Summary: Ms X complained about the Council’s failure to provide appropriate care and support to her and her father Mr Y. The Council was at fault for delays in investigating safeguarding concerns, not carrying out a formal carer’s assessments or progressing Ms X’s request for direct payments and for delays in finding a suitable care home for Mr Y. As a result Ms X was caused significant distress and uncertainty. The Council has agreed to apologise, to make a payment to Ms X and to carry out service improvements to prevent a recurrence of the faults.

The complaint

1. Ms X complained the Council:
1. failed to properly assess her father, Mr Y’s, care needs;
2. failed to put care in place for Mr Y that was suitable for his needs; and
3. failed to provide adequate support to relieve Ms X’s caring duties when she was caring for Mr Y in her home, overcrowded and experiencing carer stress.
2. Ms X said the Council’s failings have caused her and her father to experience distress and Mr Y to experience poor care.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
4. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by an organisation to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), 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. I have considered the information provided by Ms X. I have considered the information the Council provided in response to our enquiries and the relevant law and guidance.
7. I gave Ms X and the Council the opportunity to comment on the draft decision. I considered any comments I received in reaching a final decision.

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What I found

Relevant law and guidance

Needs assessments

8. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
9. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

Direct payments

10. Direct payments are monetary payments made to individuals who ask for them to meet some or all of their eligible care and support needs. They enable people to arrange their own care and support to meet those needs. The council must ensure people have relevant and timely information about direct payments so they can decide whether to request them. If they do so, the council should support them to use and manage the payment properly.
11. After considering the suitability of the person requesting direct payments against the conditions in the Care Act 2014, the council must decide whether to provide a direct payment. In all cases, the council should consider the request as quickly as possible.

Carer’s Assessment

12. Where somebody provides or intends to provide care for another adult and it appears the carer may have any needs for support, the council must carry out a carer’s assessment. A carer’s assessment 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.
13. As part of the carer’s assessment, the council must consider the carer’s potential future needs for support. It must also consider whether the carer is, and will continue to be, able and willing to care for the adult needing care. (Care and Support Statutory Guidance 2014)

The CQC fundamental standards

14. CQC is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of the fundamental standards and prosecute offences.
15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. This includes that providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

Safeguarding

16. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.

What happened

17. In May 2022 Ms X contacted the Council for adult social care support for Mr Y. An officer telephoned Ms X who explained Mr Y had dementia, he lived with her and her child. The officer noted Ms X said Mr Y was unable to do anything for himself. He required support with showering and maintaining his continence and was disorientated when he went out. The notes record Ms X said she was close to breaking down completely. The officer explained the process and that Mr Y would need a needs assessment and a best interests meeting would be necessary as Mr Y did not have capacity to make decisions about his own health and welfare. The officer advised her about contacting the carers information service. The officer made a referral for a needs assessment.
18. A social worker called Ms X later that same day. They noted Ms X felt Mr Y needed 24 hour care. The social worker explained there was a waiting list for assessments but agreed to ask the GP to assess Mr Y and to refer him to the community mental health team. They noted Ms X declined the offer of a home care package in the meantime and said she would manage until he was assessed for a placement.
19. The social worker contacted Ms X in June 2022. Ms X confirmed the GP was now involved and they were managing.
20. In early July 2022 Ms X called the Council. She said her child had an accident and needed support, so Ms X said she was no longer able to care for Mr Y. She said she could manage a few more days but needed urgent respite and potentially the placement to become permanent. The officer discussed having a care package while it arranged a placement, but Ms X declined and said the house was too small to have carers and Mr Y needed 24 hour supervision as he did not sleep. Ms X advised Mr Y was safe and not at immediate risk but she could not cope longer than a few days.
21. The next day the Council allocated a social worker who carried out an initial assessment. They noted Mr Y required 24 hour support, the property was over occupied and not suitable to meet his needs. They noted Mr Y required a temporary placement. They noted Ms X’s right to a carer’s assessment. The Council sought to find a care home placement.

Stay at care home 1

22. In late July 2022 Mr Y was admitted to care home 1 which is registered as a residential home for older people including those with dementia. Care home 1 completed a care plan which recorded Mr Y had dementia, was very confused at times and his behaviour could be quite challenging. It noted Mr Y’s continence needs and that he required prompting and support to use the bathroom regularly.
23. Six weeks later, in early September 2022, Ms X contacted the Council to raise a safeguarding issue. She said the social worker had not been in contact with her or Mr Y. She said she visited Mr Y and he had bruises on his arms and the staff could not tell her how that had happened. She said Mr Y had deteriorated since being in care home 1. She said staff reported Mr Y was aggressive and had sent her distressing video footage of Mr Y behaving aggressively. I have not seen this footage. She reported Mr Y smelled of urine as did the home. Ms X said she believed Mr Y was not being taken to the toilet as he appeared constipated and staff had not noticed. She said she felt social services and the care home had let Mr Y down.
24. The Council spoke with the care home manager who followed this up with an email. The manager said Mr Y was confused and aggressive to staff and could get confused about his continence, urinating in inappropriate places. The care home manager said Ms X had visited and was rude to staff and told them she was taking Mr Y home due to issues. They said Ms X complained Mr Y was wet prior to her visit. Staff denied this. The care workers confirmed they had noticed the bruises but had failed to inform Ms X. The manager said they had apologised to Ms X for this. The manager said they had referred Mr Y to the care home intervention team regarding his mental health and to the incontinence team.
25. The manager reported that Ms X had visited Mr Y and told a staff member Mr Y and his room smelt of urine. The staff member said Ms X accused staff of not caring properly for Mr Y. Ms X left a note that she was removing Mr Y from the care home due to safeguarding concerns. The care home manager said they had contacted Ms X who confirmed she had removed Mr Y from the care home.
26. An entry on Mr Y’s care plan, a couple of days before Ms X’s visit, noted Mr Y had some bruising/discolouration on his arms and that a body map was in place. There are no records to show Mr Y behaved aggressively or any behaviour charts. The daily activity charts provide no details beyond indicating Mr Y was either sleeping, eating, wandering or resting. The care home has advised us that it cannot access any safeguarding/complaints records it may have had due to a change in computer systems.

Care and support after the care home stay

27. The social worker visited Mr Y and Ms X at home and carried out a review of Mr Y’s needs. They noted Ms X requested direct payments support so she could provide 24 hour care and support to Mr Y in her own home. The social worker noted Ms X said the extended family would also support Mr Y while waiting for direct payments or an appropriate level of care to be put in place. The Council sent Ms X a financial assessment form which she completed and returned mid September 2022. The Council wrote to Ms X with the outcome of the financial assessment for a care home placement in early October 2022.
28. In late December 2022 Ms X called the Council to report she could no longer cope with Mr Y and she wanted a placement for him. A duty officer called Ms X who said Mr Y’s behaviour had become challenging and she was unable to manage supporting him at home. The officer agreed to forward a copy of the care directory to Ms X listing the care homes in the area. The officer asked if she required an emergency care package to support her with her father but Ms X declined this as Mr Y did not like strangers supporting him and this would confuse him. The officer also agreed to forward her information to the carers support centre so she could contact them for her own assessment. The officer agreed to update the allocated social worker. The officer advised her to contact the Council again if she required emergency support in the interim.
29. Ms X complained to the Council about the lack of support and that she never received any feedback on the safeguarding concern she raised about the care at the care home. She complained the social worker had visited but nothing had been put in place to make caring more manageable for her and that she needed help.
30. In mid January 2023 Ms X contacted the Council again to request a new placement for Mr Y.
31. The Council responded to Ms X’s complaint in February 2023. It noted the Council has recognised the need for a care home placement and arranged this in July 2023. Ms X had concerns about the care provided and took Mr Y home. The concerns were noted by the social worker who responded to Ms X about them in September 2022. It noted a review of Mr Y’s needs was planned as was an alternative residential dementia placement.
32. The social worker called Ms X in early February. Ms X was upset and felt she had been left to care for Mr Y on her own. Ms X reported Mr Y had been assessed by the mental health team and prescribed medication to calm him down. She said his incontinence was getting worse and his speech was mumbled. Ms X asked about a carer’s assessment. The social worker said Ms X’s needs were considered in the assessment carried out in September 2022. They discussed care options going forward. Ms X named two residential dementia care homes she would prefer and said she was willing to wait for her preferences to become available. Ms X agreed to accept emergency home care support in the meantime. This consisted of two calls a day of 45 minutes at lunchtime and 30 minutes in the evening. The social worker updated Mr Y’s needs assessment to reflect that Mr Y needed 24 hour care with support for dementia.
33. In February 2023 the social worker completed a safeguarding record. This noted Ms X took Mr Y home with care to be provided by direct payment once a financial assessment was completed. They noted daily care visits were arranged in February 2023 and that they were exploring an alternative placement.
34. In mid February 2023 Ms X cancelled the emergency care package. The records note she confirmed she was able to meet Mr Y’s needs.
35. The social worker spoke to Ms X in early March when she agreed for the care home search to be widened.
36. In March 2023 the social worker spoke with a manager from the safeguarding team. They noted:
• The safeguarding was followed up at the time but not properly recorded.
• Mr Y had only been at the placement six weeks so it was likely he had not yet settled there and his dementia may have progressed further at the time.
• Appropriate steps were taken to safeguard Mr Y.
• Staff may need more training around client’s living with dementia and the care home should be referred to the Council’s Quality Assurance Team for support around staff training.
37. Following this the social worker referred the safeguarding concern to the Council’s Quality Assurance Team.
38. Ms X contacted the Council in early April as Mr Y’s behaviour was becoming more challenging. She confirmed she did not want the home care package restarting. She had looked for a care home placement but could not find anything within budget. Ms X contacted the Council again in late April asking about progress on finding a care home placement.
39. In May 2023 a third party raised a concern with the Council that Ms X was struggling to cope with Mr Y’s needs. This noted Ms X would ideally like to keep Mr Y at home with a suitable package of care.
40. In June 2023 care home 2 agreed to assess Mr Y. The notes recorded the officer had contacted nine other care home who had no places or had refused to assess Mr Y. In July 2023 the social worker notified Ms X of this potential placement so she could view it. Mr Y moved into care home 2 later that month.

Findings

41. The Council allocated a social worker and carried out an initial assessment of Mr Y’s care needs within two months of Ms X’s request for support. This is in line with the timescale of six to eight weeks which we would normally expect. The assessment acknowledged the impact of Mr Y’s care on Ms X as a carer. The Council offered Ms X emergency care and support whilst it arranged a care home placement which Ms X declined. The Council was not at fault for the way it carried out the assessment.

Stay at care home 1

42. The Council identified a place for Mr Y at care home 1 which is registered as a residential home for older people and those with dementia. The Council was therefore not at fault for identifying this as a suitable care home for Mr Y in the first instance. Mr Y was in the care home for six weeks. The Care and Support Statutory Guidance suggests a review should be carried out six to eight weeks after a care plan has started, so the Council was not at fault for not carrying out a review sooner. There is no evidence Ms X raised any earlier concerns with the Council which would have prompted an early review.
43. Six weeks into Mr Y’s stay Ms X raised safeguarding concerns about Mr Y’s care. This included a failure to advise her about bruises he had, concerns about the way the care home was dealing with Mr Y’s continence and its reports that Mr Y was aggressive.
44. Ms X removed Mr Y from the care home which meant he was safe from any risk of harm. The social worker acted appropriately by speaking with the provider and by conducting a review of Mr Y’s care needs. However, the Council delayed properly recording the safeguarding and following up the concerns. This meant there was a delay in considering whether the concerns raised may have impacted others at the care home.
45. When it did consider the concerns, in February 2023, it acted appropriately and referred the care home to the Council’s Quality Assurance Team to consider if further staff training was required.
46. Ms X raised concerns about bruising on Mr Y’s arms. The care provider had acted appropriately when it noticed the bruising and had recorded this and completed a body map. However, it acknowledged it failed to advise Ms X of the bruising. This was fault. It has already apologised to her for this which was appropriate.
47. The care provider also reported Mr Y behaved aggressively. However, it kept no notes/records of Mr Y’s behaviour and did not complete behaviour charts. This is fault and causes uncertainty over what happened and the extent of Mr Y’s behaviour. In addition, due to a change in its computer systems, the care provider says it cannot provide any records about how it responded to Ms X’s safeguarding concerns. This is fault and not in line with the CQC fundamental standards regarding record keeping. This leaves a sense of uncertainty over whether it has addressed Ms X's concerns appropriately.
48. Ms X raised concerns about Mr Y’s continence care but that is not sufficient to say the care provider did not manage Mr Y’s continence properly. This is because the care provider had also raised its concerns with the social worker about Mr Y’s continence and had referred Mr Y to the incontinence team and mental health team.

Care and support following the care home stay

49. The Council reviewed Mr Y’s care needs following the care home stay. The assessment in early September noted Ms X requested direct payments to manage Mr Y’s care at home. However, there are no records to show the Council took any further action to progress this with Ms X or to explain how direct payments could be used. This is fault. I cannot say with any certainty that Ms X would have progressed with direct payments or whether they would have been used successfully to support Mr Y but this leaves Ms X with a sense of uncertainty over whether some appropriate support may have been provided sooner.
50. Ms X contacted the Council again in late December 2022 as she was struggling to cope with Mr Y’s care and in early February 2023 the Council carried out a review. Ms X had identified two care homes she wanted Mr Y to be considered for and agreed to go on the waiting list. In March Ms X agreed to extend the search to other care homes. However, it was not until five months later the Council found Mr Y a care home place. The Ombudsman can make findings of fault where there is a failure to provide a service, regardless of the reasons for that service failure. The records show it tried a number of providers but they were not willing or able to take Mr Y. However the delay was service failure and is fault. The delay between March and July caused Ms X distress as she had to continue to meet Mr Y’s care needs in the meantime. The Council did provide a care package to support Mr Y whilst it sought a care home place but Ms X cancelled this due to overcrowding in the house and Mr Y not responding well to strangers.
51. The records show the Council referred Ms X to the carer’s support network for support in her role as a carer. Mr Y’s needs assessments and reviews did acknowledge and take into consideration the impact of caring for Mr Y. However, there is no record the Council completed a separate carer’s assessment for Ms X which would have considered if there was any additional support Ms X herself required. This is fault and causes uncertainty over whether any additional support may have been available for Ms X.

Injustice

52. Ms X was unhappy with the care Mr Y received at the care home and there is evidence of fault in the care provider’s record keeping. However, I cannot say with any certainty, based on the evidence available that Mr Y received poor care. When Mr Y lived with Ms X, she sought to meet Mr Y’s care needs. I therefore cannot say the faults have caused him an injustice.
53. However, the faults caused Ms X distress and uncertainty and meant she had the added strain of providing care to Mr Y without support for longer than she should have.

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Agreed action

54. Within one month of the final decision, the Council has agreed to apologise to Ms X and pay her £750 to acknowledge the distress and uncertainty caused by the failure to follow up her request for direct payments, the failure to complete a carer’s assessment and the delay in finding a care home for Mr Y.
55. Within two months of the final decision, the Council has agreed to:
1. Provide evidence of the action taken by the Quality Assurance Team to follow up Ms X’s concerns about the care home.
2. Remind relevant officers of the need to:
1. Properly record safeguarding concerns in a timely manner.
2. Offer a separate formal carer’s assessment to those providing care and support to an adult whose needs they have assessed.
3. Follow up any requests for direct payments to ensure these are progressed in a timely manner.
56. The Council should provide us with evidence it has complied with the above actions.

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Final decision

57. I have completed my investigation. The Council was at fault causing injustice which it has agreed to remedy. It has also agreed to make service improvements to prevent a recurrence of the faults.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman