Summary: The care and support plan was inaccurate by the time Mrs B was discharged from hospital to the care home. That did not cause any injustice to Mrs B as the care home had ample information from the hospital, although it was distressing for Mrs X to read. The Council did not provide comprehensive information to Mrs B or her family about the likely charges for her care.

The complaint

1. Mrs X (as I shall call the complainant) complains on behalf of her late mother (Mrs B) that the Council did not properly include her or her mother in the care planning process, and did not explain to her or her mother there would be a charge for Mrs B’s care after her discharge from hospital. Mrs X says this led to an inaccurate care plan for Mrs B. Mrs X received an unexpected invoice for a significant sum after Mrs B’s death.

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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. 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

3. I considered the information provided by Mrs X, the Council and the care provider. Both Mrs X and the Council commented on earlier versions of this statement, and I considered the complaint further in the light of their comments. They had another opportunity to comment before I reached this final decision.

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What I found

Relevant law and guidance

4. The Care Act 2014 gives local authorities a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the local authority must involve any carer the adult has.
5. The charging rules for residential care are set out in the “Care and Support (Charging and Assessment of Resources) Regulations 2014”, and the “Care and Support Statutory Guidance 2014”. When the Council arranges a care home placement, it has to follow these rules when undertaking a financial assessment to decide how much a person has to pay towards the costs of their residential care.
6. A temporary resident is someone admitted to a care or nursing home where the agreed plan is for it to last for a limited period, such as respite care, or there is doubt that permanent admission is required. The Care and Support (Charging and Assessment of Resources) Regulations 2014 and the Care and Support Statutory Guidance 2014 set out charging rules for temporary residential care.
7. The council must assess the means of people who have less than the upper capital limit, to decide how much they can contribute towards the cost of the care home fees.

What happened

8. Mrs B received a package of care (arranged by the Council) at home, where she lived on her own. In May 2019 she had a stay at care home A which she paid for herself (with Mrs X’s help). The Council’s record of a social worker’s conversation with Mrs B in May notes she was offered a funded short-stay reablement bed at a different care home, which the Council would arrange, or an increased care package at home (Mrs X says she does not think this offer of an increased hone care package was made). Mrs B chose to go to care home A instead. She said she could afford to stay there for 2 – 4 weeks. The notes conclude, “(Mrs B) said she has money and would pay for (care home A). (Mrs B) has capacity and this was all put to her clearly so she could understand.”
9. Mrs B was admitted to hospital again in September 2019 after a fall. A social worker completed an assessment of her needs on 2 October. The Council says the assessment was completed from information including “speaking with (Mrs B) in the hospital along with information from the medical notes/staff.” The Council’s records show the social worker also spoke to Mrs X on 2 October at the hospital. Mrs X told the social worker her mother would be happy to go to care home A but would “play up” if she had to go somewhere else: the social worker explained she would request a short term bed but care home A would not necessarily be among the choices. She recorded in her notes that if Mrs B and her family declined the choice of care homes available she would either go home with a package of support or fund her own care at care home A. Mrs X says her mother would not have paid for her own care at care home A.
10. The social worker sent the following request to the Council’s brokerage team to arrange a placement on discharge: “Short term bed required to assess whether (Mrs B) will be able to return home. Needs full assistance with personal care, transfers with a sturn, has ulcerated feet. (Mrs B) is sight and hearing impaired. (Mrs B) is Type II diabetic”.
11. The social worker who received the placement request noted on 3 October, “no reablement potential identified at this time. STB [short term bed] chargeable from start”.
12. Mrs B’s consultant completed a PEACE (Proactive Elderly Advanced Care) for her on 4 October. The hospital discharge note which was sent with her to care home A recorded that by 8 October when she was discharged, Mrs B (who was noted as being blind) was doubly incontinent, unable to mobilise due to her leg ulcers, needed the assistance of two people, was “verbally able” in communication, and was no longer being given insulin to manage her type II diabetes.
13. Mrs B was discharged from hospital on 8 October 2019 to a short term (4 week) placement in care home A.
14. The Council’s records show Mrs B was discharged from hospital without pain relief or antibiotics. A community nurse who attended Mrs B in the care home on 9 October to redress her foot was said to be ‘shocked’ at the state of the wound and would not redress it until Mrs B had proper pain relief.
15. The care home contacted a GP. He would not prescribe pain relief without seeing the wound. He examined Mrs B on 10 October and said she had an infection of the bone. He arranged for her readmission to hospital. The hospital staff advised Mrs X that Mrs B had gangrene in her foot and now required palliative care.
16. Mrs B was discharged back to the care home on 11 October. The Council says it received no assessment notice from the hospital. It was not aware of her admission overnight or her discharge the following day until a safeguarding alert was raised by the care home about the way Mrs B had been sent to the care home on 7 October without pain relief or antibiotics.
17. On 4 November Mrs B’s social worker contacted Mrs X again to discuss extending Mrs B’s placement for a further four weeks. The case recording notes: ‘(Mrs X) asked me what she should do about Housing Benefit and the NCC financial assessment - forms are apparently on her way for completion. I advised that I was proposing EXTENDING the SHORT TERM PLACEMENT and that (Mrs X) should make this clear on the finance forms.’ Mrs X says there was no conversation about the care and support plan.
18. The social worker sent a completed care and support plan to the care home after the agreement to extend the placement. The care plan was based on the assessment of Mrs B in hospital prior to her initial discharge to the care home, the discussion with her family and staff in hospital, and the telephone conversation with Mrs X on 4 November. It did not reflect any changing needs arising from the hospital admission on10 October as the social worker was unaware of that.
19. Sadly Mrs B died on 13 November.
20. The Council’s finance office sent Mrs X the forms to complete for Mrs B’s financial assessment so it could calculate her level of contribution towards the cost of her care in the care home (Mrs X asked for paper forms not an online assessment). The Council initially sent the forms to an incorrect address (that is, Mrs B’s address and not to Mrs X); it also sent a follow-up letter to the same wrong address. Staff noticed the error and posted the forms to the correct address on 28 November. Mrs X completed and returned the forms and the Council completed the assessment on 20 December.
21. The Council first sent an assessment based on Mrs B funding her own care but then adjusted the assessment and issued a revised invoice of £1733.
22. Mrs X believes her mother’s care should have been fully funded by the NHS and says she asked the hospital to carry out an assessment for NHS funding.

The complaint

23. Mrs X complained to the Council. She complained the care plan said she had been involved in compiling it, but she said she had not and it did not reflect Mrs B’s changing needs. She said for example it did not say Mrs B had a sight impairment, nor did it explain she had been taken off her diabetes medication. She also complained she had not been told there would be a financial cost to Mrs B’s stay in the care home.
24. The Council says the care plan was accurate for the placement based on the 2 October assessment and information from the hospital records. A reassessment of Mrs B’s needs was not undertaken because there was no notification from the hospital or the care home at that time that Mrs B had been readmitted and her needs had changed.
25. The care provider says Mrs B’s care plan was built up from a combination of information from the hospital and from Mrs B’s family, as well as observations in the care home.
26. The Council says it advised Mrs X and Mrs B from the outset that care would be chargeable. It points out it had discussed this previously (in May 2019) when Mrs B had asked to stay at the care home: “(Mrs B) said she would like to go into (care home A) before going home. I asked how long she planned to stay she said 2-4 weeks she could afford it. I advised that if her finances ran out Norfolk County Council would not support with costs because her needs could be met at home.” The social worker’s discussion with Mrs X on 4 November refers to the fact that Mrs X was expecting a financial assessment.
27. The Council acknowledges the forms were sent to an incorrect address and apologised for the error in its letter to Mrs X. It says there was no personal information contained on the forms.

Analysis

28. The Council says the care and support plan was sent by its brokerage team to care home A but the care provider has no record of it. It appears the care plan (by then out of date and inaccurate, as Mrs B had had a further hospital admission) was not sent until 4 November when her short-term placement was extended.
29. There is evidence the social worker spoke to Mrs X on 2 October, when she first compiled the care plan and again by telephone on 4 November when she extended the placement. However, it was confusing and upsetting for Mrs X to receive a care plan after Mrs B’s readmission to hospital which did not reflect her current status or her need for palliative care. The social worker should also have included in the care plan more details about Mrs B’s lack of mobility and the management of her diabetes. It was not the fault of the Council it was not informed by the hospital of Mrs B’s readmission and discharge.
30. I have not seen any evidence that Mrs B personally suffered any injustice or lack of appropriate care because of the contents of the care plan. The discharge summary from the hospital contained the necessary details. Mrs X says she was shocked and distressed when she received a copy of the care plan which did not reflect her mother’s needs or that she was dying.
31. There was no question that Mrs B’s care would be chargeable. There is evidence that Mrs B and her family were aware that charges were made for care and that Mrs X knew a financial assessment would be undertaken.
32. However, I have not seen evidence that the Council gave the family all the relevant information about the likely charges for the stay at care home A. That was fault, but it did not cause significant injustice. Mrs X says her mother would have insisted on coming home had she known there would be care charges but that was not possible: Mrs B required 24-hour care on discharge from hospital.
33. The Council was at fault in sending financial assessment forms to an incorrect address. The Council has apologised for that error. It says no personal information was contained in the letters except for surnames.
34. It is for Mrs X to pursue her concerns about NHS funding with the NHS direct.

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Agreed action

35. My recommendation was that the Council should review the way care and support plans for people leaving hospital are compiled, and provide details to me of how it will ensure their timely and accurate completion. The Council says it is updating its current care and Support planning procedures which should be completed by the end of January; it has revised its computer systems to ensure the service user remains at the forefront of its plans, and has established a hospital discharge project with the three acute hospitals in its area.
36. My recommendation was that the Council should review the provision of information to service users and families about care charges and provide me with details. The Council says “a significant amount of work has taken place with social workers over the past few months to ensure all understand the current way of working as far as charging is concerned and that the need to have a full financial conversation, giving information regarding financial assessment and charging with service users and families is also understood”. The Council says it will provide details of further work in due course once the county-wide system is in place.
37. The Council agrees to apologise to Mrs X for the distress caused by the inaccuracy of the information it sent to her.

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Final decision

38. There was fault by the Council in the failure to compile an accurate care plan, and to notify the family properly of the likely charges for care. These caused some injustice to Mrs X which the completion of the recommendation at paragraph 35 has remedied.

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Investigator's decision on behalf of the Ombudsman