Summary: There was a seven-month delay in completing a financial assessment for care home charges and inadequate advice about council funding which was fault causing Ms X avoidable distress. The Council has already offered £200 payment to recognise the distress and this is an appropriate remedy. To minimise the chance of recurrence, the Council will remind officers in the adult social care team to refer cases to the finance team when the NHS has withdrawn continuing healthcare funding.

The complaint

1. Ms X complained the Council delayed completing a financial assessment for her late relative Mr Y’s residential care and gave poor advice. She said this caused avoidable distress and a financial loss to the estate because the Council reclaimed money back from the Care Home which the estate now has to pay. She said it caused avoidable distress and confusion.
2. Ms X also complained about a decision by the Integrated Care Board (ICB) to stop Mr Y’s NHS continuing care funding. She said the decision was not made properly as it was done by phone. And his needs had not changed.

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What I have and have not investigated

3. I investigated the first complaint. I did not investigate the second complaint because it is an NHS decision. We have no power to investigate complaints about the NHS.

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The Ombudsman’s role and powers

4. 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)
5. 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

6. I considered the complaint to us, the Council’s response to the complaint and document set out in this statement. A colleague discussed the complaint with Ms X.
7. Ms 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

Relevant law and guidance

8. The NHS Continuing Healthcare (CHC) framework sets out the criteria for fully funded care. People who receive this funding do not have to pay anything towards the cost of care.
9. Adults who live in a care home and who do not receive CHC come under the framework of council funding for adult social care. Councils charge for residential care. The law says adults who have savings over £23,250 have to pay the full cost of their care. Those who have savings under £23,250 pay a contribution towards the cost of their care and the council pays a contribution.

What happened

10. Mr Y lived in a care home, had dementia and received CHC funding.
11. At the start of January 2022, a case worker from the Council’s adult social care team attended a meeting with the ICB about Mr Y’s CHC funding. The Council’s note of the meeting said a nurse assessor from the ICB decided Mr Y did not meet the criteria for CHC funding and so the ICB would withdraw funding. This happened on 19 January.
12. The Council’s adult social care team did not take any further action after the meeting with the ICB.
13. A note by a social worker in May 2022 says Mr Y “fell out of CHC funding in January, worker to complete a permanent residential care assessment form.”
14. A note by the same social worker in the middle of July says they spoke with Ms X and explained Mr Y needed to have a financial assessment and he may need to pay a contribution towards the cost of his care. The social worker apologised for the delay and said it was an oversight. The social worker sent out relevant forms and information leaflets about charging.
15. The Council’s finance team case notes say a referral was received in July 2022 for a financial assessment. A finance officer visited Ms X at home at the start of August. The Council calculated the date Mr Y’s savings fell to £23,250 by deducting the full care home fee from his savings each week.
16. The finance team wrote to Ms X in August 2022 to say it had carried out a financial assessment for Mr Y and he had to pay the full cost of his care as he had savings over £23,250. It said it had worked out Mr Y’s savings would fall to £23,250 on 30 October.
17. Mr Y died on 16 November. Ms X said just before his death, the care home had contacted her advising that Mr Y owed £36,0000 due to the Council/NHS clawing back payments.
18. A finance officer from the Council spoke with Ms X at the start of November. Ms X was unhappy with the ICB’s decision in January to withdraw CHC funding. Ms X told the finance officer another CHC application was submitted in July and she was intending to complain to the ICB. She said she had been informed Mr Y owed money to the care home.
19. In December, Ms X complained to the Council, raising the same issues as she has raised with us. She said the family believed Mr Y’s care was fully funded and it came as a shock to discover there was a large fee owed. She said there was no contact from the Council between January and July 2022.
20. The Council upheld Ms X’s complaint and apologised for the delay in completing a financial assessment and said this was due to Mr Y’s case not being allocated to a worker because of pressures within adult social care. The Council offered a payment of £200 to reflect the avoidable distress.
21. Ms X told me in response to a draft of this statement that the Council continued to pay the nursing home in full until November, when they were aware from July that he should have been self-funding.
22. The Council’s case records set out the funding periods in 2022:
• CHC ended on 18 January
• Mr Y was self-funding from 19 January to 30 October
• Council/Mr Y funding from 31 October to 10 November
• CHC funding (for end-of-life care) from 11 November to 16 November.
23. Ms X and a finance officer spoke in April 2023. The finance officer wrote to Ms X explaining Mr Y’s charge. The letter set out what was owed for relevant periods.

Findings

24. There was fault by the Council. It should have completed a financial assessment in January 2022 when the ICB withdrew CHC funding. Had there been a financial assessment in January, Ms Y would have been notified that Mr Y had savings of over £23,250 and so would be required to pay the full cost of his care. She would then not have had such a shock in discovering this some months later.
25. There was a delay of about seven months in completing a financial assessment, which the Council has already accepted was fault. In terms of advice, no advice was given about Ms X needing to apply for council funding in January 2022 when CHC funding stopped. This was also fault.
26. It would have come as a shock to the family to find out Mr X needed to pay for all his care. It was also confusing for Ms X that the Council continued to pay the care home when there should have been a timely and efficient decision on the financial assessment soon after the withdrawal of NHS funding. The Council has recognised this and offered a payment of £200 to reflect this.

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Agreed action

27. Ms Y wants the Council to pay £36,000 owed to the care home. I am not making this recommendation because of the charging rules set out in paragraph nine. Mr Y had savings and so he would have been required to pay even if the Council had not delayed in completing the assessment. The Council’s suggested payment of £200 to Ms X is an appropriate remedy to reflect the avoidable distress caused by the delay.
28. To reduce the risk of the same thing happening again, the Council will remind staff to refer customers to the finance team where they have attended a CHC meeting resulting in the NHS withdrawing funding. The reminder should be issued to all staff in the adult social care team within one month of my final decision.
29. The Council should provide us with evidence it has complied with the above actions.

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Final decision

30. There was a seven-month delay in completing a financial assessment for care home charges and inadequate advice about council funding which was fault causing Ms X avoidable distress. The Council’s offer of a £200 payment to recognise the distress is an appropriate remedy. To minimise the chance of recurrence, the Council will remind officers in the adult social care team to refer cases to the finance team when the NHS has withdrawn continuing healthcare funding.
31. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman