Summary: There was an incident where a care agency failed to give Mrs C her medication. The Council addressed the problem appropriately by starting a safeguarding investigation and preventing any repeat of the problem. There was some fault in the Council’s assessment of Mr B’s needs as a carer and the Council has agreed to offer Mr B a further assessment.

The complaint

1. Mr B is the carer for his elderly mother, Mrs C. He complained about the care Mrs C received from a care agency and said the Council was failing to provide him with adequate support as a carer.

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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. 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

4. I have discussed the complaint with Mr B. I have considered the documents that he and the Council have sent, the relevant law, policies and guidance and both sides’ comments on the draft decision.

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What I found

Law, guidance and policies

5. The Care Act 2014, the Care and Support Statutory Guidance 2014 (updated 2017) and the Care and Support (Charging and Assessment of Resources) Regulations 2014 set out the Council’s duties towards adults who require care and support and its powers to charge. The Council also has its own policies.

Eligible needs

6. The threshold for eligibility is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing. A council must consider whether:
• The adult’s needs arise from a physical or mental impairment or illness.
• As a result of the adult’s needs the adult is unable to achieve 2 or more of the specified outcomes.
• As a consequence of being unable to achieve these outcomes there is a significant impact on the adult’s wellbeing.

Outcomes

7. The outcomes are:
• Managing and maintaining nutrition.
• Maintaining personal hygiene.
• Managing toilet needs.
• Being appropriately clothed.
• Being able to make use of the home safely.
• Maintaining a habitable home environment.
• Developing and maintaining family or other personal relationships.
• Accessing and engaging in work, training or education.
• Making use of necessary facilities or services in the local community.
• Carrying out caring responsibilities for a child.

Carer’s eligible needs

8. The national eligibility threshold is based on the impact a carer’s needs for support has on their wellbeing.
9. In considering whether a carer has eligible needs, local authorities must consider whether:
• the needs arise as a consequence of providing necessary care for an adult
• the effect of the carer’s needs is the carer’s physical or mental health is either deteriorating or is at risk of doing so, or the carer is unable to achieve any of a list of other outcomes which may apply.
• as a consequence of that fact there is, or there is likely to be, a significant impact on the carer’s wellbeing
10. A carer’s needs are only eligible where they meet all 3 of these conditions.

Carer’s assessment

11. Carers’ assessments must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself. This includes the practical and emotional support the carer provides to the adult.

Carer’s personal budget

12. The carer’s personal budget must be an amount that enables the carer to meet their needs to continue to fulfil their caring role, and takes into account the outcomes that the carer wishes to achieve in their day to day life. This includes their wishes and/or aspirations concerning paid employment, education, training or recreation if the provision of support can contribute to the achievement of those outcomes. The manner in which the personal budget will be used to meet the carer’s needs should be agreed as part of the planning process.
13. Local authorities must have regard to the wellbeing principle of the Act, as it may be the case that the carer needs a break from caring responsibilities to look after their own physical/mental health and emotional wellbeing, social and economic wellbeing and to spend time with other members of the family and personal relationships.

Safeguarding

14. Since the Care Act 2014 councils have a statutory duty to safeguard adults. Section 42 of the Act says a local authority must make necessary enquiries if it reasonably suspects an adult who has care and support needs is, or is at risk of being abused or neglected and unable to protect himself against the abuse or neglect or risk of it because of those needs.

What happened

15. Mrs C has dementia and lives in extra care housing. Mrs C receives support from the Council and from Mr B. The Council’s support package consists of four visits a day by care workers from an agency. The care workers help Mrs C with personal care, preparing meals, managing medication, cleaning the flat and changing the bedding.
16. Mr B received a carer’s grant of £250 a year in 2015, 2016 and 2017. Both this parents were still alive at the time. The social worker said Mr B’s physical and mental health was deteriorating because of his role as a carer. The Council said the carer’s grant should allow Mr B to have a short respite break to prevent the risk of carer’s breakdown.
17. Mr C died in April 2018. The Council assessed Mr B in July 2018 and said he did not qualify for a carer’s grant. Mr B complained to the Council about this decision and later complained to the Ombudsman. The Ombudsman did not find fault with the Council’s actions.
18. Mr B raised concerns about the care agency that provided support to Mrs C in July 2019. He said the care workers were not washing all of Mrs C’s dishes and one of the care workers did not know what support Mrs C needed and she did not know where Mrs C’s prescription cream was. The agency responded that sometimes the dishes were left in the evening but they would be dealt with first thing in the morning. The agency said that all carers were trained to administer medication but some care workers felt anxious when Mr B was there because of his conduct towards the care workers.
19. The Council contacted Mr B’s brother in relation to the complaints. It says it did so because it was concerned about the number of concerns Mr B was raising and it wanted to know whether other family members shared Mr B’s concerns. The agency also had concerns about Mr B’s conduct towards the care workers and had said that, if the behaviour continued, the agency may require two carers to attend at Mrs C’s home to manage the risk.
20. The Council carried out a carer’s assessment of Mr B on 13 August 2019.
21. The social worker assessed how much support Mr B provided. Mr B said he cooked some meals for Mrs C, took her to appointments such as the doctor, hair and warfarin clinic. Mr B took Mrs C for a meal once a week and took her on days out.
22. Mr B said he provided support on five days, morning and daytimes.
23. The assessment said: ‘You may be entitled to carer’s allowance if you provide over 35 hours of support each week.’
24. The social worker considered Mr B’s outcomes affected by his role as a carer:
• Maintaining a habitable home. Mr B did not have time to clean up or do jobs around the house.
• Nutrition. Mr B did not have time to cook for himself. He did not have decent meals but snacked. He did not have time because he helped Mrs C and she tired him out.
• Developing relationships with people. Mr B did not have time and was too tired. He was becoming depressed.
• Making use of facilities in the community. Mr B could not do things he wanted to do with other people or by himself. He was tired and depressed.
25. However, under each section the social worker noted: ‘There are challenges to my independence, but this is not due to my caring role.’
26. The social worker concluded:
• Did Mr B have eligible outcomes? Yes.
• Was Mr B’s mental or physical health getting worse due to his caring role or was there a risk of this happening? No.
• Was there a significant effect on his wellbeing? No.
27. In the most recent assessment of Mrs C’s needs, the social worker said that Mr B provided care and support on a daily basis. Mr B carried out Mrs C’s food shopping, took her to all her appointments, took her out in the community and managed her paperwork and finances.
28. The Council wrote to Mr B on 13 August 2019 with the outcome of the carer’s assessment. The social worker said:
• Mr B did not have needs that arose from providing care to Mrs C.
• Mr B was able to manage all the areas of his life but he was having some difficulty, namely anxiety and depression. She and Mr B discussed how these difficulties could be addressed in informal ways, but Mr B declined those options.
• Although Mr B was having difficulties with some areas of his life, these did not have a significant impact on his health and wellbeing.
29. The letter provided Mr B with links to support that he could access through his GP, mental health support and the carers hub.
30. On 29 August 2019, Mr B appealed the Council’s decision not to give him a carer’s grant. He said:
• He supported Mrs C by taking her to all her appointment and taking her on days out.
• He prepared some of her meals as the carers did not always have enough time to do so.
• He struggled to find time to do his own housework, visit friends or participate in social activities, because of his role as a carer.
• His carer’s role impacted significantly on his health and he suffered from anxiety, depression and hypertension.
• He met the eligibility criteria for a carer’s personal budget.
31. The Council held a meeting with Mr B on 20 September 2019. The Council agreed to review Mrs C’s care package.
32. One of the Council’s workers spoke to Mr B on 23 September 2019 and said he was no longer eligible for carer’s support as he was not Mrs C’s main carer.
33. The Council wrote to Mr B on 24 September 2019 and said:
• Mr B said he had been informed that he was no longer eligible for a carer’s support because he was not Mrs C’s main carer.
• The writer of the letter had reviewed the carer’s assessment and based on the information he provided, eligibility for support was identified and the social worker discussed the support available to him.
• The support consisted of signposting and advice to other agencies to support him with financial hardship and anxiety and depression, including carers’ hub, the GP and mental health services. It explained that the carers’ hub could support him with breaks in his caring role.
• Mr B had declined a referral to his GP or mental health services.
• The outcomes that had been identified were support with anxiety and depression and financial hardship to relieve him from aspects of his caring role.
34. Mr B contacted the Council on 1 October 2019. He had found a warfarin tablet on the floor on 29 September 2019, but the care worker had signed the medication administration chart to say that Mrs C had taken her medication.
35. The Council started a safeguarding enquiry into the matter. The procedure the care workers were meant to follow was that they passed the medication to Mrs C in a pot and observed Mrs C taking the medication with a glass of water. The care worker then signed the chart.
36. The care worker who administered the medication on the evening of 28 September 2019 said she saw Mrs C take the medication from the pot before signing the chart.
37. The social worker said Mrs C was not given her medication on that day, but she suffered no ill effects.
38. The Council closed the safeguarding investigation based on the recommendations that:
• All care workers had been asked to check a service user’s clothing and surrounding areas when giving medication to ensure that no dose was missed. They should also check that the medication was not stuck to the sides or the bottom of the pot.
• The agency would provide medication training to the care worker in question.
• The agency would ensure that all care workers were aware that they had to observe Mrs C taking her medication.
• The Council would continue to monitor the agency.
39. Mr B made a further complaint on 28 October 2019 and 28 November 2019. He still disagreed about the decision not to give him the carer’s grant. He said he provided 35 to 40 hours a week support to Mrs C which was more than the care agency did. He did not want mental health support but wanted the grant to have a break. He also made complaints about the care worker’s failure to give Mrs C her medication.
40. The Council informed Mr B of the outcome of the safeguarding enquiry on 31 October 2019.
41. The Council held a meeting with Mr B on 22 November 2019 and discussed the concerns about the medication with him.
42. In its response to the Ombudsman the Council said the following about why Mr B did not receive a carer’s grant:
• ‘[Mrs C is in receipt of a formal care package in an Extra Care Housing Scheme and therefore [Mr B] is not considered to be [Mrs C’] primary carer. Due to this, Mr B is not eligible for carer support or a carer’s grant.’
43. I spoke to the manager as I had some questions about the assessment. I said it was difficult to understand the conclusion of the assessment as it did not flow from the narrative.
44. The social worker had outlined four outcomes which were affected by Mr B’s role as a carer and appeared to link his depression to the pressures of the caring role. However, she concluded that Mr B’s mental health was not getting worse because of his caring role and that the caring role did not have a significant effect on his wellbeing.
45. That was not how Mr B felt and there was no explanation in the assessment why the social worker came to her conclusion.
46. The manager said that the social worker was of the view that Mr B’s depression and anxiety issues were more general and linked to what was going on in his life, not his role as a carer. She felt that a grant would not solve the problem and discussed with Mr B that he could obtain help from mental health services or his GP to deal with the underlying problem.
47. The manager said the Council had spoken to Mr B recently and had offered him a further assessment as a carer.

Analysis

48. Mr B has made complaints about the agency’s care (for example the unwashed dishes, prescription cream) and the agency has already responded to those complaints. There is nothing further the Ombudsman can add to the response.
49. The most serious complaint, in terms of the agency, was the failure relating to the medication. The agency has admitted that there was a failure so this was fault. I have further considered the Council’s response in terms of its safeguarding action.
50. The Council took the problem seriously by starting a safeguarding investigation. It considered what procedure the care workers were following to ensure that the medication was taken. This basic procedure was fine, but, of course, would only work if the care workers followed the procedure.
51. The Council made appropriate recommendations to mitigate the problem which included further training and a reminder to staff of the importance to observe Mrs C while she took the medication. Therefore I find no fault in the Council’s safeguarding investigation into this complaint.
52. I have also considered Mr B’s complaint about his carer’s grant. I cannot say, of course, whether Mr B should receive a grant or not. Only the Council can do so. I have considered whether the Council’s actions were in line with the law, guidance and its own policies and whether the conclusions of the assessment were properly justified.
53. The carer’s assessment of Mr B does not contain the detail required to understand the conclusions that were reached and this was fault.
54. It was the social worker’s judgment that Mr B’s mental health and wellbeing were not affected by his carer’s role and she may have good reasons for this. However, she did not explain why she reached this conclusion in the assessment and this was fault.
55. I do note, however that the letter dated 13 August 2019 provided some of the detail of the discussions which took place between the social worker and Mr B and provided some of the explanation that was lacking in the assessment.
56. I am also concerned about the Council’s repeated claim that the reason why Mr B did not receive a grant and would never be able to receive a grant was that he was not Mrs C’s main carer. The Council said that, as Mrs C lived in extra care housing and had a support package, it was prevented from providing Mr B support as a carer.
57. That is not correct and is fault. The threshold for support as a carer is clearly set out and neither the CASS Guidance nor the Council’s own policy say that the carer has to be the only or main carer, or that they have to provide at least 35 hours support to be eligible for support.
58. I cannot say, of course, to what extent Mr B has suffered an injustice. I appreciate that, even if the Council agreed that Mr B had an identified need for support as a carer, it did not automatically follow that it had to offer him a grant.
59. I note that the Council has offered Mr B a re-assessment. This assessment should clearly set out what support Mr B provides to Mrs C, whether the threshold for carer’s support is met and, if it is met, how the Council and Mr B have decided to meet it. If there is disagreement in any of those areas, the Council should clearly set out its analysis and explain its decision.

Agreed action

60. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mr B in writing.
• Offer him a further assessment as a carer.
• Remind relevant staff that there is no requirement for carers to be the main carer or to provide care for 35 hours a week to be eligible for carer’s support.

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Final decision

61. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman