Summary: Ms X complained about the way the Council assessed her mother’s needs for homecare support. Ms X says this resulted in distress and a delay in her mother’s discharge. We found fault with the way in which the Council responded when Ms X and the care home raised concerns about the proposed support at home. The Council has agreed to apologise for this.

The complaint

1. The complainant, whom I shall call Ms X, complained on behalf of her (late) mother, whom I shall call Ms Y. Ms X complained that the social worker failed to appropriately respond, when her family and the care home raised concerns that the support proposed for her mother at home would not be sufficient.
2. As a result, her mother could only return home on 8 January 2021, instead of 24 December 2020. This meant she could not see any family / friends during that time, which had a negative impact on her overall wellbeing.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. 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

6. I considered the information I received from Ms X and the Council. I shared a copy of my draft decision with Ms X and the Council and considered any comments I received, before I made my final decision.

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What I found

7. Ms Y was admitted to hospital in November 2020, following recurrent falls and with a fractured shoulder. The NHS hospital completed a Discharge to Assess tool on 10 December 2020 and sent this to the Council. It said:
• Ms Y lives with Ms X, who is struggling to support Ms Y with her personal care, food, fluid, medication, cleaning, and shopping.
• She was deemed to have capacity, alert and orientated to place, person and time. She was able to communicate her needs and hold a conversation.
• Incontinence: she needed regular checks and changes of her pads.
• She was at very high risk of developing pressure sores.
• Family want patient to go straight home, and they will continue to support.
8. The next day the assessment was changed, because Ms X tested positive for COVID-19 and now needed a dedicated Community Bed in a care home so she could complete her Covid-isolation period (ending 24 December 2021) before going home. The assessment recommended she should have four calls a day by two care workers when she goes home.
9. The Council says that:
• At the time of Ms Y’s discharge, the responsibility to assess adult care needs in a hospital setting was that of NHS colleagues. This was in line with COVID 19 discharge guidance set by government in the response to the pandemic.
• The Council received the outcome of the assessment on 11 December 2019 from the nurse assessor, stating Ms Y’s family would like four calls a day with two carers with reablement.
• Ms Y moved into a designated covid isolation bed in a local care home, after which the Council allocated Ms Y’s case to a social worker who was responsible for facilitating her move from the Community Bed to her own home.
• The social worker spoke to Ms Y on the phone on 18 December 2020. The record states that Ms Y appeared alert, and said she was keen to return home and was happy for the social worker to arrange for her support at home. It says the carer who was present and supported her during the conversation, told the social worker that Ms Y was well aware of where she was and did not present with any confusion.
10. The Council told me the social worker did not carry out a further assessment / review before the proposed discharge date of 24 December 2020, because there was no indication her needs had changed, and he did not receive any concerns that the package would not be sufficient and/or that she had time night needs that needed to be supported. There was therefore no reason to believe that the care plan would not meet Ms Y’s needs. Had the Council received information to suggest that the plan proposed was unsafe or that Ms Y needs where substantially changed then our actions would have been different.
11. The proposed package was based on the understanding that “the family will continue to support”; that Ms X would continue to live with her mother. However, the family told the social worker on 18 December 2020 that this would no longer be the case as Ms X had gone abroad. As such, the family told the social worker that the proposed package would no longer be sufficient.
12. The care home record states the care worker confirmed that Ms Y had told the social worker on 18 December that she wanted to go home. However, the care worker said Ms Y was not able to respond to any of the other questions, because she was hard of hearing.
13. The social worker spoke to Ms X’s sister on 18 December 2020. The record of the conversation states she had doubts about her mother being able to manage at home with the proposed package and would prefer she would go into a care home until January 2021 when 24 hours care privately arranged by the family could start.
14. As part of my investigation, I requested and received records from the care home that showed there were two conversations between the social worker and the care home on 22 December 2020. When I asked the Council about these conversations, it said: it did not have a record of these conversations and the social worker did not remember them. The care home’s record states that:
• It said it had great concern if Ms Y would go home with only four visits a day, and no-one in the house with her overnight.
• They went through Ms Y’s needs and the care home advised:
1. She needed full support with all activities of daily living.
2. She was not orientated in time and place and would be frightened on her own.
3. Whilst she had not attempted to get out of bed on her own, she did call out if she needed something or just wanted to see someone.
4. She often received personal care at night and accepted fluids.
• The home said it was shocked about the plan for Ms Y to go home with the proposed package, and it would be very fearful of Ms Y being alone at her home.
• The care home said Ms Y would need a full assessment of her needs beforehand, as it appears her needs have deteriorated since first admitted to hospital.
• The home said that people always say they want to go home, without realising their situation has changed. The home said it believed Ms Y did no longer have capacity to make this decision and that a full assessment of needs and MCA should be done.
• It said it was negligent to discharge Ms Y in this manner and she would be highly at risk.
15. The care home records also show there was a conversation between Ms X and the care home after the above calls. In it, Ms X said she was extremely anxious about her mother going home with a package of four calls, saying the social worker was not listening to their concerns. The care home said that staff was concerned as well as she would be home alone, bed bound on her own in the house.
16. In response to the above, the Council told me it has reviewed the care home records, which:
• Do not appear to evidence that Ms Y frequently called out in the night, as claimed by the home manager. Most of the care plan records state she is asleep overnight.
• There were only a small number of entries for continence care and repositioning, but this was not every night and do not appear indicative of an ongoing need.
• There is little evidence in the care home records that showed Ms Y was not orientated to time, place and unable to make decisions around her care needs. In fact, her care plan of 18 December 2020 said she “is alert to time” and that she is “able to verbalise her needs and hold a conversation”.
17. I reviewed the care home’s records (15 to 23 December 2020), which stated that:
• Ms Y was at high risk of skin breakdown and had a Grade 2 and a Grade 3 pressure ulcer (4 is the worst). Her care plan at the home said she needed four hourly turns (including at night).
• She was on hourly checks at night
• During nine nights, there was:
1. No intervention from care staff on 5 nights when she slept throughout.
2. Staff changed her position at night on four nights and changed her pads on two nights.
• Staff noted on 20 December that Ms Y could be a little disorientated in time and place at times.
• Her care plan said she was alert to time, space and person most of the times and ‘pleasantly confused’. However, her Dementia Assessment Tool said she was disorientated.
• On 22 December, a MUST weight assessment showed Ms Y was severely underweight and the assessment put her at High Risk.
18. Ms X made a complaint to the Council on 23 December, in which she mentioned that:
• Her sister told the social worker on 18 and 22 December 2020 that four visits would not be enough because her mother needed 24-hour care.
• The social worker had no knowledge of her mother's case, her condition or her needs, but was adamant that the care package he had put in place was enough.
• Ms X herself also spoke to the social worker and it was clear that he would not change his mind.
• The above was causing her and her mother great anxiety and distress.
19. Ms Y did not go home on 24 December because the family did not want her to go home with the proposed package. Instead, the family was trying to recruit a 24-hour live in carer, which the family would pay to provide support in addition to the care package the Council would put in. As of 4 January 2021, the family had not been able to find a 24-hour care worker yet. During this time, none of the family had been able to visit Ms Y at the care home. The Council was trying to find a reablement package of four visits a day by two carers in addition to that.
20. Ms Y was discharged home on 8 January 2021.

Analysis

21. Once the family had said Ms X would no longer be at the property to support Ms Y, and the care home and the family raised significant concerns about the proposed care package, the Council failed to look into those concerns further. This was fault, which caused Ms Y great anxiety. It should, as a minimum, have requested Ms Y’s care records from the care home to verify if these indicated: whether her needs had changed; if she needed more than the original four visits proposed per day, and whether Ms Y did not (currently) have capacity to decide where and how her needs should be met in a safe manner. It did not do this, which is fault. If the Council had done this, it would have been in a better position to discuss the proposed package with Ms X and explain why it believed the proposed package was (still) suitable. While this situation was always likely to be stressful for Ms Y’s family, this added to the distress.
22. However, the Council has told me that, after now considering the care home records, and discussing Ms Y’s needs for repositioning with district nurses, it remains of the view that four visits would have been enough.
23. Having now considered all the relevant information and facts, the Council remains of the view the proposed package was suitable. I am unable to challenge the merits of this decision (see paragraph 4).
24. The Council failed to make a record of the two important conversations it had with the care home on 22 December 2020. This was fault.

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Agreed action

25. I recommended that, within four weeks of my decision, the Council should:
• Apologise to Ms X for the additional distress caused.
• Share the lessons learned with its adult social care assessors.
26. The Council has told me it has accepted my recommendations.

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Final decision

27. For reasons explained above, there was fault in the actions of the Council.
28. 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