Summary: Miss X complained about the Council’s Adult Social Care Service’s involvement with her mother, Ms Y, after Ms Y was discharged from hospital. There was no fault in the Council’s decision making, communication, or in the processes it followed.

The complaint

1. Miss X complained about the Council’s Adult Social Care Service’s involvement with her mother, Ms Y, after Ms Y was discharged from hospital. Miss X said the Council:
• Did not properly assess Ms Y and ignored her needs.
• Was unclear in its communication, ignored Miss X’s complaints, and did not treat her fairly.
• Wrongly charged the family for care which should have been free under the Discharge to Assess process.
• Did not offer any care homes close to the home within Ms Y’s personal budget.
2. Miss X said the matter caused significant distress to Ms Y and the family, and Ms Y stayed in an unsuitable placement for 8 months longer than she should have.

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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. 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)
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended) 

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How I considered this complaint

6. As part of the investigation, I considered the complaint and the information Miss X provided.
7. I made written enquiries of the Council and considered its response along with relevant law and guidance.
8. Miss X 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

Discharge to Assess

9. The Discharge to Assess (D to A) process supports people to leave hospital when they no longer need hospital care, but they need more assessment to establish their ongoing health and social care needs. It usually involves short-term funding for support while an assessment takes place, and may involve care at home or a short stay in a care home.
10. Under the Council’s D to A procedure, it assesses people over 28 days to determine their long-term support needs.
11. The Council will refer people with a nursing recommendation from hospital to a nurse assessor for a nursing needs assessment and Continuing Healthcare screen (checklist).

NHS Continuing Healthcare Assessments

12. NHS Continuing Healthcare (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. Such care is provided to people aged 18 years or over, to meet needs arising from disability, accident or illness.
13. Individuals may need care and support provided by their local council and/or services arranged by an Integrated Care System (ICS). If, following an assessment, a person is not found to be eligible for NHS CHC, the NHS may still have a responsibility to contribute to that person’s health needs, either by directly commissioning services or by part-funding the package of support.
14. Complaints about NHS CHC are dealt with by the Parliamentary and Health Service Ombudsman.

NHS Funded Nursing Care

15. 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.

Choice of care homes

16. The Care and Support and Aftercare (Choice of Accommodation) Regulations 2014 set out what people should expect from a council when it arranges a care home place for them. Where the care planning process has determined a person’s needs are best met in a care home, the council must provide for the person’s preferred choice of accommodation, subject to certain conditions. This also extends to shared lives, supported living and extra care housing settings.
17. The council must ensure:

• The person has a genuine choice of accommodation;
• At least one accommodation option is available and affordable within the person’s personal budget; and,
• There is more than one of those options.

18. However, a person must also be able to choose alternative options, including a more expensive setting, where a third party or, in certain circumstances, the resident is willing and able to pay the additional cost. This is called a ‘top-up’. But a top-up payment must always be optional and never the result of commissioning failures leading to a lack of choice.

What happened

19. I have summarised below some key events leading to Miss X’s complaint. This is not intended to be a detailed account of what took place.
20. Ms Y had a long stay in hospital following a bleed on the brain. The hospital discharged her to The Dell Care Home under the D to A pathway. Ms Y was only there a few days when family discharged her home as she was refusing care. Ms Y then attended hospital in February 2024 with confusion and headaches. The hospital again discharged Ms Y under the D to A pathway in March 2024, this time to Gorton Parks Care Home (Goron Parks).
21. Ms Y’s allocated social worker met Ms Y, her husband, Miss X, and the senior carer at Gorton Parks to complete an assessment of Ms Y’s care and support needs on 8 April 2024.
22. The Council received a CHC checklist from the nursing team on 1 May 2024. The checklist was negative and did not trigger a multi-disciplinary team (MDT) meeting. The Council also received a nursing needs assessment showing no nursing needs. The nurse assessor considered Ms Y needed 24-hour dementia residential care.
23. Miss X contacted the Council on 14 May 2024. She said it did not follow the correct process. She also raised unspecified safeguarding concerns and complained the Council was not present at the CHC screening. Miss X said Ms Y needed 24-hour care at home and this is what NHS CHC would give.
24. The Council allocated Ms Y a new social worker, who met Miss X at Gorton Parks on 21 May to complete a mental capacity assessment (MCA). The MCA found Ms Y lacked capacity to make decisions around her residence and care. The social worker also completed a best interest’s decision with family and professionals. The outcome was that Ms Y needed 24-hour residential care.
25. Miss X was unhappy with the outcome of the nursing assessment. Ms Y’s social worker advised Miss X to raise this with the Integrated Care Board or the nurse assessor.
26. Ms Y’s social worker completed their support plan on 22 May and sent it to the Council’s brokerage team to commission a 24-hour residential care placement. They requested care homes close to Ms Y’s home due to family travel needs.
27. Miss X complained to the Council on 23 May 2024. She raised several issues, including:
• Ms Y has a diagnosis of dementia, but this was not referred to by her social worker.
• Ms Y was allowed to go home despite Miss X’s concerns and despite the hospital saying she needed 24-hour care and a CHC assessment.
• The CHC checklist did not include Ms Y’s correct diagnosis and medical conditions, such as psychological and mental health struggles, and should be done again.
• Ms Y’s needs were not being met and without a diagnosis, no one can speak on her behalf.
• Miss X wanted the Council to assign Ms Y a new social worker.
• Miss X said they were told the Council would not charge Ms Y until after she moved. She said there should be no charges until after a CHC assessment, psychological assessment and mental health input.
28. The Council emailed Miss X to clarify the points of her complaint but did not receive a response.
29. The Council’s finance team requested financial information from Ms Y on 18 June 2024.
30. Miss X telephoned the Council on 20 June 2024 raising concerns that the nursing needs assessment was not valid as a diagnosis was missing. Miss X also raised concerns about Ms Y’s support, and social worker. The Council agreed a meeting with Miss X on 21 June. It also passed the concerns on to the nurse assessor, who agreed to re-visit Ms Y.
31. The Council found a potential placement for Ms Y on 28 June at Laurel Court Care Home. The placement had a top-up fee of £19.49 a week, which was a premium for an en-suite bathroom. Miss X was happy with Laurel Court but raised concerns about affordability, as Ms Y’s income was needed for bills at home. Miss X asked for clarity around finances. The Council contacted its finance team.
32. Miss X told the Council on 3 July that she could not make a decision on Laurel Court until she knew Ms Y’s contribution to the costs. The Council sent a follow up email to its finance team.
33. The Council also received Ms Y’s updated nursing needs assessment on 3 July. This time the outcome was positive, triggering a MDT meeting with health professionals to decide whether Ms Y qualified for NHS CHC or nursing care.
34. The Council wrote to Ms Y’s husband on 4 July confirming Ms Y’s maximum contribution, based on information held, would be £188 a week.
35. The Council contacted Miss X on 18 July 2024 confirming it received a positive CHC checklist from the nurse assessor and a MDT meeting would be held.
36. The Council halted its search for a care home in the meantime.
37. The MDT meeting took place on 14 August 2024. The professionals in attendance considered Ms Y did not meet the criteria for NHS CHC. They decided she needed residential care only, with no funded nursing element.
38. The Council’s brokerage team recommenced its search for care homes for Ms Y.
39. The Council responded to Miss X’s complaint on 12 September 2024. It said:
• It recognised Miss X did not agree with the nursing needs assessment completed in April 2024, as she felt it missed information. However, that assessment found Ms Y needed a 24-hour dementia residential placement. The Council found in May 2024 that Ms Y lacked capacity to decide her long-term care arrangements. It was agreed she needed 24-hour care, but the Council decided it was not in Ms Y’s best interests to return home. Her declining cognition and lack of insight meant she would be at risk of harm or self-neglect if not in 24-hour care.
• According to Gorton Parks, Ms Y was very private and often refused support to wash. But she did change her clothes every day.
• It agreed to delay a decision on Ms Y’s placement at Laurel Court until another CHC assessment took place. The CHC decision was that Ms Y was not eligible for CHC funding and did not need a nursing placement. This was a decision by health professionals, not the Council, and they would have considered Ms Y’s medical conditions. The Council acknowledged Ms Y had been referred to the memory clinic, but she did not need a nursing placement, and there were no reports of hallucinations.
• It followed the correct process, and the D to A period had ended. Ms Y will move to a long-term placement once identified; she will then have a financial assessment.
• It confirmed it would not charge Ms Y while she is a Gorton Parks, unless it considers the family has declined reasonable options.
40. The Council telephoned Miss X on 16 September 2024 about a placement at Alexander Lodge Care Home. Miss X wanted confirmation about the garden and how the care home would meet Ms Y’s needs.
41. The Council decided to move Ms Y from the D to A pathway to a temporary residential bed while the family made a decision. That was because the Council had completed its assessment and confirmed Ms Y needed 24-hour residential care. This meant Ms Y’s bed at Gorton Parks became chargeable on 17 September 2024.
42. The place at Alexander Lodge was subsequently lost because the family had not reached a decision.
43. Another bed became available at Laurel Court on 20 September 2024. There was no top-up fee for the family to pay, as it would be covered by the dementia premium.
44. The Council wrote to Ms Y’s husband on 23 September 2024, confirming her care became chargeable on 17 September.
45. Ms Y moved to a permanent residential bed at Laurel Court on 26 September 2024.
46. The Council wrote to Ms Y’s husband again confirming the charges between 17 and 25 September 2024 were £100.94.
47. Miss X emailed the Council on 30 September disputing the charges for Ms Y’s temporary placement at Gorton Parks.
48. Miss X was unhappy with the Council’s complaint response, and wrote back asking to discuss her complaint on 16 October 2024. She said:
• The Council did not answer her questions or address the behaviour of social workers involved. The Council left Ms Y without the correct care and her health suffered.
• The Council ignored her recent complaint about the temporary placement charge.
• She made many other complaints to social workers which were ignored.
• The Council did not follow guidance in Ms Y’s care, and the CHC checklist found Ms Y needed a bathroom.
• The Council did not offer any care homes within Ms Y’s budget, and its communication about extra charges was unclear. The Council told the family they had to pay when they made it clear they could not afford it.
• The CHC checklist was invalid as it did not include medical evidence or conditions. Miss X appealed the CHC outcome and asked who was responsible for paying for Ms Y’s care in the meantime. Miss X said they should not be charged for Ms Y’s temporary placement as the Council did not follow the correct procedure. She said the means test should not have happened before the CHC assessment was complete.
49. The Council completed a review of Ms Y’s new placement on 28 October 2024. No concerns were raised.
50. The Council sent its final complaint response on 4 December 2024. It said:
• It contacted Miss X about her complaint in May 2024 and made repeated attempts to call her at prearranged times, but she was not available. It therefore closed her complaint as she had not agreed the complaint points. The Council responded to the original points raised when Miss X chased a response on 19 June 2024. It apologised for sending its complaint response on 12 September, outside its timescales.
• It acknowledged Miss X disagreed with its findings, but it investigated her complaints. Several officers spoke to Miss X about the outcome, and an officer offered to meet Miss X, but she was unavailable. The Council saw no evidence it treated her unfairly.
• Miss X had not outlined what the social workers had done that should be investigated, nor which social workers she complained about.
• CHC assessments are conducted by health professionals. Social workers do not lead the assessments. Miss X must appeal to the NHS if she disagrees with the outcome or considers it was completed without considering medical evidence.
• The CHC checklist is a screening tool to identify whether someone needs a full assessment, not to recommend whether someone needs their own bathroom. Social workers base their scores on assessed need. It would be against their code of practice to underscore someone. All professionals involved in Ms Y’s care concluded she did not meet the criteria for CHC funding or FNC.
• The outcome is therefore that the Council pays the cost of Ms Y’s care, with contributions from Ms Y based on her financial assessment. Ms Y cannot remain on a D to A pathway while Miss X appeals to the NHS over CHC funding. If Miss X’s appeal is successful, it would be for the Council and the NHS to resolve the funding of Ms Y’s care.
• Ms Y was on the D to A pathway for 121 days, instead of the standard 28 days. During those 121 days Ms Y was not contributing to the cost of her care.
• There are a small number of care homes locally offering placements without any additional costs. This is beyond the Council’s control as they are privately owned. The Council found a nearby home so family could easily visit. The Council also absorbed the top-up the family would have had to pay. Contributions towards the costs are based on a financial assessment of a person’s income, assets and outgoings.
• Ms Y’s weekly charges at Laurel Court total £780.51 including an en-suite. Ms Y’s assessed contribution is £188 a week and there is no top-up fee due from the family.
• Laurel Court was not aware of any patients entering Ms Y's room. They said Ms Y prefers to be by herself and stay in her room. A bedroom in a smaller unit has now become available, and Laurel Court will call Miss X to discuss this.
• There was no evidence it did not follow correct procedures, or that its communications were unacceptable. It said the charges for Ms Y’s temporary placement were valid.
51. The Council wrote to Miss X on 23 December 2024 advising, following review of Ms Y’s finances, her new assessed contribution from 26 September 2024 was £191.19 per week.

My investigation

52. Miss X told me Ms Y remained at Gorton Parks for a long time because the Council did not carry out a mental health assessment. She said the lack of diagnosis meant Ms Y lost out on medication and support. She did not have a bath, shower, or personal care due to her functioning. She would also not go to the toilet because she was paranoid.
53. Miss X believed the nurse assessor lowered Ms Y’s score on her first CHC checklist because they ignored her complex needs and no professional assessments were done. She said Ms Y’s second CHC checklist also flagged that she needed a toilet in her room, but nothing changed.
54. Miss X said the Council should offer three care homes on discharge, but did not do so. The Council told the family they had to pay a top-up fee and offered a care home with no garden.
55. The Council told me Ms Y was discharged from hospital to a D to A bed at Gorton Parks Care Home. This decision was made by health staff on the ward, for Ms Y’s care needs to be assessed and identify what care and support she needed. Once the assessment is completed, and if the person no longer needed the D to A bed but remained there, it could become chargeable as a temporary bed.
56. The Council said it was not its role to complete the psychological and mental health assessments Ms X referred to. If a medical professional felt they were necessary, they would be completed outside the D to A process.
57. The Council confirmed it offered Ms Y two care home places. Laurel Court, which had a top-up fee and which Miss X said the family could not afford, and Alexander Lodge which had no top-up. Both homes were within close proximity to Ms Y’s home and family as requested. The Council said Central and North Manchester have ample care homes available within the Local Authority rate, but Ms Y did not want to move to these areas.
58. Unfortunately, the Council said both placements were lost due to prolonged decision-making by the family. The Council therefore made the D to A bed a temporary residential bed on 17 September 2024 as it had completed all assessments. A week later, another place came up at Laurel Court. This time no top-up fee was needed as it could be covered by a dementia premium, pending diagnosis. Ms Y moved to Laurel Court on 26 September 2024.
59. The Council said it charged Ms Y for the temporary bed at Gorton Parks from 17 to 25 September 2024, which amounts to £100.94. It did not charge for the period from 19 March to 16 September 2024.
60. The Council said its complaints team made numerous attempts to contact Miss X to discuss her concerns, arranging telephone appointments with her directly, but she did not respond to those calls or did not answer.
61. The Council also said its records show regular and clear communication with Miss X. It sent emails to her outlining decisions made and explaining processes to her.

Analysis

62. The Council assessed Ms Y’s care and support needs when she moved to Gorton Parks. Its assessments included Ms Y, her family, and the care home. While I appreciate Miss X disagreed with the assessment and subsequent support plan, the social worker who assessed Ms Y is entitled to their professional judgement. I did not find they ignored Ms Y’s needs, or the views of her family. There was no fault in the Council’s assessment.
63. The Council completed a MCA for Ms Y to consider whether she could decide where she wanted to live. The Council noted Ms Y had no current diagnosis of cognitive impairment, but she was waiting to see the memory clinic. The Council also noted Ms Y presented with short term memory issues and confusion. She had periods where she was disoriented to place and time. The Council decided Ms Y did not have capacity to decide where she lived. She was not aware of where she was and not able to show she could retain or use information to make informed decisions. That was a professional judgement by the Council, and I did not find fault in the assessment.
64. I considered the Council’s best interest decision report when deciding Ms Y needed permanent residential care. I found the Council considered the views of Ms Y and her family. However, the Council felt there were more risks involved if Ms Y returned home, and more benefits to Ms Y if she went into permanent residential care. The Council and the family disagreed about whether Ms Y needed 24-hour residential care, but the Council was supported by the Occupational Therapist and the senior carer at Gorton Parks. This was also the view of health professionals when Ms Y had her CHC assessment. I did not find fault in the Council’s assessment or decision.
65. Miss X complained to the Council about the CHC assessment, including that it did not consider Ms Y’s diagnosis. The Council is not responsible for the CHC assessment, but it did refer some of Miss X’s concerns to the nurse assessor, who agreed to re-assess Ms Y. The re-assessment was positive, but health professionals ultimately decided Ms Y did not qualify for NHC CHC or FNC. That was not the decision of the Council, and there was no fault by the Council in the assessment process.
66. The Council must ensure people have a choice of care homes, with at least one option being within their personal budget. I have not seen evidence the Council must offer people a choice of three care homes as Miss X suggests. I found the Council offered Ms Y two care homes. One was within her personal budget. The other had a small top-up fee. However, this top-up fee was later covered by the dementia premium, meaning the home was affordable for Ms Y and she moved in. There was no fault by the Council in this regard.
67. The Council decided to start charging Ms Y for her D to A accommodation following the family’s initial failure to accept or decide on either of the care home’s the Council offered. While D to A accommodation is usually free of charge, this is while the Council determines a person’s longer term care needs. This process is usually completed within 28 days. The Council had completed the necessary assessments and established Ms Y’s long term care needs. And it alerted Miss X to the fact it may start charging Ms Y if the family refused reasonable care home offers in its complaint response. The Council was therefore entitled to say the D to A period had ended. Ms Y’s care home placement under the D to A pathway was free of charge for six months, significantly longer than normal. I did not find fault by the Council.
68. I found the Council fully considered and responded to Miss X’s complaints. It tried to clarify Miss X’s complaints with her, and offered telephone calls to discuss her complaints. However, it was unable to contact Miss X at pre-arranged times. I also saw evidence the Council responded to Miss X’s emails and telephone calls throughout the period Ms Y was at Gorton Parks. Miss X may not have received a response to every communication, but I am satisfied the Council provided suitable responses.
69. The Council’s stage one complaint response took three months after Miss X got back in touch with the Council in June 2024. The Council aims to respond to Adult Social Care complaints within 25 working days, so there was a delay of about two months. However, I am mindful that the Council tried to clarify Miss X’s complaint initially, but she did not respond. I have also considered the fact the Council gave full responses at stage one and then at stage two, offered to meet Miss X, and was in regular communication with her. I therefore found there was no significant fault or injustice.

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Final Decision

70. I found no fault in the Council’s decision making, communication, or in the processes it followed.

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Investigator's decision on behalf of the Ombudsman