Summary: Mr X complained the Council failed to assess his relative’s needs and delayed agreeing funding for her long-term residential care placement. There was no fault in the way the Council supported her hospital discharge. The Council failed to properly explain the financial assessment process, residential care funding and top ups and failed to keep proper records of conversations with relatives. The Council has already apologised to the family for this. It has agreed to take action to prevent a recurrence of the faults.

The complaint

1. Mr X complained the Council failed to properly assess his relative Mrs Y’s needs and failed to consider the needs of the family when Mrs Y was discharged from hospital. He says it also delayed agreeing to fund her long term care placement which caused the family distress and frustration.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. If we are satisfied with a council’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 have considered the information provided by Mr X and have discussed the complaint with him on the telephone. I have considered some initial information provided by the Council and the relevant law and guidance.
6. I gave Mr X and the Council the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.

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What I found

Care home funding

7. When a council arranges a care home placement it will undertake a financial assessment to decide how much a person has to pay towards the cost of the residential care. If the person has funds over the upper capital limit they are expected to pay for the full cost of the care home fees. The council must assess the means of those who has less than the upper capital limit to decide how much they should contribute towards the cost of the care home.
8. As part of the care and support planning process, the council must provide the person with a personal budget. In circumstances where a placement in a care home is necessary, the Care Act says there must be at least one placement choice available that is affordable within the personal budget. If no suitable accommodation is available at the amount identified in the personal budget, the council must arrange care in a more expensive setting and adjust the budget to ensure it meets the person’s needs. In these circumstances, the council must not ask anyone to pay a top-up fee.
9. However, if a person chooses to go into a home that costs more than the personal budget, and the council can show that it can meet the person’s needs in a less expensive home within the personal budget, it can still arrange a place at the home if:
• The person can find someone else (a ‘third party’) to pay the top-up.
• The resident has entered a deferred payment arrangement with the council and is willing to pay the top-up fee himself.
10. In such circumstances, the council needs to ensure the person paying the ‘top-up’ enters into a written agreement with the council and can meet the extra costs for the likely duration of the agreement.

Discharge to Assess

11. The Coronavirus Act 2020 introduced a range of measures to help the care system manage growing pressures arising from the pandemic. In March 2020 the Government introduced a new Hospital Discharge and Community Support Policy and Operating Model. The intention of the discharge to assess model was to reduce the length of stay of acute admissions and to ensure a higher proportion of people were discharged as soon as they no longer needed hospital support. As part of this the Government provided a national discharge fund to support new or additional care needs following a discharge from hospital. This meant care needs would be delivered free for a limited period to enable time for an assessment of the person’s long term care needs to take place.
12. The model sets out that assessments of eligibility of finances and discussions about care planning and options should be made in a community setting. They should not take place during an inpatient stay. It says, ‘systems should work to be in a position where no one has to transfer permanently into a care home for the first time following an acute hospital admission – everyone should be offered the opportunity to recover and rehabilitate at home or in a bedded setting before their long term needs and options are assessed and agreed’.
13. It explains hospital staff must make clear that discharge will be organised as soon as clinically appropriate and people will not be able to stay in a bed after the point where this is clinically necessary.
14. The model contains four pathways 0-3. Pathway 3 is for those who require bed-based 24-hour care including those discharged to a care home for the first time who are likely to require 24-hour bedded care on an ongoing basis following an assessment of their long term care needs.
15. Anyone needing a long term package of support in their own home or care home would have an assessment and care planning undertaken following discharge from hospital and this would include a financial assessment if social care was needed.

What happened

16. In September 2020 Mrs Y was admitted to hospital after a fall. Later that month a hospital employee conducted a mental capacity assessment which concluded Mrs Y lacked capacity to be safely discharged home. A best interests’ meeting with Mrs Y, her daughter and the hospital employee concluded it was in Mrs Y’s best interest to move to a 24-hour placement in a care home. This would be arranged by the NHS and funded initially through COVID-19 funding.
17. The hospital discharge team asked the Council to contact Mrs Y’s daughter to discuss the discharge to assess process. The notes record Mrs Y’s daughter understood the process, but she wanted Mrs Y to go to care home B. The Council officer explained under the discharge to assess process it was not possible to choose a specific care home. It would depend on whether care home B had discharge to assess beds. If not Mrs Y would be placed in an available care home bed and it would follow its home finder process to identify a care home to meet her long term care needs which would take into account her finances. Mrs Y’s daughter explained the importance of Mrs Y being near family. The officer explained a Council panel make funding decisions. They explained the allocated social worker would have further discussions with her about funding placements following Mrs Y’s discharge.
18. In early October following contact from the hospital discharge manager a Council officer spoke to Mr X. The officer explained two care homes were identified under the discharge to assess process. Mr X said the family did not want either. He considered Mrs Y required a specialist dementia placement and a placement other than at care home B would be detrimental to Mrs Y’s mental health.
19. The discharge manager confirmed they recommended a residential care home. The notes record Mr X said the family would only accept care home B. The officer explained no long term decisions could be made in the hospital setting. Preferences would be considered at the point long term decisions were made. They advised the family could self-fund a placement at care home B if they chose to opt out of the discharge to assess process. Mr X said a placement other than care home B would be detrimental to Mrs Y’s mental health as visits would be restricted. He suggested Mrs Y stay in hospital while the decision was challenged. The officer explained it was not in Mrs Y’s best interests to stay in hospital and that the case would be handed back to the Discharge Manager to proceed with the discharge. Mrs Y was offered a residential care discharge to assess bed at care home C.
20. Mr X considered care home C would not be able to manage Mrs Y’s needs in a residential care bed and she needed specialist dementia care. The discharge to assess referral was updated to include the concerns raised by Mr X. Care home C considered the additional information within the referral which included continence issues, wandering and an episode of aggression and confirmed it could accept Mrs Y.
21. Mrs Y’s family paid for a six week respite stay at care home B. The Council was satisfied care home B could meet her needs but confirmed it was not being offered as a discharge to assess placement. Mrs Y was discharged to care home B.
22. The Council agreed to assess Mrs Y’s long term care needs. Mrs Y’s daughter contacted the Council to chase the assessment and in early November the case was allocated to a social worker. The social worker contacted care home B which provided information about its weekly fees. There are no notes of any contact with the family.
23. The social worker submitted a form to the Council’s decision making panel for approval of the residential care home. The panel refused the placement as the cost was too high, so the social worker referred the case to a team to identify a long term placement.
24. The following week the social worker noted they completed a needs assessment, mental capacity assessment and best interests’ assessment. They noted the current placement was meeting Mrs Y’s needs. A financial assessment confirmed Mrs Y had below the upper capital limit and so required Council funding.
25. The social worker submitted a further funding application to the Council panel in early December 2020. This was refused. The social worker noted they had identified an alternative care home. The social worker recorded in the notes they had made the family aware funding was refused. There are no notes of the discussion with the family.
26. In February 2021 Mr X submitted a formal complaint to the Council.
27. In March 2021 the social worker noted in the case records ‘the view of [Mrs Y’s] family from conversation with [Mr X] when alternatives were suggested’. The notes record the family wanted Mrs Y to remain at care home B as it was close to family, Mrs Y knew the area well and knew some of the other residents. Due to caring responsibilities Mrs Y’s daughter would find it difficult to visit a home in another area. It is unclear when this conversation took place.
28. In April 2021 the Council responded to Mr X’s complaint. In investigating the complaint, the investigating officer spoke with Mr X and reviewed the records. They found the hospital discharge was in line with hospital COVID-19 procedures. However, they noted the social work department could have been more supportive in relation to the emotional stress and anxiety the family were experiencing.
29. They noted there was no documented evidence of any financial discussions with family about the financial assessment process or any discussions noted about third party top ups.
30. They found the relevant assessments were not completed until after the social worker made the first application for funding. There were no records of any discussion with the family about the funding process and the social worker failed to support the family in considering alternative options. The officer noted the Council had fully funded the placement from the end of November onwards. They found the social worker had failed to adequately involve, clarify and communicate with the family to enable them to make informed decisions and had not completed the required assessments before submitting a funding application.
31. They recommended the social worker communicate with the family providing clarification and information on the funding process, possible outcomes and their options. They also recommended the social worker complete an exceptional Council top up form, resubmit a funding application and present this to the panel for approval for Mrs Y’s long term placement at care home B.
32. In May 2021 the social worker submitted a panel application and exceptional top up form to the panel for approval of long term funding of care home B.
33. Mr X remained unhappy and complained to us. Around that time the Council agreed to the long term funding of Mrs Y’s placement at care home B.
34. The Council sent Mr X a letter by email in September 2021 to confirm it would pay Mrs Y’s care fees minus her assessed contribution. In the letter it apologised for the stress and inconvenience caused to Mrs Y and the family.

Findings

35. Mr X did not agree with the decision to offer a temporary discharge to assess placement at care home C. Mrs Y’s discharge was managed in line with the Hospital Discharge and Community Support Policy and Operating Model. In line with this, the Council were not permitted to assess Mrs Y’s long term care needs while in hospital. When Mr X provided further information regarding Mrs Y’s needs, the Council updated care home C which remained satisfied it could meet Mrs Y’s needs. The Council was not at fault in relation to its involvement in Mrs Y’s hospital discharge. However, in its complaint response the Council acknowledged it could have been more supportive to the distress the family were experiencing.
36. The Council’s complaints’ investigation found there was no documented evidence of any discussions with the family regarding the financial assessment process, the requirements for a third party top up because the cost of the placement exceeded the personal budget or any discussion about the family’s ability to pay this. This was fault.
37. It acknowledged the family were clear they could not afford to fund the placement but there was no documented evidence this was addressed or discussed and alternative options were not discussed with the family. This was fault.
38. The mental capacity assessment and best interests’ assessments were not completed until after the first submission of funding to the Council’s panel. This was fault.
39. I have considered the Council’s case records and am satisfied the Council properly investigated Mr X’s concerns through its complaints procedure and identified faults in its actions. I do not consider I could achieve anything more by investigating this further.
40. The Council has since confirmed it has agreed to fund Mrs Y’s placement, including any top up and wrote to Mr X in September 2021 to advise him of this.
41. The Council’s faults have caused Mr X frustration. However, if not for the Council’s faults Mrs Y may have had to move to an alternative care home or the family would have had to pay a top up fee in order for her to remain at care home B. The Council has agreed to fund the full cost of Mrs Y’s care, minus her assessed financial contribution, so there is no outstanding injustice to Mrs Y. I have recommended service improvements to prevent a recurrence of the faults in future.

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Agreed action

42. The Council has already apologised to Mr X for the stress and inconvenience caused to him and the family. This was appropriate.
43. Within one month of the final decision the Council has agreed to remind relevant officers of the need to:
• ensure all assessments are completed before a funding application for a care home placement is presented to panel;
• involve family members in assessments;
• keep appropriate records of conversations and contacts with family members; and;
• clearly explain the funding assessment process to relatives and the implications of a choosing a care home which costs more than the personal budget and to ensure they keep proper records of such discussions.

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Final decision

44. I have completed my investigation. There was evidence of fault by the Council causing injustice which the Council has already remedied. It has agreed to make service improvements to prevent recurrence of the faults.

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Investigator's decision on behalf of the Ombudsman