Summary: Mrs A has complained about a hospital trust and a council in relation to her mother, Mrs B’s discharge to a care home and the fees her mother was charged. We found fault with the Council and the Trust in relation to the discharge a delay in moving Mrs B to a new home and with the Council’s complaint handling which led to distress for Mrs A and a financial shortfall for Mrs B. The Council has agreed to remedy the matter with an apology and a financial payment. The Trust has agreed to apologise and take action to improve communication.

The complaint

1. Mrs A is unhappy with East Lancashire Hospitals NHS Trust (the Trust) and Lancashire County Council (the Council) in relation to the discharge of her mother, Mrs B, to a care home (the Home) and the fees the stay at the care home incurred.
2. Mrs A said she was misinformed about the amount the care home charged. In addition, there were delays in her complaint being responded to and in the Council moving her mother to a different care home.
3. Mrs A said the events of the complaint have caused her physical and emotional suffering as well as her mother financial loss. She has said delays in the care home move and complaint handling have also affected Mrs A’s health and wellbeing.
4. Mrs A would like a refund of the extra £15,000 her mother has been charged over what she was led to believe she would have to pay. Mrs A also wants improvements to services to stop this happening to other people.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA). The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended).
6. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
7. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
8. If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
9. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

10. I have considered information from the Trust and Council including medical and social care records. I have also taken evidence from Mrs A including paperwork and a telephone conversation.
11. I have considered the relevant legislation and guidelines.
12. I issued a first draft decision, and after considering comments from all parties, I then issued a second draft decision which the Council and Mrs A commented on before I made this final decision.

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What I found

Background

13. Mrs B had Alzheimer’s disease and had previously lived at home with carers coming in daily to help her. Alzheimer's disease causes the brain to shrink and brain cells to eventually die. Alzheimer's disease is the most common cause of dementia — a gradual decline in memory, thinking, behaviour and social skills.
14. In 2022 Mrs B had several falls and entered hospital. The hospital assessed Mrs B’s needs and decided she needed to go into a care home.
15. Mrs B moved to a care home in February 2022 where she stayed until she moved to another home in July 2023.
16. Mrs A was in correspondence with the Council throughout this time to complain about her mother’s care home fees and to ask that she was moved to the second care home.
17. The Council provided a final response in July 2023 and Mrs A approached the Ombudsmen.

Choice of care home

18. Mrs A said that she had told staff at the hospital she wanted her mother to enter a home that charged the local authority rate and there should be no top up fees. The local authority rate is the rate which homes charge Councils and this is usually less than what the home charges a private individual for their care home stay.
19. If care home accommodation costs more than a local council is willing to pay, someone else can make up the difference between that figure and the home’s fee. This is known as a top-up fee.
20. Mrs A also said that she told the Hospital and the Council the practical side of the move should be handled by them but to keep in touch about any decisions in relation to the care home.
21. She said the Council and Hospital assured her that the care home met her criteria of the local authority rate and no top up fees.
22. However, shortly after the move, Mrs A said the Home told her that there would be a top up fee. She said a social worker from the Council assured her that there was no top up fee and her mother would only be charged the £654.60 weekly rate.
23. Mrs A said she then began to get bills from the Home at £865 a week. She queried these with the Council and this investigation by the Council went on for some months.
24. During this time Mrs A decided her mother should move to another home with smaller charges and so was asking the Council to organise this move along with getting to the bottom of the current charges.
25. In July 2023 Mrs B moved to the new home with a weekly fee of £756 and the Council responded to the complaint.
26. Mrs A is unhappy that her mother is £15000 out of pocket due to what she feels were the mistakes of the Council and hospital discharge team in choosing a home that was charging too much.
27. In addition, she feels the Council exacerbated the financial amount which Mrs B had to pay by taking so long to arrange her transfer to the new home. She asked the Council to move her mother over a year before she actually moved. In addition Mrs A said at no time did the Council tell her that she could move her mother herself as she was self funded.
28. The Council said it failed to ask the Home what its financial arrangements were if someone is over the financial threshold for having to pay for their own care.
29. Councils have a financial threshold at which people must pay for their own care. Mrs B had assets which took her over this threshold and so she was always going to have to pay for her care.
30. The Council also said in its response to Mrs A that the Home sent it its terms and conditions but the Council failed to forward them on to Mrs A.
31. The Council said due to a breakdown in communication and staff being off work it did not follow up and make arrangements for a more financially stable home for Mrs B.
32. It said it tried to negotiate the Home down to its local authority rates but was unable to. It said the new home would have funding in place in line with local authority rates.
33. The learning the Council took from the complaint was when staff were off work it needed to reallocate work so families are kept informed about what is going on. It said it would address this with the hospital discharge team.
34. It also said regarding learning from the case that it would hold conversations with homes and families following discharge from hospital so that both are aware of the costs, especially if someone is over the financial threshold and so will have to pay for their own care.
35. The Council said it agreed a fee of £608.94 a week for the Discharge to Assess period. The NHS was funding this stay for this period.
36. When this period ended in March 2022, the Home began to charge Mrs B. In correspondence with the Council, the Home quoted its terms and conditions which stated:

‘The weekly fee charged for self-funding residents is currently from £868

ranging to £896 per week. Dementia: Single room with en-suite: The weekly fee

charged for self-funding residents is currently from £868 ranging to £896 per week.’

37. The Council said that despite trying to negotiate with the Home the fees actually went up again in April 2023 to £935 per week.
38. The Trust also responded to the complaint and said that its discharge team (which contains social workers and nurses and GPs) decided Mrs B needed a 24 hour care home environment under Discharge to Assess funding for up to 28 days.
39. This was to allow further recovery assessments and discussions with social care around finance. Discharge to Assess is a model where people with new or additional health and social care needs on discharge receive post-discharge recovery support (usually funded by the NHS), and where assessments of longer-term or ongoing needs are fully completed only once a person has reached a point of recovery and stability.
40. The Trust said the Home confirmed the rate of £654.60 but did not confirm what the fees would be after the Discharge to Assess period.
41. The Trust said it then contacted Mrs A and explained the discharge plan which she agreed to.

Analysis

42. The Department for Health and Social Care Hospital Discharge and Community Support Guidance October 2021 to March 2022 states that:

‘4.10 Anyone needing a long-term package of support in their own home or a care

home will have an assessment and care planning undertaken following

discharge from hospital and this will also include a financial assessment, if

social care is needed which will be undertaken by the Local Authority.’

and

‘6.3 The government has agreed to fund, via the NHS, up to four weeks of care

for new or additional needs of an individual on discharge from hospital, where

care is delivered up to and including 31 March 2022.’

43. Therefore, Mrs B’s care home fees should have been paid for by the NHS until 31 March 2022, following this, she would then have become responsible for her fees as she was over the threshold for financial support.
44. However, there is no evidence that Mrs A was told of this before the move to the Home. In addition, the Council did not inform her of the care home fees, and the Trust discharge team did not clarify the Discharge to Assess arrangements.
45. Considering her request for a home without top up fees, we can say on the balance of probabilities she would not have agreed to this placement if not for the fault by the Hospital and Council.
46. In addition, there is evidence in the social care notes that when Mrs A raised this discrepancy in the fees with the Council in March 2022, it confirmed it would pay for the care home fees until the Continuing Healthcare (CHC) assessment. CHC is funding for care from the NHS if someone meets the criteria of having a primary health need.
47. Therefore, it is fault that the Council has not paid for the care home fees as it had agreed with Mrs A from the end of the Discharge to Assess period of Mrs B’s stay until the CHC assessment of June 2022.
48. The Council has said that there was a delay in finding a new home as Mrs A was waiting for a Continuing Healthcare assessment of her mother. This took place in June 2022. Mrs B moved into her new home in July 2023.
49. The Council told the Ombudsman that it was agreed that in July 2022 an alternative placement would be found by the Council. This is also evidenced in the social work records which state Mrs A wished to go through the Council for an alternative placement.
50. Care and support statutory guidance 2024 Annex A
51. 2) The care and support planning process will have determined what type of accommodation will best suit the person’s needs. This could be, for example, a care home, shared lives or extra care housing. Where the type of accommodation is one of those specified in regulations, the person will have a right to choose the particular provider or location, subject to certain conditions. Where this is the case, the following guidance should be applied and in doing so, local authorities should have regard to the following principles:

• good communication of clear information and advice to ensure well informed decisions
• a consistent approach to ensure genuine choice
• clear and transparent arrangements for choice and any ‘top-up’ arrangements
• clear understanding of potential consequences should ‘top-up’ arrangements fail with clear exit strategies
• the choice is suitable to the person’s needs

3) Local authorities must also remember that the regulations and guidance on choice of accommodation and additional costs apply equally to those entering care for the first time, those who have already been placed by a local authority, and those who have been self-funders, but because of diminishing resources are on the verge of needing local authority support.

4) Local authorities should also be mindful of their duties under Section 1 of the Care Act 2014 to promote individual wellbeing.

52. Care and Support Statutory Guidance section 8.13 states, where a person is above the financial threshold, ‘the local authority may choose to meet the needs and arrange the care, but it is not required to do so.’
53. However, as it had been agreed that the Council would take the lead in finding an alternative, it was the Council’s responsibility to find an alternative placement. In addition the Council never told Mrs A she could move her mother herself.
54. It took from July 2022 to July 2023 to find an alternative placement for Mrs B. However, the Council only started looking in February 2023 when it started to compile a list of alternative placements. It then took to July 2023 for the Council and Mrs A to find an alternative placement and move Mrs B. We can accept it can take up to a month to source and move a resident, but any more than this is a delay that represents a fault on the Council’s part.
55. This fault led to Mrs B being charged a higher rate of care home fees than she would have if she had moved to the new care home sooner. This financial loss would be lessened by the Council paying for the three months full fees it already agreed to pay Mrs B.

Complaint handling

56. Mrs A found the length of time it took the Council to provide her with updates and a response to her complaint as inadequate and it caused her distress and frustration.
57. The Council has admitted fault in relation to not providing Mrs A with updates and has provided an explanation for how long it took to respond. It said it received the complaint in August 2022 and it was only in February 2023 it realised it would need an input from the Trust.
58. The Trust provided a response to the complaint in March 2023 and then the Council provided both responses in July 2023.
59. I do not find this an adequate explanation to the length of time the Council took to provide a response. In addition, it was fault that it took until February 2023 to realise it needed the Trust’s input. Also, it did not provide Mrs A with regular updates.
60. Therefore, there was fault in the way the Council handled this complaint and this led to distress and frustration for Mrs A whilst also trying to sort out the care home move and the outstanding charges.

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Recommendations

61. The Council has taken adequate learning action in relation to communication to prevent this happening again. However, both the Trust and Council have not yet addressed the distress and financial effects the circumstances of this complaint have had on Mrs A.
62. In view of this, I recommend that by 16 August 2024 Council:

• write to Mrs A acknowledging and apologising for the distress and frustration caused by the faults outlined in this investigation,
• pay either the Home or repay Mrs A the care home fees for Mrs B’s stay from the end of the Discharge to Assess funding in March 2022 until her CHC assessment in June 2022, or to pay the difference in the care fees between the new home’s rate and the rate Mrs B was charged from April 2022 to July 2023, whichever is the greater amount; and
• pay Mrs A £500 for the distress and frustration caused by the faults in complaint handling.

And the Trust:

• write to Mrs A acknowledging and apologising for the distress and frustration caused by the communication faults outlined in this investigation;

and by 18 October 2024:

• carry out action in its discharge team to improve its communication in relation to communicating clearly with families about discharge planning.

63. The organisations should provide us with evidence they have complied with the above actions.

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Final decision

64. I find fault with both the Council and the Trust which led to distress and frustration for Mrs A. I have made recommendations to rectify the situation.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman