Summary: Ms B complained that the Council, in respect of her late uncle Mr D failed to provide adequate care for him at home, failed to respond appropriately to signs of his cognitive decline and failed to properly carry out a best interests decision in respect of his finances. We have not found fault in the Council’s actions.

The complaint

1. Ms B complained that Manchester City Council (the Council) in respect of her late uncle, Mr D:
• failed to provide adequate care for him at his home;
• failed to pick up signs of increasing confusion and lack of capacity regarding his care needs; and
• failed to carry out the correct procedure for the best interest decision regarding his finances.
2. This has caused Ms B distress and uncertainty, particularly when she found him in a neglected state on 26 March 2024.

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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(i), as amended)

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How I considered this complaint

5. I considered evidence provided by Ms B and the Council as well as relevant law, policy and guidance.
6. 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

Mental capacity assessment

7. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves.
8. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:

• because they make an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

9. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
10. An assessment of someone’s capacity is specific to the decision to be made at a particular time.

Best interest decision making

11. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
12. If there is a conflict about what is in a person’s best interests, and all efforts to resolve the dispute have failed, the Court of Protection might need to decide what is in the person’s best interests

Intermediate Care and Reablement

13. Intermediate care and reablement support services are for people usually after they have left hospital or when they are at risk of having to go into hospital. They are time-limited and aim to help a person to preserve or regain the ability to live independently. The National Audit of Intermediate Care lists four types of intermediate care:

• crisis response – services providing short-term care (up to 48 hours);
• home-based intermediate care – services provided to people in their own homes by a team with different specialties but mainly health professionals such as nurses and therapists;
• bed-based intermediate care – services delivered away from home, for example in a community hospital; and
• reablement – services to help people live independently which are provided in the person’s own home by a team of mainly care and support professionals.

What happened

14. Mr D lived independently in his own home until December 2023 when his sister found him in a concerning state without any food. She took him to live with her over Christmas and contacted the adult social care team at the Council. Ms B is his niece: she had been very close to him but due to her own circumstances she had not seen him since May 2023.
15. Mr D returned to his home in early January 2024 and the Council arranged reablement care and an assessment to work out his care and support needs. Carers visited three times a day, supporting him with daily living tasks including nutrition, washing and personal hygiene.
16. During January his sister and carers raised concerns about Mr D not eating properly. Changes were made to his support plan, adding a lunchtime visit ensuring carers observed him eating or found clear evidence that he had eaten. Concerns were also raised about him leaving the door unlocked at night and not letting carers in, so a key safe was installed.
17. The Council’ social care assessor (SCA) felt Mr D was disoriented and confused at times. They arranged a home visit from the GP in mid-January 2024. The GP had no concerns about his memory or cognition but took a blood test to rule out other conditions and agreed to follow up a referral to the memory clinic. They also noted he had a cough.
18. Over the next few days Mr D’s confusion continued, and he developed problems with incontinence which had previously never been an issue. SCA arranged another GP home visit, and a social worker (SW) started a mental capacity assessment (MCA) of Mr D’s ability to manage his finances. The care provider also requested the crisis team come in to clean his house.
19. The GP prescribed some antibiotics for a possible chest infection and made another referral to the memory clinic due to his confusion. They did not consider he needed to go to hospital.
20. SW visited and noted Mr D seemed much better, particularly when a friend visited: he was alert and cogent throughout the visit. Over the next few days all those involved in his care felt Mr D was much better.
21. At the end of the month a memory clinic doctor visited but said Mr D was too quiet to carry out the assessment. They said they would return in a month’s time.
22. SW completed the MCA. She had carried out five visits with Mr D over three weeks, with SCA and another SW. She found that he was not able on any occasion to answer questions about his finances appropriately. She had also spoken to Mr D’s siblings, the care team and the GP. She concluded that Mr D did not have the capacity to manage his finances, and he should be referred to client financial team to manage them for him.
23. SW spoke to Ms B on 30 January 2024. She explained they had assessed Mr D as lacking capacity to manage his finances and would be referring him to client financial services. Ms B said he would want to stay in his own home as long as possible and if this meant someone else managing his finances that that would be fine. SW asked if Ms B wanted to be involved in any best interests meeting about Mr D. She said she would think about it as she had her own health concerns to consider.
24. SW also spoke to Mr D’s siblings who agreed he could not manage his finances, but felt Mr D had improved significantly with the reablement support.
25. In early February 2024 the Council completed a care act assessment and concluded Mr D needed the same level of care he had been receiving since January.
26. SW started the best interest process regarding Mr D’s finances. She spoke to Ms B on 5 February 2024 who said she was happy to give her views over the telephone. She said again that Mr D wanted to remain in his own home as long as possible and if having someone else manage his finances would facilitate this then he would want that.
27. SW visited Mr D. She explained what was going to happen with his finances and his care. He was happy with the arrangements for both. He said he wanted to stay at home rather than go into a care home. SW discussed options for social engagement such as a befriending service, but he declined the options given, saying he was happy at home.
28. SW also spoke to Mr D’s siblings who agreed that he could not manage his finances. She made the best interests decision on 15 February 2024 that she would refer Mr D to client financial services to manage his finances and ensure that the care package continued otherwise he would be at high risk of self-neglect.
29. SW spoke to the doctor who agreed the memory assessment could now go ahead as the infection had gone and no other conditions had been identified. They felt dementia was a possibility. At the end of February Mr D’s brother raised a safe-guarding concern about soiled bedding and a dirty toilet. The Council raised the issue with the Care Provider who said they would talk to the carer. In early March 2024 the Council checked with the Care Provider who said everything was fine with Mr D. There had been no incontinence, and they had no other concerns.
30. SW visited Mr D on 11 March 2024 and had no concerns about Mr D or the state of the property.
31. On 22 March 2024 Mr D’s sister said she felt Mr D needed 24 hour care. SW said that was a big decision to make but was under consideration.
32. On 26 March 2024 Mr D was found wandering outside in a confused state. Medical staff called Ms B as she was on his records as the next of kin. She went to Mr D’s house and waited with him until the ambulance arrived. She said the house was very dirty and smelled bad with faeces on the banister and toilet. She also said there was evidence of out of date food.
33. Mr D was admitted to hospital and Ms B raised a safeguarding concern about the care of Mr D. The Council opened a safeguarding enquiry and spoke to the Care Provider who started their own investigation. It also spoke to Ms B who was happy the Council would be managing Mr D’s finances. The hospital said Mr D had no infection, was eating well but was agitated and at high risk of wandering.
34. SW said she had been supporting Mr D for several months, had visited him regularly at home and put the package of care in place. She said the house had never smelt and no such issues were reported by the carers. She said colleagues who were doing his shopping also did not raise any concerns about the house. SW considered the care plan fully mitigated the risk of self-neglect. Mr D had regular medical check-ups and she was chasing his memory assessment.
35. The carers said that they regularly checked the house for signs of soiling and defrosted frozen meals for Mr D, hence the appearance that the food was out of date. One carer accepted they may not have checked Mr D’s hands for faeces on one occasion and apologised for this.
36. The Council concluded the safeguarding enquiry with no further action It was satisfied the risks to Mr D were mitigated as he was in hospital awaiting discharge to residential care. The Care Provider had recognised the need for more awareness around identifying cognitive deterioration. But all actions by the Care Provider were appropriate and effective with Mr D receiving appropriate care and actions were taken in Mr D’s best interest.
37. Ms B also complained to the Council about the poor care of Mr D and the lack of consultation over the decisions regarding his finances. The Council responded in early May 2024. It upheld the complaint about poor standards of cleanliness as the carer had admitted on the day Mr D was found wandering that they had not checked his hands or encouraged him to wash them before bed. It also apologised for the standards of cleanliness. With regard to domestic tasks not being satisfactory to Ms B, it said it was sourcing alternative agencies to improve this. It did not uphold the complaint about the capacity assessment or the referral to the court of protection as it considered the Council had followed the correct procedures and appropriately involved family members. It said nobody had offered to manage Mr D’s finances and no other friends had been mentioned. It did not uphold the complaint about leaving Mr D in an unsafe environment for too long. It said the social work team had visited Mr D over 20 times between January and March 2024 and family members including Ms B were consulted during this period along with Mr D. SW had been looking at socialisation options and arranging a further memory assessment.
38. Ms B escalated her complaint, raising specific concerns about the best interests decision-making, ignoring the fact Mr D clearly could not look after himself, the period prior to his wandering and the risk-mitigation, and the failure to ask family members if they wished to manage Mr D’s finances.
39. The Council responded to the complaint in early June. It did not uphold any of the elements. It said the Council provided Mr D with appropriate care and support first through reablement and then by a package of care. It noted concerns were raised at points about his ability to look after himself but they were addressed by changes to the support plan and consulting health professionals.
40. It noted Ms B had been consulted on the capacity decision and the management of his finances and that all parties, including Mr D, agreed he should stay at home. It said no family member had offered to take on the task of managing Mr D’s finances and so his case was referred to client financial services who ultimately applied to the Court of Protection for a solicitor to manage them.
41. It explained that Mr D had no history of wandering or falls prior to the incident in March 2024 and so there was no referral for a community alarm or tracking device .It accepted that there were signs of cognitive decline, but the picture was changeable and his safety was managed by the care and support he received, while waiting for a formal diagnosis from the memory service.
42. Ms B then complained to us. Before we started our investigation Mr D passed away.

Analysis

Care and support

43. I understand it must have been very distressing for Ms B to witness her uncle Mr D so confused and disoriented and his house in a state of apparent neglect. However, on the basis of the documents provided I have not found evidence of fault in the actions of the Council.
44. The Council acted promptly in December 2023 in response to his sister’s concerns, putting in place reablement care and assessing his care and support needs. When concerns were raised about his nutrition and continence, staff took steps to increase the visits and make other changes to the support plan to ensure he received appropriate support. There were no issues with the care visits and the social work team visited frequently and spoke to Mr D at length on many occasions. They arranged several GP visits and chased up the memory assessment.
45. It is evident that issues still arose around his personal care and the cleanliness of the house. Sometimes that was due to him refusing care or changing his mind about what he wanted. The chest infection in January was also a complicating factor as it exacerbated some of the concerns for a period of time. However, from the end of January 2024 all parties involved agreed that he was significantly better, engaging with friends and visitors and attending to his personal care needs to some degree.
46. One incident of soiled bedding and toilet at the end of February 2024 was dealt with promptly and appropriately. The Care Provider apologised for not checking the cleanliness of Mr D’s hands on one occasion just before the wandering incident. But overall, there is insufficient evidence to conclude that the care was inadequate.

Lack of capacity

47. SW started a MCA within two weeks of the reablement care starting as it was apparent Mr D was sometimes confused and disoriented. She took three weeks to complete this, visiting Mr D on five occasions. She involved Mr D’s siblings, his GP and the carers and concluded that he lacked capacity to manage his finances. All family members agreed with this, including Ms B. I do not find fault with this decision-making process.
48. In respect of his capacity to understand his care needs, SW and other people noted at times he was confused and disoriented and this was exacerbated when he had the infection. However, everyone was also in agreement that he improved significantly after the end of January and that he wanted to stay at home for as long as possible. SW was satisfied that the care package adequately supported him and mitigated any risks until the memory assessment as carried out. Further concerns were only raised shortly before he quickly deteriorated and was admitted to hospital. There were no signs of wandering prior to 26 March 2024. I have not found fault with the decision not to carry out a MCA in respect of his care needs.

Best interests decision

49. Records show that SW consulted Ms B and Mr D’s siblings regarding the question of who should manage Mr D’s finances. She explained she was referring the matter to client financial services to manage them on Mr D’s behalf. At no point did any family member question this, offer to do it themselves or suggest any other person who might be willing to do it. Ms B said it was the best thing to do if it meant Mr D could stay at home for longer. I do not find fault with the Council’s actions here.

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Decision

50. I find no fault.

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Investigator's decision on behalf of the Ombudsman