Summary: Mrs C complained about the Council’s decision that her parents did not have to go into residential care, because the Council believed they could still be supported at home. Mrs C says this caused her a lot of distress. The Ombudsman did not find fault with regards to the process through which the Council reached its decision.

The complaint

1. The complainant, whom I shall call Mrs C, complained to us on behalf of herself and her parents, whom I shall call Mr and Mrs X. Mrs C complains that the Council’s decision that her parents did not need residential care yet, was wrong. Furthermore, the Council failed to meet her father’s need for support with his medication, while he was still at home.

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The Ombudsman’s role and powers

2. 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)
3. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. 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

5. I considered the information I received from Mrs C and the Council. I also carried out a telephone interview with a Council staff member. I also made enquiries with the care home Mr and Mrs X have stayed since June 2019 and interviewed the current manager and regional support manager. I shared a copy of my draft decision statement with Mrs C and the Council and considered any comments I received, before I reached my final decision.

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What I found

Legislation

6. The Care and Support Statutory Guidance says that:
• Councils must carry out an assessment for any adult with an appearance of need for care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must also involve the individual and where appropriate their carer or any other person they might want involved.
• If a person has eligible needs (needs which meet the eligibility criteria), a council can meet these by providing or arranging care and support at home, in a care or nursing home or in other ways.
• A council has to have ‘due regard’ to an adult’s wishes as a starting point, but social workers are entitled to exercise their professional skills and judgement in deciding how to meet eligible needs.

The Council’s decision about where her parents should live

7. Mrs C’s parents are in their 80s. Mr X has a medical condition that results in swallowing difficulties. Mrs C told me this means he is at risk of choking 24 hours. He can get spasms and pooling of saliva (that he has to keep coughing up), which can result in food or fluid entering his lungs. Mrs C says this means there always has to be a person around who can alert an ambulance, in case he chokes during the day or at night. This meant her father had 24-hour care support needs in 2019. It also meant his medication needed to be crushed.
8. Mrs C says her mother’s health declined during 2019, which meant she could no longer give the support she had always provided to her husband. Mrs X went into hospital in April 2019, after which she needed support at home. Mrs C says her mother subsequently became regularly confused. Mrs C, who lives in her parents’ neighbourhood, had been providing support to her parents as well.
9. The Council carried out a needs assessment and put a homecare support package in place; first for Mr X and soon after for Mrs X. The package consisted of three visits per day, during which the carer would provide support to both. Mrs C told me that her mother’s dementia deteriorated and, even though she did her best to keep her parents in their own home, she realised this was no longer possible. However, Mrs C says the Council failed to acknowledge that and decided instead that her parents could remain in their property with a support package.
10. Information obtained from assessments by the Council and the care agency in April 2019 said: Mr X suffered from depression and swallowing difficulties. He could make his own decisions, was mobile and could eat and drink. Mr X could get dressed and do his own personal care, with prompting. He needed a carer to prepare drinks and a soft fork-mashable diet. His swallowing difficulties resulted in him coughing and spitting saliva all day. He also needed his medicines to be crushed so he could swallow them. He did not need support at night.
11. The Council’s needs assessment also had a section on carers (Mrs C). It said that:
• I assist my parents with management of finances, buying food and other daily needs as required
• At this moment it is much better because my dad has carers in place.
• I am able to carry on with this role as long as it takes. But when I go on holiday, I would like the Council to consider respite for my parents.
• Do you feel that your needs as a carer have been appropriately assessed within this combined assessment? Yes
12. Information obtained from assessments by the Council and the care agency in April 2019 said Mrs X had dementia and could sometimes be confused. She was able to stand and could only manage a few steps due to pain. She was no longer able to prepare drinks and meals or (un)dress herself. She did not always recognise the feeling of hunger and would need carers to encourage her to eat at mealtimes. Mrs X would need support with washing, dressing, personal care, meal preparation, light domestic duties and medication prompts.
13. The Council proposed to meet Mr and Mrs X’s needs by having a carer visit them four times a day. However, Mr and Mrs X believed this was too much and preferred two visits a day. In the end, they agreed to receive three visits a day. Mrs C said the fourth visit was not necessary as she would be with her parents anyway at that time.
14. Mrs C and her husband Mr C asked the Council mid-April 2019, if Mr and Mrs X could move into a residential care home they found. The Council explained that residential care is usually provided to those who need a significant amount of support and monitoring throughout the day, and also have support needs at night. The record states that Mr C told the Council that Mr X sleeps throughout the night and Mrs X sleeps once settled. However, the Council suggested that Mr and Mrs X could go into a care home for a short period, to give Mr and Mrs C a break from caring. Mrs and Mr C did not take up this offer. The Council also called the care agency to ask them for an update. The agency did not report any problems or concerns.
15. Mrs C told me that:
• While her parents may have slept at night, her father needed somebody around 24 hours who could alert an ambulance if he was choking.
• She did not take up the suggestion of residential respite care, because she thought it would not be good for her mother, because her dementia would cause her distress if she would move to a different environment for short periods.
16. The records show that whenever Mrs C raised an issue about the way her parents’ care was being delivered by the agency, the records show the Council would contact the agency to discuss this.
17. The Council carried out another assessment of Mr X’s needs at the end of April 2019. The record states, among others, that all ‘appreciated the service rendered’. The Council concluded the assessment did not establish that Mr X had night-time and concluded he did not need residential care.
18. Two weeks later, the Council carried out a review of Mrs X’s care. The review states that:
• Mrs X struggled to remember to complete her daily living tasks. Carers visited three times a day to prompt and support her with these tasks.
• Mrs X needed a lot of encouragement and monitoring to eat when her meals were in front of her. She also needed encouraging to drink enough as she didn’t always drink enough.
• With Mrs X receiving care support, her daughter found she was under less strain and the support was helping her.
• The Council concluded, following the review, that Mrs X continued to need three visits a day, which was reducing carers’ strain from her daughter. The Council would refer Mrs X for a bathing and stairs assessment.
19. Mrs C told me that, although the care package was helping her as a carer, it did not reduce her strain because she was constantly with her parents to administer his medication and ensure her mother would not fall.
20. The Council explained to Mrs C that people tend to get on better if they remain living at home and in their own community. The Council would therefore try to keep Mr and Mrs X at home for as long as possible. However, once they would deteriorate to the extent where they would need care over a 24-hour hour period, the Council would look at moving them into a care home. The record states that Mrs C said that things settled a little more now that her mother was receiving support as well. Mrs C and her husband continued to look into care homes.
21. A week later (mid-May 2019), Mrs C told the Council that her mother’s needs had increased, and she wanted both parents to go into a care home; she did not want them to be separated. The Council gave Mrs C a telephone number she could call if she wanted her mother to be assessed again. It also asked Mrs C to explain what had changed since the care review one week ago. Mrs C said:
• She had to stay with her parents for most of the day to provide support. As such, she felt under great carer strain.
• Her mother's Dementia was getting worse and she was no longer safe to be at home. Her mother did not know any longer where she was.
• Her mother was not eating/drinking enough and was putting herself at risk of dehydration and getting a urine infection.
• She visited a care home that would cost £1,600 per week for a double room. Mrs C knew she would have to sell her parents’ house to pay for this, which was worth approximately £300,000.
22. The Council subsequently allocated the case back to a social worker to arrange another visit one week later. The record of the visit states that Mrs C said that carers were not providing food and drinks to her mother and she had to fill any gaps in support, which was taking a toll on her. Mrs C said the agency was not performing as required and the family had lost confidence in them. The social worker explained to Mrs C that her parent’s support needs were not to a level where they needed 24-hour care support. The Council offered to change the care agency and increase the care package to four visits per day. In addition, it said again that Mrs C and her husband could have a break from caring by accepting the Council’s offer to temporarily accommodate Mr and Mrs X in a care home.
23. The care agency also carried out its own care review at the end of May 2019, together with Mrs C and her parents. The agency’s spot check that day had shown the carer had completed all tasks to a good standard. Mr C subsequently sent an email to the care agency with bullet points summarizing the support Mr and Mrs X should receive:
• Mr X:
1. AM: clean toilet; apply cream; make bed; check he washed himself; check he had breakfast; make him a drink
2. Lunch: heat ready meal and make drink
3. 430PM: heat up some food and make drink
• Mother:
1. AM: body wash; help with getting dressed; get breakfast and encourage to eat / drink; remind about medication
2. Lunch: heat ready meal and make drink
3. 430PM: heat up some food and make drink
24. Mrs C told the Council on 7 June 2019 that they had organised for her parents to go into residential care on 12 June.
25. Mrs C says her mother’s needs could no longer be safely met at home. She says:
• Her mother was at risk of dehydration and not eating enough.
1. Mrs C said on 9 May 2019 that three drinks a day (one during each visit) was not enough to keep her mother hydrated.
2. The Council told me that Mrs X had three visits a day during which carers ensured she would eat and drink. The information from assessments and reviews did not indicate that Mrs X would not drink anything in between visits. The Council offered to increase the visits to four a day, which was turned down. The carers, nor the GP or other professionals raised any concerns about Mrs C being dehydrated and/or losing weight. If there had been such a problem developing, the Council could have addressed this by longer visits or more frequent visits.
3. The information I received from the care home indicates that Mrs X was independent with eating and drinking. However, she needed staff to prompt her to eat and drink as at time she would forget to eat. She only needed to be reminded and no active help was needed. She could also drink on her own without staff around (to prompt).
• As a result of her mother’s dementia, she was a danger to herself in between care visits.
1. Mrs C told me her mother would not know where she was or what to do, which resulted in her being constantly distressed. She was in danger of accidents with any household items (knives, kettle, toaster) or falling over and onto items. She was constantly distressed and in tears because she was very confused.
2. The Council told me that Mrs C only raised some of these issue after her parents moved into the care home. Neither Mrs C, nor the carers or any of the assessments identified that Mrs C could not be left alone in between visits. If there had been such a problem developing, the Council could have addressed this by more frequent visits, exploring day centre opportunities etc.
3. The care home told me that Mrs X needed to be reassured as she had the tendency to get anxious and feel unsafe. This tended to be more prominent at night and she responded well to reassurance.
• Her mother was at risk of falls:
1. Mrs C told me her mother was unable to mobilise unsupported but would forget this due to her dementia. She had a fall just before she went into the care home.
2. In response, the Council told me that Mrs X had walking aids to assist her with mobilising. The assessments did not identify there was an enhanced falls risk at the time or that Mrs X needed support with mobilising between care calls. Mrs C did not raise such a risk with the Council at the time. If Mrs X would have had a fall at home, the Council would have carried out a risk assessment to alleviate the risk. This was not a reason to go into residential care.
3. The care home told me that Mrs X is able to mobilise around the care home independently, with the use of mobility aids (stick / zimmer frame). However, staff supervise her when she needs to go longer distances, as she can become disorientated.
26. Mrs C says her father’s needs could also no longer be safely met at home:
• Mrs C told me her father was at risk of choking, 24 hours a day. Previously, her mother had been able to monitor this and act when needed. However, since April 2019 she was no longer able to do this. He therefore needed something else to replace this on a 24-hour basis.
• The Council told me Mr X was on a soft diet, which the carers would give him. He had full capacity and was aware what he could and could not eat. Mr X has received support with his swallowing via Speech and Language Therapy (SALT). There is no assessment record that says Mr C was at significant risk of choking that warranted 24-hour support.
• The care home told me that Mr X is at risk of choking when eating and drinking. He is independent with both eating and drinking, with staff around to monitor this. Once in bed he has a settled night. He has no support needs at night and has had no difficulties related to his dysphagia during the night. There has not been any choking incident related to his Dysphagia since Mr X arrived in June 2019.
27. The Council says:
• Some of the issues only came alight after Mr and Mrs X moved into residential care. All the issues Mrs C raised could have been solved in the community. The Council could have put in place an additional visit, longer visits, day centre opportunities (for Mrs X) and (as a last resort) have considered a live-in carer.
• Mrs C did not allow the Council the time and opportunity to work through these options, as she was more or less set on the idea that her parents should be in residential care. Mrs C was free to make that choice.
• It acknowledges that Mrs C felt strain as her parents’ informal carer. As such, the Council offered residential respite care breaks, which Mrs C turned down. It could also have increased the care support.
• Mr and Mrs X currently pay for their own care, because they have capital above £23,250. This would also have been the case if the Council had decided that they would need residential care.
28. At the interview, the care home told me that it is not their role to determine if a person needs residential care. The assessments they carried out of Mr and Mrs X in 2019 were only to determine if the care home could meet their needs.

Analysis

29. There was no fault with the way through which the Council concluded that Mr and Mrs X’s care needs could be met at home. The Council carried out several assessments and reviews that captured Mr and Mrs X’s needs. The Council engaged Mrs C in the assessments and considered her comments and any concerns she raised. Furthermore, it offered to increase the care support, change care agency and try residential respite care to enable Mrs C breaks from her role as a carer.
30. Without fault in the process through which the Council made its decision, I will not question the merits of the Council’s decision (see paragraph 3 above).

Mr X’s support with medication

31. Mrs C told the Council that her father needed support with his medication; three times a day. Carers would need to crush his medication, because he has difficulty swallowing pills. However, the carer agency told her they were not allowed to crush her father’s medication. As a result, she had to continue to support her father with this, which added to her burden.
32. The Council’s policy says that:
• A care provider must have a clear written policy on the prompting, assistance and the administration of medicine which promotes the safety and wellbeing of the Service User.
• When giving medications do not: Crush tablets or open capsules without the consent of the pharmacist, as this is an ‘off licence’ use of the medication.
• Care workers should give medicines directly from the container they are supplied in by the Pharmacist. Supplying pharmacists and dispensing doctors should supply medicines in their original packaging. Medication must be administered from the original packet in which they have been dispensed, with adherence to the instructions on the label or leaflet.
33. Mrs C told the Council in April 2019 that the carers were not prompting her father with his medication. The Council discussed this with the care agency, who explained that Mrs C puts the medication in a dosette box. The agency said they asked Mrs C to ask the pharmacist to put it into a dosette box. Carers can then prompt Mr C. The Council reminded Mrs C at the end of April 2019 to talk to the pharmacist.
34. Mr C called the care agency on 20 May 2019 and said the carers should support Mr X with his medication. The agency explained that carers were not allowed to crush medication and advised Mr C to speak to the GP and ask if the medication is available in liquid form. Mr C said he would look into this.
35. A week later, Mr C told the care agency that the GP said the medication is not available in liquid form. The Council subsequently decided to look into this further. It contacted the GP who advised to contact the Pharmacy. The pharmacist advised that Mr X had three tablets that should not be crushed. There was no liquid alternative.
36. Mrs C told me she asked consent from her father’s GP and the Pharmacist to crush the tablets. I have not seen a record to show they provided consent.
37. The care agency’s clinical lead nurse advised that if the tablets are able to be crushed, this must be specified on the Pharmacy label and on a pharmacy blister pack. If they cannot be crushed, and no liquid alternative is available, then carers are not allowed to prompt Mr X’s medication. The agency subsequently explained this to Mr C.
38. The Council says that care providers are unable to support individuals from family filled medication aids. It advised Mrs C how to resolve this. If Mrs C was concerned that the Pharmacy said that three different tables should not be crushed, Mc C should have discussed this with the GP at a medication review.
39. Mr and Mrs X moved into a care home on 12 June 2019. The home received written consent from the GP to crush his medication. His medication has recently been reviewed and it no longer needs to be crushed.

Analysis

40. The Council and the care agency explained to Mr and Mrs C why the carers were not allowed to assist with crushing Mr C’s medicine. It asked Mrs C to obtain permission from either the GP or the Pharmacy that his medication could be crushed. However, it did not receive this.
41. Furthermore, the care agency also explained that it could also only assist with prompting medication if Mrs C kept her father’s medication in its original package, or if the Pharmacy fills the dosette box.
42. The Council and care agency explained to Mr and Mrs C why, under these circumstances, they were not allowed / able to support Mr X with his medication management. As such, there was no fault with the way in which they arrived at this decision or the advice they gave.

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Final decision

43. For reasons explained above, I did not uphold Mrs C’s complaint.

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Investigator's decision on behalf of the Ombudsman