Summary: Ms X complained about the way the Council charged for Mrs Y’s care and for delays in completing financial assessments. Ms X said this left Mrs Y with a large, unexpected care bill. We do not find fault with the way the Council assessed Mrs Y’s finances or how it reached its decision to charge for the care she received.

The complaint

1. Ms X complains about the way the Council charged for the care Mrs Y received and for delays in completing reassessments. Ms X says the Council told her it would cover the cost of Mrs Y’s care from the time she entered a residential care home until she had settled and had a Continuing Healthcare (CHC) assessment but she received an unexpected bill for £30,204.

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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 future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
5. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6)
6. 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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What I have and have not investigated

7. We cannot usually investigate events that took place more than 12 months before a complaint was brought to our attention. We can only exercise discretion to look back further if there are good reasons to do so. Ms X first contacted the Ombudsman in October 2023, meaning anything that took place before October 2022 is a late complaint.
8. The events Ms X complains about go back to April 2022 when Mrs Y first entered a care home. However, I have decided to exercise discretion to investigate from this point as Ms X did not receive a care bill until January 2023 and it is at this point she would have been aware she had cause to complain.
9. As Ms X brought her complaint to the Ombudsman in October 2023, I have investigated up until that point. If Ms X is unhappy about any events that have occurred since that time, she would need to raise a new complaint with the Council and give it an opportunity to respond before we could investigate.
10. Any reference below to events that took place before April 2022 or after October 2023 are for reference only.

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How I considered this complaint

11. I spoke to Ms X about her complaint and considered information she provided. I also considered information received from the Council.
12. 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 policy

13. The Care Act 2014 (the act) and the Care and Support (Charging and Assessment of Resources) Regulations 2014 (the regulations) provide details of councils’ duties towards their residents with eligible social care needs and rules for charging for the services provided.
14. Where a council arranges care and support to meet a person’s eligible need, the council is entitled to charge that person for costs, except where the regulations require it to arrange care and support free of charge.
15. When exercising their social care functions councils must follow the Care and Support Statutory Guidance (the Statutory Guidance) issued by the Department of Health and Social Care, which is based on the act, unless they have very good reasons not to. They should also follow the regulations.
16. The Council’s charging policy for adult social care services explains it uses financial assessments to determine a person’s ability to pay and whether they will be required to pay all of, part of, or none of the cost of their care and support. It explains if a person declines a financial assessment, it will be assumed they can meet the full cost of their care and support from the date of the service.
17. CHC is a package of ongoing care arranged and funded solely by the NHS where the person has been found to have a ‘primary health need’. Complaints about CHC are dealt with by the Parliamentary and Health Service Ombudsman.

What happened

18. I have summarised below some key events leading to Ms X’s complaint. While I have considered everything submitted, this is not intended to be a detailed account of what took place.
19. The Council had previously assessed Mrs Y’s finances and found she had savings above the threshold for funding assistance. Mrs Y was living at home with Ms X and receiving a self-funded package of care.
20. In April 2022, Mrs Y entered a care home to receive respite care. While she was there, in May 2022, the Council completed a needs assessment with input from Ms X and the care home. This found Mrs Y now needed 24-hour care in a residential setting and her care became chargeable from this point.
21. The Council did not immediately complete a care and support plan or a financial assessment as a decision was made to apply for CHC funding. However, at that point the NHS explained medication changes meant it was not the right time to assess Mrs Y for CHC. They said they would consider a checklist again once Mrs Y’s medication had been changed and reviewed.
22. The Council provided Ms X with an Individual Placement Agreement (IPA) for Mrs Y. This set out the details of her placement and the associated costs. This explained the Council would pay the fees to Care Home A, and the fee would incorporate any personal contribution.
23. Ms X has said the Council told her it would fund the first three months of Mrs Y’s care, until she could be assessed for CHC. However, there are no available records to support this. The Council has said it still had Mrs Y recorded as self-funding. However, the available records do not show this was discussed with Ms X.
24. In August 2022, the Council contacted Ms X to ask for the information it needed to arrange a financial assessment for Ms Y.
25. Ms X responded in September 2022 to confirm Mrs Y’s savings were still above the threshold for funding assistance and to provide information about her outgoings. The Council asked Ms X for further information about Mrs Y’s outgoings, but the records do not show it received a response.
26. The Council contacted Ms X again in December 2022 to ask for clarity on the information she had provided. The Council asked for the current balance of Mrs Y’s savings.
27. Telephone notes from January 2023 show Ms X confirmed Mrs Y’s savings were still above the threshold for funding assistance.
28. The Council wrote to Ms X to confirm it had completed a financial assessment and Mrs Y was above the funding threshold. The Council confirmed it had paid Mrs Y’s care fees since she entered the care home but, as she was over the funding threshold throughout that time, she would need to repay the £30,204 it had cost.
29. Mrs X wrote to the Council to disagree with the charges and to say she had been told Mrs Y’s care would be fully funded by the Council until a CHC assessment was completed. Ms X also said the Council had delayed in completing a financial assessment.
30. The Council explained it does not deal with CHC funding. It said it had completed a needs assessment for Mrs Y in May 2022 and that was the date from which her care was chargeable.
31. In July 2023, Mrs Y moved into a new care home as a self-funding resident. Ms X asked the Council to reassess Mrs Y’s needs and confirmed she was still above the funding threshold. The Council reassessed Mrs Y’s needs and explained it would now close her case as she is self-funding but invited Ms X to contact it in the future if anything changed.
32. Ms X brought her complaint to the Ombudsman in October 2023.
33. In response to our enquiries, the Council has said the social worker who acted in arranging the placement at the original care home has said they advised Ms X that Mrs Y would be financially assessed, with a contribution often required. However, they said they never advised that fees would be funded.

Analysis

34. When considering complaints, if there is a conflict of testimony or evidence, we make findings based on the balance of probabilities. This means weighing up the available relevant evidence and making findings on what we think was more likely to have happened. Sometimes it is not possible to come to a finding, even on the balance of probabilities, where there is no independent evidence and both sides have differing views on the same events.
35. Ms X has said the Council told her it would pay for Mrs Y’s care fees while it awaited the outcome of her CHC assessment. The Council has said this is not the case and the social worker told Ms X that contributions would be dependent on a financial assessment. There are no records to allow me to say, even on the balance of probabilities, whose recollection is correct here, so I could not find the Council at fault for saying it would cover Mrs Y’s fees.
36. However, even if I did find the Council at fault, it is unlikely I would recommend it refund the care fees to Mrs Y. I say this because our remedies are intended to put people back in the position they would have been in, but for any mistakes made, and these fees would always have been payable. I would not expect the Council to simply honour any incorrect information it had given.
37. The Council is entitled to charge for care Mrs Y received but would need to properly assess her finances and inform Ms X of the outcome of any assessments.
38. Based on the information I have seen, Mrs Y was above the funding threshold throughout the period I have investigated. This being the case, I do not find the Council at fault for considering her care to be chargeable.
39. The Council was aware Mrs Y was above the funding threshold when she entered the care home in May 2022, and agreed to wait for the outcome of the CHC assessment before making a decision on her care and support plan. I do not find the Council at fault here.
40. The Council then asked Ms X to provide the information it needed to complete a financial assessment for Mrs Y and appears to have asked for further information as it saw necessary. Once it had the information it needed from Ms X, the Council promptly wrote to her with the outcome of the assessment, setting out what charges it had decided Mrs Y needed to pay, and why. I do not find fault with the process the Council followed when reassessing Mrs Y’s finances.

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Final decision

41. I find no fault with how the Council assessed Mrs Y’s finances or made the decision her care was chargeable. I find there is insufficient evidence of fault for me to find it provided incorrect information about whether it would fund part of Mrs Y’s care. I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman