Summary: Ms B complained that the Council failed to properly assess and review her mother’s care plan, and the care plan and care provided did not meet her mother’s needs. The Council also failed to carry out a CHC checklist. We have found fault which led to an injustice. The Council has agreed to apologise, pay a financial remedy and carry out a service improvement.

The complaint

1. Ms B complains on behalf of her mother, Ms C, who lacks the mental capacity to make this complaint. Ms B’s complaint relates to events from February 2024 when Ms C received a package of care at home and the end of April 2024 when she was taken to hospital.
2. Ms B says the Council failed to properly review Ms C’s care plan, when her needs for care and support had changed and this meant the care provided no longer fully met Ms C’s needs. She also says the Council promised to carry out a CHC checklist but failed to do so.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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(1), as amended)

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What I have and have not investigated

5. Ms B complains about the district nurses’ management of Ms C’s pressure sores. Ms B also complained that two morphine patches had fallen off which were administered by the nurses.
6. The district nurses were employed by the NHS. The Local Government and Social Care Ombudsman cannot investigate complaints against the NHS as the Parliamentary and Health Service Ombudsman investigates complaints against the NHS so I have not investigated the complaints about the nurses’ management of the pressure sores or the morphine patches.

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How I considered this complaint

7. I have discussed the complaint with Ms B and I have considered the evidence that she and the Council have sent well as relevant law, policy and guidance.
8. Ms B and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

9. The Care Act 2014, the Care and the Support Statutory Guidance 2014 set out the Council’s duties towards adults who require care and support. The Council also has its own policies.

Assessment and care plans

10. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs.

Eligibility

11. 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. 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

12. 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, education or
• Making use of necessary facilities or services in the local community
• Carrying out caring responsibilities for a child.

Review of the care plan

13. Councils should review care plans at least once a year. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.
14. The CASS Guidance also says:
• If there is any information or evidence that suggests that circumstances have changed in a way that may affect the efficacy, appropriateness or content of the plan, then the local authority should immediately conduct a review to ascertain whether the plan requires revision.
• The review should be performed as quickly as is reasonably practicable. As with care and support planning, it is expected that in most cases the revision of the plan should be completed in a timely manner proportionate to the needs to be met. Where there is an urgent need to intervene, local authorities should consider implementing interim packages to urgently meet needs while the plan is revised.

NHS Continuing Healthcare (CHC)

15. NHS CHC is a package of ongoing care arranged and funded solely by the NHS where the individual has been found to have a ‘primary health need’.
16. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. The threshold for meeting the CHC Checklist is set low.
17. If the completed CHC Checklist indicates the person may be eligible for CHC, the next step is a full multidisciplinary assessment. This assessment is completed using a decision support tool (DST).
18. If, after a full multidisciplinary assessment and DST, a person disagrees with the Integrated Care Board’s (ICB) decision that they are not eligible for CHC or nursing care, they can ask the ICB to review its decision. If they disagree with the outcome of the review, they can appeal to an Independent Review Panel (IRP) organised by NHS England. The third stage is to refer the case to the Parliamentary and Health Service Ombudsman for independent investigation.

What happened

19. Ms C is an older woman who was living at home at the time of the complaint. Ms C had decreased mobility and dementia. She lived alone at home and received a care package of four visits a day.
20. Ms C’s care plan was reviewed on 26 July 2023 following a hospital admission because of a fall. The plan said the following:
• Ms C had been able to mobilise (walk) on her own with a frame and make her breakfast. Her mobility was now reduced (after the fall) and the care worker should support her when she was mobilising with her frame.
• The care package was increased to support Ms C in transfers from bed/chair/toilet/commode.
21. Ms C’s care plan recommended that that one care worker visited Ms C to provide support with medication, washing and dressing, toileting and preparing meals. The plan was:
• Morning – 1 hour
• Lunch time – 1 hour
• Tea time – 45 minutes
• Bedtime – 45 minutes
• In addition, Ms C received 1.5 hours weekly support for laundry and housework.
• Total hours per week was 26 hours.
22. On 29 November 2023 the ambulance team (who had attended following a fall) made a referral to the Council asking for a review of Ms C’s care plan as she may need a care home placement. A referral was made for an occupational therapist (OT) to reassess Ms C.

OT’s assessment – 5 January 2024

23. The OT reassessed Ms C on 5 January 2024 and said:
• Ms C had a standard bed and the OT recommended an adjustable floor bed and crash mats.
• Ms C used a Zimmer frame for walking/mobilising.
• Ms C needed assistance for transfers/mobility with the Zimmer frame as she did not remember to use the Zimmer frame. Between care calls, Ms C would mobilise without her Zimmer frame and would ‘furniture walk’ (use the furniture to hold on to).
• Ms B said Ms C had 20 falls in the last 6 months and the carer’s reports said Ms C had a fall every 2 weeks. The falls usually happened in between care calls when Ms C was walking without her Zimmer frame. The ambulance service records showed Ms C had 3 falls since 17 November 2023.
• Ms C was incontinent of urine and occasionally of faeces.
24. The OT concluded that Ms C was at a ‘very high falls risk’ when not supervised and between care calls. The OT recommended that Ms C’s care plan should be reviewed and a move to an environment with increased supervision to reduce the risk of falls should be considered.
25. Ms C’s new bed was delivered on 16 January 2024.
26. The Council reviewed Ms C’s needs on 27 February. The social worker involved Ms B’s main care worker, the Agency, the OT and Ms B in the assessment.
27. The social worker noted that there had been a decrease in Ms C’s mobility. Ms C’s care worker said Ms C’s care needs changed in December. Ms C now needed support to get in and out of bed, she had to be supervised to walk and the care worker often had to feed her.
28. The social worker noted that Ms C mobilised very slowly with a Zimmer frame and had great difficulty walking from one room to another. She had tissue injury on her heal and on the base of her spine. She was being treated with antibiotics and the district nurses were visiting.
29. Ms B was opposed to the OT’s recommendations of the low bed and crash mat. This was partly because there was a problem with the shower in the wetroom and a risk of flooding. Ms C was waiting for the housing association to fix the problem. Ms B felt that Ms C’s bed should be raised and Ms C should be moved by hoist.
30. Ms B asked for extra support in toileting for Ms C and said this should be ‘on call’. The social worker said that would not be practical as it was not known when Ms C would use the toilet.
31. The social worker offered moving Ms C to extra supported living but Ms B declined this as she said Ms C would not eat the meals the supported living placement offered. The social worker also offered residential care but Ms B also declined this offer as she felt Ms C would not fit in with the routine of a care home.
32. The plan was for the social worker to assess whether Ms C had the mental capacity to decide where she wanted to live. The Council would also carry out the CHC checklist as some of Ms C’s needs may be health related.
33. The social worker emailed Ms B on 11 March 2024 and attached a copy of the NHS CHC checklist, the public information leaflet and the consent form. The social worker said it was 'for you to look over before we book the telephone appointment for us to complete it.'
34. The OT emailed the social worker on 15 March as she said Ms B planned to buy a hoist privately. The OT had not recommended a hoist and had explained this to Ms B. The OT said she was concerned whether Ms C was receiving the appropriate care with her deteriorating function and cognition, and said the main issues related to social care. She asked that a professionals’ meeting be organised to agree the way forward.
35. The social worker emailed the other professionals involved with Ms C on the same day and said she was planning to complete a CHC checklist with Ms C but she wanted to know the professionals’ view on whether Ms C had the mental capacity to complete this form.
36. The social worker organised an appointment with Ms B on 26 March 2024 to carry out the CHC checklist but then cancelled this on 26 March and said: ‘The meeting was supposed to be this morning, but on reflection it is better for your mother to have an opportunity to voice her opinions for the checklist. The meeting for today is now cancelled and I will call you later to arrange another time and date.’
37. On 2 April 2024 Ms B emailed the multi-agency team (managing Ms C’s care) and copied in the Council. She said she wanted a different OT. She said 999 was being called daily. She said Ms B needed a hoist, drag sheets and bedrails, but the OT had refused this. She said care workers were refusing to attend and Ms C needed two care workers to meet her needs.
38. The multi-agency team chased the Council on 2 April 2024 for a date of the professionals’ meeting so that a care plan could be formulated for Ms C.
39. The agency’s manager visited Ms C on 4 April 2024 as care workers had said that Ms C was now being cared for entirely in bed (‘bedbound’) and this was putting a strain on them. The Agency noted the following:
• Ms C was unable to sit on the edge of the bed independently.
• All personal care was provided in bed. Two care workers were needed to provide personal care.
• There were no slide sheets in the flat. Ms C was sliding down the bed which led to her legs being squashed against the bed board and care workers could not leave her in that position.
• The Council needed to urgently approve two care workers per visit.
• An urgent OT assessment was needed.
40. The social worker visited Ms C on 4 April. The purpose of the visit was to obtain Ms C’s views about the CHC checklist and to see if she could understand the process and wanted to participate in it. The outcome of the visit was that Ms C gave consent that Ms B could complete the checklist on her behalf. The social worker said she would contact Ms B on a later date to complete the checklist.
41. The OT assessed Ms C on 4 April and sent an email to the social worker with an updated assessment. She said Ms C was at very high risk of falls between calls and the Council should consider increasing her care package to double handed care (two care workers) at each visit and move Ms C to an environment with increased supervision.
42. The multi-disciplinary professionals’ meeting to agree Ms C’s care plan was due to take place on 9 April, but the social worker sent an email to the professionals on 8 April to cancel the meeting as Ms C’s case would be reallocated to another social worker. The new social worker would also carry out the CHC checklist.
43. The social worker emailed the internal funding panel asking for urgent approval to fund double handed care for Ms C. The social worker said the care workers were ‘under severe strain and many carers had refused to return.’ Mrs C had a UTI and pressure sores. There was a risk that the Agency would decline the care package.
44. The Council approved extra funding for a second care worker on 9 April 2024, but the Council reduced the length of the first two visits of the day and only paid for a short visit (30 minutes) for the second care worker.
45. So the plan was:
• Morning – 45 minutes and 30 minutes
• Lunch time – 45 minutes and 30 minutes
• Tea-time – 45 minutes and 30 minutes
• Bedtime – 45 minutes and 30 minutes
• Ms C continued to receive 1.5 hours weekly support for laundry and housework.
• The total hours per week was increased from 26 hours to 36.5 hours.
46. On 12 April 2024 the OT’s recommendations were as follows:
• Ms C should be cared for in bed as there was insufficient time to carry out transfers with hoists.
• Ensure Ms C was sat up as much as possible in bed for her meals and take time with feeding tasks to reduce risk of aspiration/choking.
• Ms C should remain on the floor bed with crash mats between care calls as she was at risk of slipping from the bed.
• Heel protection boots to be worn in bed.
• Double handed repositioning with slide sheets during each call.
47. The OT would visit again next week and a referral would be made to the speech and language therapist.
48. The Agency emailed the Council on 17 April and asked for the doublehanded care to be increased so that both care workers stayed for the full time of the visit as there was not enough time for care workers to provide the care Ms C needed. There was also increasing disagreement between Ms B and the Agency about Ms C’s care plan. Ms B had bought a hoist and sensor mat for Ms C but the Agency said this had not been recommended by the OT and the staff had not been trained on how to use the equipment safely for Ms C.
49. The OT had said that one of the reasons a hoist could not be used was that the room was too small for a hoist. Also, Ms C said the company delivering the mat had told her to place the mat on the mattress, but the Agency was concerned about that advice as Ms C’s mattress was a pressure relief mattress and it was not clear whether this mat could be used in combination with a pressure relief mattress.
50. Ms B called an ambulance for Ms C on 28 April 2024. Ms C did not return home and eventually was admitted to a hospital outside of Haringey (Council 2).
51. On 9 May 2024 the hospital’s Community Healthcare team made a referral to Haringey Council as Ms C was ready for discharge from hospital. Haringey’s OT was consulted on the proposed discharge plan.
52. The OT said:
• Ms C had a ‘QDS (four visits a day) double handed package of care but was not managing in between care calls. The care calls were not sufficient as they only had 30 minutes which was not enough time to support with transfers, washing and dressing and meals’.
• ‘…patient needs placement as care calls are not sufficient and patient was not managing at home. She reports the patient had some falls at home in between care calls so would benefit from 24/7 care.’
53. The Council reviewed Ms C’s care plan on 8 June 2024, but the care plan remained unchanged.
54. Ms C was eventually discharged into a care home into Council 2’s area.

Agency’s records

55. The Agency’s care plan for Ms C said Ms C should be offered personal care (changing her continence and providing a wash) in bed by two care workers. Ms C’s continence pad had to be checked at each visit and changed when necessary. The care workers also provided support in nutrition. The district nurses were visiting three times a week to support with pressure care. The care workers should check Ms C’s skin and report any deterioration of the skin. They should also apply a barrier cream when needed.
56. The case notes for the two weeks prior to Ms C being admitted to hospital showed that the care workers offered or provided Ms C with a strip wash in her bed several times a day and they offered or provided a change of continence pad at each visit. They applied the barrier cream. There were several times in the records when the care workers noted that the allocated time to provide care to Ms C was not enough and they had to stay longer than the allocated time to finish the care provision.

Ms B’s complaint – March 2024

57. Ms B complained to the Council (via the Ombudsman) on 11 March 2024. Ms B said:
• The Council had failed to review and amend Ms C's care plan at the yearly review and her needs were not being met.
• The Council had not provided Ms C with the grab rails and equipment that she needed, which meant she was ‘bedbound’, depressed and sleeping on the floor. A hoist had been declined by the Council.
• The care provided by the Agency did not meet Ms C’s needs and the Agency should have been allocated more hours to care for her.
• The Council failed to carry out a CHC checklist even though this had been agreed at the assessment in February 2024.
• Morphine patches supplied by the district nurse had gone missing.

The Council’s response – May 2024

58. The Council responded to Ms B’s complaint on 7 May 2024. I have summarised the Council’s response to Ms B and to the Ombudsman. The Council said:
• In its response to Ms B, the Council said that it was regrettable that the care plan did not meet her expectations and apologised for this. The team had been asked to proactively endeavour to rectify the situation. The social worker would contact Ms B to undertake a comprehensive review of Ms C’s needs and explore the possibility of moving to another care provider if this was deemed necessary.
• In its response to the Ombudsman the Council said it had reviewed Ms C’s needs in in July 2023, February 24 and then June 24. The Council said this reflected the Council's ongoing involvement in assessing and reviewing Ms C's needs.
• In terms of the OT assessment and the disagreement about how Ms C’s needs should be met, the Council said that OT had told the Council on 12 April 2024 that the allocated time was not sufficient to carry out a hoist transfer and therefore Ms C should be cared for in bed. The Council said that the continued involvement of the OT showed that the Council was reviewing Ms C’s needs and her needs were being met.
• In response to the complaint about the CHC checklist, the Council said the social worker emailed Ms B the consent form and the public information leaflet to ensure informed participation in the process. Unfortunately, Ms B did not return the consent form and therefore the checklist could not be completed. The social worker told the family that the case would be reallocated to a different social work and she and they would complete the CHC checklist, but this was not done because the consent form was not returned signed.
• The Council said this demonstrated that it had taken steps to initiate the process of the CHC checklist but was unable to proceed without the required consent from Ms B.

Analysis

59. It is not the Ombudsman’s role to say what Ms C’s care plan should be or to carry out an assessment. I have only considered whether there was any fault in the way the Council carried out its functions.
60. Ms B’s main complaint was that that the Council failed to properly assess and review Ms C’s needs and that her care plan did not meet her needs.
61. I note that, in its response dated 7 May 2024, the Council appears to uphold this complaint and apologised to Ms B. The Council offered Ms C a comprehensive review of her needs. The Council took a different position in its response to the Ombudsman. In my view there was some fault in the Council’s assessments and reviews from February 2024 onwards.
62. I note good practice in the February 2024 assessment as the social worker involved Ms B, the OT and the care agency in the review. Ms C's needs had changed considerably since the last review in July 2023. Ms C could no longer move out of bed or walk/mobilise without support. In addition, Ms C was at high risk of falls if she tried to mobilise between visits so the decision was made that Ms C should not leave her bed unless supervised.
63. I note that the OT recommended, on 5 January 2024 that that the Council should move Ms C to an environment with higher supervision.
64. The Council offered Ms C a move to a care home during the assessment in February 2024 but this was declined. So, there was an indication that the Council thought that 24/7 supervision in a care home may better meet Ms C’s needs.
65. There were increasing problems in the weeks and months following February 2024 and an urgent review of Ms C’s needs was needed from mid-March 2024 onwards as the care plan was not fully meeting her needs. I am of the view there was fault in the Council's failure to review the care plan during that time.
66. I note that the other professionals involved with Ms C, namely the multi-agency team and the OT asked the Council to carry out a multidisciplinary meeting so that the care plan for Ms C could be agreed. I also note that the Agency said on 4 April 2024 that the current plan was no longer sustainable.
67. The multi-disciplinary meeting had been agreed for 9 April 2024 but the Council cancelled this at the last moment. That was a missed opportunity. There was fault in the continued delay to carry out the review and formulate the care plan. The multi-disciplinary meeting did not take place and neither did the review even though by then the matter had become urgent as Ms C needed double handed care immediately, as advised by the OT and requested by the Agency.
68. I accept that the Council agreed an increase in the care package on 9 April, but I note that the Council decided to decrease the length of the morning and lunch visits and did not allow the second care worker to stay for the same time as the first care worker. As there was no review assessment or care plan, there is no explanation on how the Council came to this decision and this was further fault.
69. The Agency noted repeatedly that the length of visits was not long enough for the Agency to meet Ms C’s needs and care workers were often staying longer. I also note the OT's comments on 9 May 2024 that that the care plan had not met Ms C’s needs before she went to hospital as the Council had only allowed 30 minutes to provide the care.
70. So therefore overall I uphold the complaint that Ms C’s care had not been properly reviewed in the weeks before she was taken to hospital. Ms C suffered an injustice as a result as it meant that it was not certain whether the care plan met her needs fully. Ms B also suffered an injustice having to witness the problems with Ms C’s care and trying to resolve the problems with the Council and the Agency.
71. There was further fault in the care plan dated 8 June 2024. This care plan appears to be a cut and paste of the care plan from February 2024. There does not seem to have been any consideration of the changes in Ms C’s needs or the fact that the existing care plan had not met her needs in the weeks before she was admitted to hospital. Ms C’s needs had increased significantly and the hospital team and the OT were of the view that her needs could only be met in a care home.
72. I have also considered the related complaint that the Council failed to provide the correct equipment to meet Ms C’s needs and that the Agency was not providing the care that Ms C needed.
73. There was a continued disagreement after the review in February 2024 between the OT and Ms B on how Ms C’s care should be managed. Ms B wanted Ms C to be hoisted into a reclining chair and wanted bed rails. The OT said Ms C should be cared for in bed, on the lowest setting with crash mats by her side so that, if she fell out of bed, she did not hurt herself.
74. The Council and the Agency followed the OT’s advice and I find no fault in that respect. The OT was the appropriate professional to advise on moving and handling Ms C and ensuring her safety. But I understand Ms B’s point which was that, if the care plan had included extra hours, there would have been time for Ms C to be hoisted and to sit in her reclining chair while supervised. As it was, Ms C’s quality of life and wellbeing were reduced as she was in bed all day.
75. In terms of the delay of the CHC checklist, I uphold Ms B’s complaint that the Council failed to carry out the checklist and this was fault. I do not agree with the Council's claim that the failure to carry out the CHC checklist was Ms B’s fault for not returning a signed consent form. The Council sent the consent form to Ms B on 11 March 2024 but it did not ask her to sign the form or ask Ms C to sign the form. The Council also never chased Ms B for this form.
76. There was no expectation for Ms B to sign the form and I do not agree that the lack of signature was the reason for the delay. It appears to me the Council initially planned to carry out the CHC checklist on 26 March 2024 but then realised it had not assessed Ms C’s mental capacity in relation to the CHC checklist so it cancelled the appointment at the last minute. The social worker then visited Ms C and planned to carry out the CHC checklist after her visit to Ms C on 4 April 2024 but Ms C’s case was then reallocated to another social worker and no further action was taken regarding the CHC checklist. That appears to me to be the main reason why the CHC checklist was not carried out.

Remedy

77. The aim of the Ombudsman’s remedy is to put the complainant in the position they would have been if the fault had not happened. Unfortunately, that cannot be achieved in Ms C’s case.
78. In a complaint such as this one, where there has not been a direct financial injustice, the Ombudsman can recommend a small financial symbolic remedy and I recommend the Council pays Ms C and Ms B £250 each.
79. I also recommend the Council reminds relevant staff of the importance to review the care plan urgently when the care needs have changed.

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Action

80. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Ms B and Ms C in writing.
• Pay Ms B and Ms C £250 each.
• Remind relevant staff of the Council’s duty to carry out a review of a person’s care plan in a timely manner if their needs for care and support have changed. It will provide training or guidance as needed.
81. The Council should provide us with evidence it has complied with the above actions.

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Decision

82. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman