the process had gone to plan.
Anyone who has noticed that the Discharge to Assess process has left people up in the air as to who exactly is responsible for the first package after hospital discharge, will also have noticed that it is foggy about what it is that will then need to be assessed for, when someone gets round to it.
“Pathway 2
Discharge co-ordinated through the care transfer hub to a community bedded setting with dedicated health and/or social care and support, including bed-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery in a community bedded setting (bed in care home, community hospital or other bed-based rehabilitation facility).”
At the same time, the National Framework has reduced the instances of when a checklist for CHC screening should really be done, (see paras 101-121 of the NHS Framework documents online) and we think that this is a deliberate attempt to manage CHC entitlement down so the the NHS is less exposed to having to fund it.
This report offers a perfect example of these tendencies, and the investigator’s referral to these as a ‘missed opportunity’ could give the impression that it was a slip up. However the investigator does ALSO call out these missed opportunities as breaches of the Care Act, and on that footing, the family may well have been out of pocket, and should in our view have been given some of the money back that they had spent, no doubt in disgust at the glacial pace of progress towards discharge and desperation to get the man out of the hospital.
The report could have highlighted that it is a requirement in regulation 7 of the Care Act Assessment regulations that the council MUST refer the person on to the ICB.
“7.—(1) Where it appears to a local authority carrying out a needs assessment that the individual to whom the assessment relates may be eligible for NHS continuing healthcare, the local authority must refer the individual to the relevant body.”
Here, even though the allocation of a staff member was made in October, it was 2 months before anyone turned their mind to CHC, and even THEN the social worker said that there would not be one until Mr Y was more ‘stable’. The concept of doing a checklist when one is ‘optimised’ is for people with short term conditions, not people who are coming to the end of their lives.
The longer one takes to start an assessment, of course, the longer one will take to discharge the referral duty and if one leaves it long enough, the person will die.
Other people in this situation must read the NHS Framework Guidance for CHC here and pore over the Hospital Discharge guidance here.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Norfolk County Council (23 017 874) report.
If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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