Summary: Mrs F complained about the Council’s handling of her grandmother’s interim care arrangements in a care home and the discharge planning from hospital. The Council agreed it had provided incorrect information about paying for the care and agreed to pay the care home directly. We found there was not enough evidence of fault in how it handled the hospital discharge, but there was fault in how it communicated with Mrs F and its complaints handling. The Council agreed to apologise and make payment to remedy the injustice this caused her.

The complaint

1. The complainant, whom I shall refer to as Mrs F, complained about the Council’s handling of her grandmother’s (Mrs X) care arrangement. She said it:
• wrongly amended its Social Worker’s Continuing HealthCare Checklist (CHC);
• communication with her was poor and misleading, and its social worker lied and used bullying tactics;
• wrongly accused her of being verbally abusive and obstructive;
• failed to implement the refunds and next step it agreed to in July 2022;
• wrongly told her she could escalate her complaint and failed to respond as promised which caused a further delay; and
• delayed her grandmother’s discharge from hospital.
2. Mrs F said as a result she and her family experienced distress and uncertainty.

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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 consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. If we are satisfied with an organisation’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. As part of my investigation, I have:
• considered Mrs F’s complaint and the Council’s responses;
• discussed the complaint with Mrs F and considered the information she provided;
• considered the information the Council provided in response to my enquiries; and
• considered the relevant law, guidance and policy to the complaint.
7. Mrs F and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law, guidance and policy

Continuing Health Care

8. NHS Continuing Healthcare (CHC) is a fully funded package of care some people may be entitled to receive as a result of disability, accident or illness. It covers the full cost of the persons care and residential accommodation.
9. To assess if a person is entitled to CHC a checklist is normally completed. Practitioners should compare descriptors to the needs of the individual and select the appropriate level, choosing whichever most closely matches the individual. Practitioners should briefly summarise the individuals needs which supports the chosen level and record references to evidence as appropriate.
10. A full NHS Continuing Healthcare assessment is required if:
• two or more domains are selected in column A;
• 5 or more domains are selected in column B, or one selected in A and four in B; or
• One domain is selected in column A in one of the boxes marked with an asterix (priority level), with any number of selections in the other two columns.
11. Outcome must be communicated to the individual or their representative in writing as soon as reasonably practicable. This would normally include providing a copy of the checklist.
12. A positive checklist will result in a multidisciplinary team completing a full assessment of a person’s needs. If found eligible, the whole cost of care and support services provided to meet the persons eligible needs are covered by the NHS.
13. There is also a ‘fast-track tool’ if a person has rapidly deteriorating condition that may be entering a terminal phase. This must be completed by an appropriate clinician.

Council’s Complaint Policy

14. The Council’s Policy says it will consider complaints under a three-stage process:
• Stage one is local resolution by officers and managers responsible for the service. The emphasis is on trying to find a resolution. A response will be provided within 10-20 working days depending on the complexity;
• Stage two is a review or appeal stage response by an officer who have not been involved previously. A response should be provided within 25-65 working days depending on the complexity of the case; and
• Stage three is to inform a complainant about their right to seek independent review from the Ombudsman or similar services.
15. The Policy also says for stage two complaints, it may try and deal with the dissatisfaction before the stage two is considered, or decide there are no ground for a stage two investigation and explain this decision to the complainant.

What happened

16. Mrs F’s grandmother (Mrs X) had several health conditions and support needs. In spring 2022 she had a fall and a chest infection. She was admitted to hospital.
17. In Summer 2022 Mrs X was ready to be discharged. The Council discussed the discharge with the hospital and Mrs F. The Hospital’s multidisciplinary team found Mrs X would benefit from an interim care placement to see if she could recover some of her functional abilities. It also allocated a social worker to her case.
18. Mrs F agreed with the Council’s view and the family suggested a privately funded care placement for Mrs X, which could also provide the physiotherapy she needed. She said was because there was no space in the care home the Council had proposed.
19. Mrs F said the Council’s social worker initially said it would fund part of the payment and the family would top up the rest, but then told her due to its policy she would have to pay the care home costs and claim this back when Miss X was in the community.
20. Following Mrs F request, the Council’s social worker visited Mrs X in the care home to complete the CHC checklist to determine whether she may be eligible for fully funded NHS care. She found Mrs X was eligible for a referral for a full CHC assessment, and shared the checklist with Mrs F.
21. The following day the social worker’s manager reviewed the checklist. This led to a reduction in two domain outcomes, but the decision remained that Mrs X should be referred for a full CHC assessment. The Council made the referral the same day.
22. Mrs F was not happy with the support the social worker had provided following Mrs X’s discharge from hospital. So, she complained to the Council. She said the social worker had been rude, bullying and argumentative, and she had provided unclear and misleading information about paying for the care home.
23. Mrs F also became aware the Council had amended the social worker’s CHC checklist scores and raised her concerns with the Council. The Council apologised she had not been informed of its amendments. It explained its reasons, and said the outcome remained the same and it had referred Mrs X for a full CHC assessment.
24. The Council partially upheld Mrs F’s complaint. It said Mrs F and the family decided not to place Mrs X in the interim care home offered by the Council, but to place her in a privately arranged care home. Normally, it would not be responsible for reimbursing costs in such arrangements. However, it found the information it had provided was unclear and misleading, but it found no evidence to support Mrs F’s claims about its social workers behaviour.
25. The Council said it would:
• reimburse Mrs X’s care home placement for the four-week period;
• pay for two further weeks of Mrs X’s stay at the care home, and complete a full Care Act Needs assessment with the aim of returning her home with a care package;
• allocate an Occupational Therapist to advise on equipment and manual handling to support Mrs X’s return home;
• complete a financial assessment; and
• progress the Continuing Heathcare (CHC) process alongside these actions.
26. The following week, the Council’s social worker visited Mrs X to assess if she was fit to travel. Mrs F disagreed with the social workers view she was fit to travel.
27. Mrs X was taken to hospital the same day due to concerns about her wellbeing. She was discharged to the care home the following day. The hospital said if her eating, and drinking did not improve palliative care would be needed.
28. A GP assessed Mrs X. He found she was not palliative at the time and would like to go home. The Council’s social worker arranged transport for Mrs X and visited her to see if she were well enough to travel home.
29. The Council’s social worker wrote Mrs F in the afternoon to inform her she would visit Mrs X the following day and complete the Care Act assessment.
30. When the social worker attended the care home, she said Mrs F obstructed her from seeing Mrs X and was verbally abusive.
31. Mrs F did not agree Mrs X was fit to travel home and asked for medical professionals to assess Mrs X as she had lost a lot of weight due to not eating and drinking properly.
32. The Council wrote Mrs F to warn her about abusive behaviour against its staff. It said it believed Mrs F was not acting in Mrs X’s best interest by obstructing its social worker’s access to her and communicating with professionals. It explained it understood Mrs X’s health was declining and more medical advice was needed for her to return home. It said it intended to raise its concerns with the Office of the Public Guardian (OPG) and Adult Social Services (ASC) for safeguarding concerns.
33. Mrs X’s health deteriorated further, and she was admitted to hospital again. Mrs F said hospital staff were reluctant to speak with her and believed the Council had given it instructions not to communicate with her.
34. Mrs F asked the Council to escalate her complaint due to its allegations about her behaviour. She also said she was not satisfied with the response she had been provided, the lack of a care plan for Mrs X, and how her complaint had been handled. She also felt it had wrongly pushed for Mrs X to travel home at a time when this was inappropriate due to her deteriorating health.
35. The Council acknowledged her complaint and said it would respond within 25 working days.
36. When Mrs X was in hospital, the Council paid for the care home for a week up to the end of July 2022, which was a week more than it had initially agreed to. Mrs F and Mrs X’s family funded the cost of the care home for a further week in August 2022 due to the uncertainty over whether Mrs X would return to the care home, home, or remain in hospital.
37. Two weeks later, Mrs X was still in hospital. Mrs F raised further concerns to the Council about the delay in discharging Mrs X to her home. The Council told Mrs F it would respond to her concern as part of her escalated complaint.
38. Mrs X was discharged home a few days later and died two days after.
39. Mrs F asked the Ombudsman to consider her complaint. However, as the Council had not provided its final complaint response, we told her we could not consider her complaint at this stage.
40. Three months after Mrs F asked the Council to escalate her complaint, the Council told her it had incorrectly told her she could appeal to its stage two. It said she could complain to the Ombudsman. It also told her it believed it could resolve her complaint informally with her.
41. Mrs F asked the Ombudsman to consider her complaint. She also said the Council had not implemented all of the outcomes in is Summer 2022 complaint response.
42. In response to our enquiries the Council said it had:
• paid the care home for Mrs X’s care costs up to the end of July 2022, it had asked the care home to refund Mrs F the cost the family had paid;
• provided forms for Mrs X’s financial assessment to Mrs F, however, no assessment was completed as Mrs X was admitted to hospital and became palliative;
• adjusted Mrs X’s CHC checklist and apologised to Mrs F as it had not told her. It explained it reasons and the outcome remained Mrs X should have a full CHC assessment;
• allocated a different social worker to Mrs X’s case due to Mrs F’s loss of trust in the initial social worker;
• not told the hospital not to communicate with Mrs F or the family;
• found its warning about behaviour to Mrs F appropriate, but it had not reported concerns to the OPG or ACS safeguarding; and
• allocated an occupational therapist to advise on equipment and manual handling to support Mrs X’s return home. It had ordered a mattress, but further assessment could only be completed when Mrs X returned home. It said it had arranged for care support in line with the family’s wishes and shared the care plan. It also communicated with the hospital to get a discharge date but could not comment on delays by the hospital.
43. Mrs F shared some email communication she had with the Council and her recordings of discussions with the Council’s social worker with the Ombudsman.

Analysis and findings

44. Mrs F’s complaint relates to the Council’s handling of Mrs X’s care and support arrangements from June 2022 when she was first discharged from hospital until August 2022 when she was discharged home from her second hospital stay.
45. Mrs F has a separate complaint against the hospital regarding its handling of Mrs X’s care whilst in hospital and its handling of her discharge. If she is unhappy about the hospitals response to her concerns, she can ask the Parliamentary and Health Service Ombudsman (PHSO) to consider her concerns.

Care home placement

46. The Council offered a care home it found suitable to meet Mrs X’s needs when she was ready to be discharged in June 2022 from her first hospital stay.
47. Mrs F and the family disagreed with the suitability of the care home and decided to place her in a privately arranged care home.
48. I have not seen evidence of fault in how the Council acted. It consulted its contracted care home which confirmed it could meet the needs known about Mrs X at the time. It was entitled to reach its view an interim placement would benefit her at the time to see if her condition or abilities improved. Mrs F and the family was entitled to find a privately arranged care home.
49. However, the Council agreed its social worker had given incorrect or misleading information to Mrs F at the time about paying for Mrs X’s care. This was fault. It has since reimbursed the costs of the care directly to the care home and asked the care home to refund the family.
50. I found the Council’s remedy to be appropriate as this included the costs the family had until the end of July 2022. I acknowledge Mrs F wanted the Council to refund her directly, but its approach was in line with its normal practice. Any delay to issue the refund to Mrs D by the private care home is not fault by the Council.
51. However, the Council said it would fund the care home for six weeks, this did not include the final week of July 2022. I have seen no evidence the Council communicated with Mrs F at the time to inform her or Mrs X’s family it had decided to fund the care home placement for a further week until the end of July 2022. This was fault and caused some further uncertainty to Mrs F.
52. Mrs F has not asked the Council to refund the additional week in August 2022 which the family decided to fund in case Mrs X had to return to the care home.

Continuing HealthCare checklist amendments

53. The Council agreed it made adjustments to Mrs X’s CHC checklist the day after its social worker had completed it. It apologised to Mrs F for not informing her about the change in its scores.
54. While the Council was at fault for failing to inform Mrs F about its amendment to the CHC checklist, the outcome remained the same. This was for Mrs X to be referred for a full CHC assessment.
55. I found the Council’s approach, for a manager to check social worker’s CHC checklists before a referral are made, to be good practice. It set out its reasons and was therefore not fault for amending Mrs X CHC checklist.
56. I understand Mrs F had a loss of trust in the Council as a result of this. However, I am satisfied the Council’s apology was enough to remedy any injustice its fault caused. It has addressed the learning with the staff involved to ensure checklist are shared after its manager has completed the review.
57. I cannot consider any delays in the completion of the full CHC assessment, or the fast-track assessment tool, as this would be completed by a multidisciplinary team or an appropriate clinician. Such complaints should be made to the hospital trust. I understand Mrs F has made a complaint against the hospital, which should therefore address this part of her complaint.

Communication between Mrs F and the Council

58. Both Mrs F and the Council made allegations against each other for inappropriate behaviour.
59. Mrs F concerns relates to the amendment of the social worker’s CHC checklist, how a social worker spoke and behaved, and the manager’s warning against Mrs F’s behaviour towards its staff. She also felt the Council was wrongly pushing for Mrs X to travel home when she was not fit to do so.
60. I acknowledge Mrs F had a loss of trust in the Council as a result of her disagreements about Mrs X’s care arrangements and the amended CHC checklist. However, I have not seen enough evidence the Council’s social worker behaved inappropriately. I cannot therefore make a finding on this point.
61. The Council’s social worker said Mrs F had obstructed her in completing Mrs X’s Care Act assessment and raised her voice. The Council told her it would not accept abuse, discriminating behaviour, or obstructive behaviour. It also said it would refer the matter to the OPG and its ASC safeguarding as Mrs F was not acting in Mrs X’s best interest.
62. I have considered Mrs F’s recordings of the conversations with the Council’s social worker. I have seen no evidence Mrs F, or her husband raised their voices or behaved inappropriately in the way they communicated with the social worker. They shared their concerns that they felt the Council was trying to move Mrs X home at a time where this was not in her best interest due to her changing health conditions and needs. They wanted a trained medical professional to consider whether she was fit to travel home.
63. Mrs F did refuse for the social worker to complete the assessment with Mrs X as she did not believe she was able to engage with this at the time due to her poor health.
64. I therefore found no justification for the Council’s approach to write Mrs F with warnings about her behaviour and obstructing the social workers assessment, including alleging she was not acting in Mrs X’s best interest and threatening to report her to OPG and safeguarding. Mrs F did not refuse for the social worker to obtain information from the hospital to form her view of Mrs X’s current condition and needs, or to see Mrs X at a different time.
65. I am satisfied this caused Mrs F some distress and lack of trust in the Council’s handling of her concerns about Mrs X’s wellbeing. As the Council did not make referrals to the OPG or safeguarding there were no additional injustice to Mrs F.
66. I have not found the Council at fault for wrongly pushing for Mrs X to travel home. While this may be how Mrs F felt, the evidence shows the Council did consider their views and change plans according to Mrs X’s changing condition and the information it received from Mrs F.

Care planning and discharge from hospital

67. Mrs F said the Council delayed Mrs X’s discharge from her second hospital stay and the care plan in place was not suitable.
68. Mrs X’s care planning was challenging for the Council and Mrs X’s family as her circumstances were changing as her health deteriorated and she was not registered with a GP within the Council’s area.
69. I have not seen enough evidence the Council was at fault for delaying Mrs X’s discharge from hospital or its care planning was not suitable. In reaching my view I am conscious:
• it had allocated an OT and arranged for some equipment for Mrs X’s discharge. The OT continued to be involved and plans were in place to assess Mrs X when she returned home for further equipment and turning support;
• it found Mrs X did not have capacity to make decisions about her care and support needs, but agreed her needs would be best met in her home;
• Mrs X’s health was deteriorating which made it unclear if and when she could be discharged. The Council therefore relied on information from professionals;
• some planning was not possible until Mrs F had re-registered Mrs X with a GP within the Council’s area. This meant a district nurse, who could progress some care planning and support, could not be assigned;
• it discussed care planning with Mrs F for Mrs X’s discharge. This included a substantial amount of care from one or two carers through a direct payment as requested by Mrs F, and initially 24 hours of care upon her discharge until further assessment was completed;
• the NHS became responsible for Mrs X’s wellbeing and discharge toward the end of July 2022 when she was entitled to a fast-track CHC assessment and full funding from the NHS to meet her eligible care needs; and
• the evidence shows the Council communicated with the hospital discharge team and chased it for responses regarding Mrs X’s discharge to her home.
70. I understand Mrs F has a separate complaint against the hospital for its handling of Mrs X’s care and discharge. I cannot consider the hospital’s actions. If she remains unhappy after it has responded to her complaint, she can ask the Parliamentary and Health Service Ombudsman to consider her concerns about the hospital’s actions.

Complaints handling

71. The Council responded to Mrs F’s complaint as set out in its Policy. This included the actions it would take to progress Mrs X’s care arrangements and payment for her care costs. I found no fault in how the Council handled its stage one process.
72. However, when Mrs F escalated her complaint to the Council’s stage two process, it told her it would investigate, and it took the Council nearly three months to tell her she could go directly to the Ombudsman. This was fault.
73. While the Council’s Policy allows it to reach a decision it will not investigate under its stage two, I would expect such decisions to be provided without delay. In this case, the Council caused delays and required prompting from Mrs F and the Ombudsman.
74. I found the Council’s apology was not enough to remedy the injustice this caused Mrs F. This is because she experienced some distress due to the uncertainty and loss of trust in the Council’s ability and willingness to address her concerns over a three-month period.

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Agreed action

75. To remedy the injustice the Council caused to Mrs F, the Council should, within one month of the final decision:
1. apologise in writing to Mrs F, and pay her £300 to acknowledge the distress and uncertainty the Council’s faults caused her;
2. pay Mrs F a further £200 for the unnecessary time and trouble she had to bring her concerns to the Council’s attention.
76. Within three months of the final decision the Council should also:
1.  
2.  
3. remind its Adult Social Care staff and managers to only issue warning letters about a person’s or their representative’s behavior, or obstructions, if this is evidence and justified in the circumstances;
4. remind its Adult Social Care staff and Complaints Team to respond to stage two complaint requests within the timescales set out in the Council’s Complaints Policy. This includes sharing its decisions not to investigate complaints under stage two without delay.
77. The Council should provide us with evidence it has complied with the above actions.

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Final decision

78. There was fault which caused an injustice, the Council has agreed with my recommendations. It is on this basis I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman