Summary: Mrs X complained that the Council’s delay in referring her mother for Continuing Healthcare (CHC) funding cost her some months of care home charges as well as a private assessment fee. The evidence shows the Council was not responsible for the costs incurred by Mrs X.

The complaint

1. Mrs X (as I shall call her) complains that a delay by the Council in assessing her mother for NHS CHC funding caused her to spend £9000 engaging a private company to carry out the assessment and delayed the implementation of the funding until June 2024. She says the Council should reimburse the agency fee and pay the care home charges back to the beginning of 2024.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
5. Mrs X 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

Relevant law and background

6. Where it appears a person may be eligible for NHS Continuing Healthcare (NHS CHC), councils must notify the relevant integrated care system (ICS). 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’ as set out in the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care.
7. NHS-Funded Nursing Care (FNC) is the funding provided by the NHS to care homes providing nursing, to support the cost of nursing care delivered by registered nurses. If a person does not qualify for NHS Continuing Healthcare, the need for care from a registered nurse must be determined. If the person has such a need and it is determined their overall needs would be most appropriately met in a care home providing nursing care, then this would lead to eligibility for NHS-Funded Nursing Care.
8. Complaints about NHS CHC are dealt with by the Parliamentary and Health Service Ombudsman.

What happened

9. Mrs A (Mrs X’s mother) has lived at a care home since 2019. After the death of her husband in 2023 Mrs A funded her own care. She also received Funded Nursing Care.
10. Mrs X says that her mother’s needs increased during 2023 and she did not have an allocated social worker at the time. The Council’s records show that during 2023 the social care team was in contact with Mrs X to discuss a Deprivation of Liberty Safeguards (DoLS) authorisation for Mrs A.
11. A social worker contacted Mrs X in November 2023 and Mrs X expressed concern about her mother’s needs. The social worker noted in her records Mrs X had already contacted an agency to look into her mother’s eligibility for CHC funding. The social worker told Mrs X she could complete the care needs review for Mrs A the following week and also then complete a checklist for eligibility for CHC funding.
12. At the review on 14 November the case recording notes Mrs X told the social worker the care home had sent her mother’s records to the agency and added she had been advised not to complete a checklist through the Council. The social worker told her she could complete the checklist and send it to the NHS but Mrs X said she had paid £5000 to the agency, and it was one month’s worth of care home fees. She also said she knew the process as she had been through it with her aunt.
13. The social worker’s outcome of the meeting was that she would discuss the CHC checklist with health colleagues in any event. The social worker subsequently went on urgent unplanned leave and the discussion did not take place. A further review was scheduled for March 2024.
14. Case recording for February 2024 shows a social worker tried to contact Mrs X. When they spoke Mrs X said she had been waiting for a copy of the November review and also to find out what had happened about the CHC checklist. After the scheduled review of Mrs A’s needs in March, the social worker contacted Mrs X again to find out about the agency she had paid. Mrs X said “she didn't mind paying as it cost the same as 1 month of care home fees and will be worth it if the outcome is (Mrs A) is CHC funded”. Mrs X also said she had gone ahead with the private agency as she had not heard any more from social care after the review in November 2023.
15. In July 2024 the Council was contacted to allocate a social worker to attend a meeting with the NHS at the care home about Mrs A’s CHC eligibility. After the meeting in August Mrs A was awarded CHC funding.

The complaint

16. Later in August Mrs X complained to the Council. She said at the review meeting in November 2023 it was agreed that the social worker would consult with NHS colleagues about arranging a CHC checklist. She said as time went on and she had not heard anything except that the social worker had left, “I therefore took it upon myself to seek continuing health funding via employing a legal firm who specialises in this”. She said her mother’s needs at the CHC meeting in August 2024 were the same as at the November review meeting and it should have been referred to the NHS at that time by the social worker. She said the agency fees and the care home fees from January 2024 would not have been necessary if the Council had acted promptly.
17. A team manager met Mrs X in September to discuss the complaint and then responded formally in November. She acknowledged the Council had not kept Mrs X up to date with contact arrangements if she had concerns about her mother’s needs. She said however that there had been contact between the annual reviews and there was no evidence Mrs X had raised any concerns then.
18. The manager said at the November 2023 review “You advised us that you had already approached a private company to complete a CHC checklist and to gather information to assist with the completion of a Decision Support Tool (DST). Therefore, as you had sought alternative provisions, a CHC checklist was not completed as this was declined at your request.” The manager added that a DST meeting would have been arranged within 28 days of a checklist submitted by a social worker, considerably faster than the private option Mrs X had employed. She said going forwards social workers would be advised a CHC checklist should be completed at the time of the assessment /review “irrespective of individuals/family members wishes to explore private completion of this process”.
19. In conclusion the team manager said it was Mrs X’s decision to employ a private company to undertake the CHC assessment which had caused the delay so it would not reimburse the fees.
20. Mrs X complained to us. She said the Council should have initiated the CHC funding process and not left it to her: she says at the November review she told the social worker she had contacted the agency but nothing else had happened. She said the delay has reduced her mother’s savings by a large amount.
21. The Council says there was “a delay in progressing and sharing the review write- up due to the worker’s unplanned leave, however, (Mrs X) had already engaged and paid for an external consultant prior to the review taking place.”

Analysis

22. The Council acknowledges that there was delay in completing the papers from the November 2023 review due to the unplanned leave by the social worker.
23. There is however no evidence that delay was the cause of Mrs X’s choice to engage a private agency: she had already done so by the date of the review, had ‘been advised’ (though it is unclear by whom) not to progress the checklist through the Council, and had paid a significant sum to the agency. She reiterated in her conversation with a different social worker in March 2024 that she didn’t mind paying the agency fees. It is conceivable if she had asked the Council even at that stage to complete the CHC checklist it would have caused less delay for her.
24. I see no reason for the Council to reimburse the agency fees or the care home fees from the start of 2024. It was not the fault of the Council Mrs X chose to employ a private agency which took longer than the Council-led process would have done.

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Decision

25. I have completed this investigation as I find no evidence Mrs X was caused injustice by the actions of the Council.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman