Hertfordshire County Council (18 016 276)

Category : Adult care services > Assessment and care plan

Decision : Upheld

Decision date : 27 Aug 2019

The Ombudsman's final decision:

Summary: Ms C complains about the Council’s decision that her elderly mother should move from the care home where she was settled, into Flexicare Housing. The Ombudsman has decided to uphold Ms C’s complaint. The Council has agreed to provide an apology to Ms C and pay a financial remedy for the distress she experienced.

The complaint

  1. The complainant, whom I shall call Ms C, complained to us on behalf of her (late) mother, whom I shall call Mrs M. Ms C complained the Council failed to carry out a needs assessment / care review, to determine where her mother’s needs could best be met. When the Council finally carried out the assessment, it failed to obtain and consider some information, which resulted in the incorrect recommendation that her needs could be met in the community.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word 'fault' to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I considered the information I received from Ms C and the Council. I also made enquiries with the care home Mrs M had stayed and interviewed a manager of the Council who had been involved in reviewing Mr M’s case. I shared a copy of my draft decision statement with Ms C and the Council, and considered any comments I received before I reached my final decision.

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What I found

  1. Mrs M lived with her daughter, at her daughter’s property. This enabled Mrs M to get an income from renting out her property.
  2. Mrs M went into hospital in July 2017 with sepsis. Ms C had a conversation with the hospital social worker on 19 August 2017. The social worker said that:
    • Mrs M would receive a four-week reablement support package, as she had specific enablement goals. During this period, the Council would work closely with Ms C to ensure there would be a long-term plan in place at the end of this period.
    • If Ms C could no longer cope with her mother’s night-time needs, her mother would have to go into a care home.
  3. Mrs M left hospital on 22 August 2017. Three weeks later, the Council allocated Mrs M’s case to a reviewing officer, to carry out the four weeks care review. The officer spoke with Ms C on 12 September to discuss an ongoing plan for her mother, as the four weeks of enablement support would end on 19 September. Ms C said she had arranged a two weeks respite break for her mother at a care home, which would start on 18 September. If her mother would like the home, there would be an option to make the placement permanent. Ms C told me she decided this, because she had been advised by the hospital social worker that if she could no longer cope, her mother should go into a care home. The officer told Ms C she should contact the Council again once her mother’s savings reduce to the £23,250 threshold for Council support.
  4. The Council has:
    • Acknowledged that it should have offered an assessment of Mrs M’s needs. It has told Ms C that it should have given her further information and advice before her mother moved into the care home. This would have enabled her to make an informed decision about possible care arrangements for her mother.
    • Concluded this fault did not result in an injustice. It said it only resulted in a delay of Mrs M being assessed; the outcome of the assessment would still have been a recommendation for Flexicare.
  5. Ms C extended her mother’s respite care several times, before she concluded the care home was the best place to meet her mother’s needs, and her mother was totally settled and happy. Mrs M’s permanent placement at the home started on 1 November 2017.
  6. The Council has told me it has since put a new team in place to review and assess people that have recently been discharged from hospital with short term services.

Assessment

  1. The Council failed to carry out a review / assessment of Mrs M’s needs, to determine how her needs should best be met after her four weeks reablement support would end. As a result of this, and the advice the hospital social worker provided to Ms C (see paragraph six point two), she decided to move her mother into a care home on a trial basis.

Ms C’s disagreement with the Council’s recommendation that her mother’s needs should be met within Flexicare Accommodation

  1. Ms C says she became aware on 20 November 2017 that her mother’s savings were far less than she had initially thought. As such, she contacted the Council’s finance team, after which she received a letter on 29 November 2017. The letter said the Council had to carry out a financial assessment and a needs assessment. The Council allocated a social worker, who arranged a visit for 5 December 2017. Ms C says that, during the visit:
    • They briefly spoke about her care needs and her mother said she wanted to stay at the home.
    • The social worker said he would review the care home’s care plans and speak to the care home staff.
  2. A risk assessment completed by the social worker on 7 December 2017 says that:
    • Falls risk: Mrs M’s mobility has improved since she arrived at the home. She is now able to transfer and walk with a frame and support of one carer. She needs prompting and supervision when walking to reduce the risk of falls. Mrs M’s cognitive impairment means she does not always recognise that her mobility has declined and can try to mobilise without proper support, putting her at risk.
    • Skin breakdown: Mrs M continues to be at high risk of pressure areas developing and had a recent pressure sore. Carers need to apply regular cream and pad changes to maintain hygiene and therefore skin integrity.
    • There was no need for a formal mental capacity assessment (MCA), as there would not be a formal decision at the moment. She has cognitive impairment and difficulty engaging in the assessment process.
  3. The social worker told Ms C on 8 December, that he was still waiting for some information from Mrs M’s GP. He explained he would need to determine if there is evidence her mother could not be left on her own. The social worker said that, according to the evidence at the care home, her mother did not have overnight needs. The social worker explained that this would determine if her mother’s needs could be met within Flexicare accommodation.
  4. In Flexicare housing, elderly people live together in flats they rent, with their own front door. Support is provided by on site care staff and emergency support is available if and when needed 24 hours a day. It also provides communal facilities and some opportunities to socialise, such as gardens and lounges.
  5. Ms C was not happy with this and said her mother should not be moved from the care home where she settled so well. She also said her mother did have night-time needs and could not be left alone. The social worker said he would talk to his manager. The social worker called Ms C again later that day to say he and his manager did not deem that her mother was eligible for residential care. The social worker explained that this was because: she did not need constant supervision and did not have overnight needs
  6. In response, Ms C told the manager that her mother could not go into Flexicare, because:
    • Her mother was at risk of falls, because she would try to mobilise on her own, which put her at risk of falling. However, in response, the manager told her that her mother could have a falls pedant alarm, which would alert staff if she had a fall.
    • Her mother had night-time needs. However, in response, the manager told her the social worker had spoken to the care home and the Council had evidence Mrs M did not currently have night needs.
    • Her mother would be socially isolated if she would leave her care home. However, in response, the manager told her that her mother would have the opportunity to meet with other clients and socialise.
  7. Ms C received a copy of her mother’s needs assessment on 13 December 2017. It said that:
    • Staying safe from harm section:
        1. Mrs M does not recognise her limited mobility and will try to mobilise independently without appropriate support. This happened on one occasion when care home staff left her alone briefly. Mrs M cannot remember that she cannot mobilise very well, putting her at high risk of falls. Care home staff do not leave Mrs M on her own throughout the day.
        2. Staff check on her two-hourly overnight in case of any concerns. However, she routinely sleeps well overnight without any support needed.
    • Under Physical Health, it says: Mrs M is at high risk of pressure areas developing. Carers need to check and change her pads regularly to manage the risk of skin breakdown.
    • Ms C said the social aspect of being at the home had been good for her mother’s wellbeing. Her mother benefits from being in such a social environment, which was part of the reasoning for choosing the care home.
  8. Ms C spoke with the social worker on 13 December 2017. She told the social worker the assessment was incomplete and incorrect:
    • The social worker explained he had spoken to the care home manager, who said Mrs M sleeps well overnight. However, Ms C said the care home had shown her night care records that indicated her mother was receiving support at night. Staff had to turn her every four hours while she was in bed, to reduce the risk of pressure sores.
    • The assessment did also not say anything about her mother's inability to use of a call bell to call for help. This is why staff would check her at night every two hours.
    • Her inability to use a bell would be a risk to her safety and wellbeing if left alone in her own flat within a Flexicare environment. This was clearly not factored into the decision.
    • Telecare falls sensors would not be able to prevent her mother from falling; it would only alert staff after she had a fall. Her mother needed constant monitoring to ensure she would not try to mobilise independently, something which could not happen if she was left alone in her Flexicare flat.
  9. The social worker told Ms C the home had not told him there were separate night-time records and he would visit the home to review them. The night-time records showed Mrs M would be awake, washed and changed at 5.30am on most nights. She had also been awake in the middle of the night on a couple of occasions. However, there was no evidence to indicate she would try to get out of bed during the night.
  10. The care home’s care plan says that two staff members are needed to reposition Mrs M in bed.
  11. After his visit to the home on 14 December, the social worker added more information about her mother’s fall history, her inability to use a call bell and information from the night-time records.
  12. However, the Council told Mrs M that these changes did not result in a different recommendation. It said that:
    • Although the records showed Mrs M was awake at times, and that she would have a pad change at 5.30am most days, the Council did not consider this significant night needs. A worker would be on site at the Flexicare scheme during the night in case of an emergency.
    • A sensor mat and falls detector would be provided with regards to her risk of falls.
    • There are numerous voluntary resources within the community that than can provide social support.
  13. Ms C told the social worker that she had spoken to a manager of a Flexicare scheme who did not feel her mother’s needs could be met at the scheme. The manager said it would only provide night-time care support (between 10pm and 8am) on an emergency basis.
  14. Ms C says the Council wanted her to decide if she wanted to move her mother from her care home (where she was settled) into Flexicare, without having explained to her in sufficient detail how each of her mother’s specific needs and risks would be met through Flexicare, on a 24 hour basis. She asked the social worker for more detailed information about Flexicare and what care support it could provide. However, she only received a one-page sheet with minimal information.
  15. Mrs M passed away on 8 January 2018.
  16. In response to Ms C’s complaint the Council told her in October 2018 that: All applications to flexi-care are carefully considered in a Multi-Disciplinary meeting. This meeting is set up to ensure a holistic approach and confirm that the individual's care and support needs can be safely met within this environment. Unfortunately, Mrs M sadly passed away before this meeting could take place and a decision be made as to her suitability for this type of accommodation. I have not seen evidence this information about panels was shared with Ms C at the time.
  17. The social worker told me, in a statement, that: every service user in the unit was changed at 5.30am, which the care home manager believed to be the end of the night shift. In my professional view, I did not deem this was a sufficient overnight need to require residential care.
  18. The care home told me that:
    • At the time of the assessment, Mrs M was on 4 hourly repositioning and pad checks at night. Her pads would be changed in bed when needed by two carer workers. The charts showed she was changed at least once most nights.
    • It is not correct to say that: Mrs M was checked at 530am, because this was the end of the night shift. The end of the night shift was at 730am.
    • It believes Flexicare would have been unsuitable for Mrs M.
  19. At interview, the Council told me that:
    • It has delegated the decision whether a person should go into a care home. This decision is made by managers, not a panel. However, if a manager recommends Flexicare, a panel decides in the end if this is suitable.
    • It is very significant that Mrs M was unable to use a call bell system. If she was unable to call for help when needed, this would her at risk and make her vulnerable.
    • While the social worker and the manager provided some information about Flexicare, and how it could work for Mrs M, it was not specific or comprehensive enough to reassure her daughter and address her concerns. He agreed that, in these specific circumstances, a meeting would have been better to discuss Ms C’s concerns, to enable her to come to a view if she would like to consider Flexicare.
  20. At the end of the interview, I asked if the manager still believed that it was the right decision not to recommend that Mrs M could stay in the care home, considering:
    • The Council’s fault (identified in paragraph 11) had contributed to Mrs M moving into the care home.
    • Ms C had raised some serious concerns about the suitability of Flexicare, particularly in relation to: preventing her mother from falls (when she is alone in the flat and tries to mobilise), and her mother’s need to be checked / repositioned / changed at night by two carers.
    • Mrs M’s inability to call for help if she needed (urgent) help, during the day and at night.
    • She was vulnerable, had settled in the care home, and it would likely have a significant impact on her mental / emotional wellbeing if it would move her to a completely different and unfamiliar environment.
  21. In response the Council told me that, taking all the above factors into account, it should have recommended that Mrs M could remain in the care home.

Assessment

  1. The Council failed to establish if Mrs M was able to make decisions about her care and/or where she wanted to live. This is fault. As such, it failed to establish who the decision maker was and only discussed with Ms C whether she wanted to consider Flexicare for her mother:
    • If Mrs M had capacity to decide where she wanted to live, the Council should have involved her mother in these discussions and ask her if she wanted to move into Flexicare.
    • If Mrs M did not have capacity to make this decision, the Council could have reassured Ms C that it would organise a best interest meeting with all stakeholders involved (including the care home), at which Ms C could raise her concerns. Based on the information I have seen, it appears Mrs M did not have capacity to decide where she wanted to live.
  2. Considering that Mrs M was very vulnerable (a 93 year old resident with dementia who had not lived independent for 9 years), I did not see evidence the Council considered (or said it would consider) what impact it may have on Mrs M’s mental/emotional wellbeing, if it would move her out of a care home environment that was familiar to her and which she liked and where she had settled, to an unfamiliar Flexicare flat. There is a lot of evidence of the drastic impact such moves can have on frail elderly dementia patients.
  3. At interview, the Council agreed that, considering all the factors above, the Council should have recommended that Mrs M could remain in the care home.
  4. The Council also acknowledged that it should have provided more specific information to Ms C, and should have better explained to her, how her mother’s needs could be met in Flexicare over a 24-hour period. The Council was asking Ms C to agree to its decision to move her mother out of the care home where she was settled and wanted to live, into an unfamiliar Flexicare setting. As such, it should have arranged a meeting with Ms C to discuss this in more detail.
  5. The Council has proposed to me that, in addition to providing an apology, it will pay and amount of £200 to Ms C for her distress and for the time and trouble she experienced in bringing the complaint.

Agreed action

  1. I recommended that the Council should, within four weeks of my decision:
    • Provide an apology to Ms C for the faults identified above, the distress this has caused her and for the time and trouble she experienced in bringing the complaint. It should also pay her £200.
    • Share the lessons learned above with staff within adult social care who are involved with carrying out needs assessments.
  2. The Council has told me it has accepted my recommendations.

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Final decision

  1. For reasons explained above, I have upheld Ms C’s complaint.
  2. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.

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Investigator's decision on behalf of the Ombudsman

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