Summary: We have decided not to investigate Mr X’s complaint about poor communication relating to funding his mother’s care. The Council has upheld the complaint and apologised. It will make a payment to Mr X to recognise the uncertainty caused.

The complaint

1. Mr X complained about the Council’s failure to tell the family it had agreed joint funding with the NHS for his mother, Mrs Y’s care. He said, if he had known, he would not have pursued an appeal against an initial refusal for health funding, which cost around £6,000 (including solicitor costs).
2. Mr X also complained about the amount of the refund due the Council said was due because the health funding was backdated and said it did not initially provide a breakdown to show how it calculated this. He thinks the refund should be much higher than the Council said.
3. Mr X said he tried to resolve the matter on many occasions, but could not get the matter escalated to managers, which caused frustration.

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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 provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we are satisfied with the actions an organisation has taken or proposes to take. (Local Government Act 1974, section 24A(7), as amended)
5. We do not start or continue an investigation if we decide:

• any injustice is not significant enough to justify our involvement, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

6. I considered information provided by Mr X and the Council.
7. I considered the Ombudsman’s Assessment Code.

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My assessment

Joint funding

8. Mrs Y was discharged from hospital to a care home with the fees initially funded by the health body. In October 2023 the health body decided Mrs Y was not eligible for NHS Continuing Healthcare (NHS CHC) funding, although she was eligible for funded nursing care. This meant Mrs Y, who had more than £23,250 in capital, had to pay the full cost of her care from November 2023. This was expensive because she needed one-to-one care to manage a health condition.
9. Mr X sought legal advice and decided to appeal the refusal of NHS CHC. Around the same time, the Council made an application for joint funding with the health body. Council records show it told Mr X it was liaising with the health body about funding for the one-to-one care, which it considered was for a health need, rather than a social care need.
10. The health body did not initially agree to fund the one-to-one carer and the Council explored whether there was another way that Mrs Y’s needs could be met. After a series of meetings, there was partial agreement in April 2024 that the health body would fund the one-to-one carer for 20 hours per day, with the Council funding the other four. The Council said this was subject to written confirmation, which it did not receive until 5 June 2024.
11. Mr X only found out about that agreement at the NHS CHC appeal meeting on 24 June 2024. In its complaint response, the Council accepted it should have communicated the outcome of the application for joint funding earlier and apologised for not doing so.
12. If we investigated this complaint, it is likely we found find fault with the Council for not providing sufficient information to Mr X about the joint funding application at the outset, and as the application progressed, so that he could make an informed choice about whether to proceed with the NHS CHC appeal. Whilst we cannot say what Mr X would have decided if he had been given more information or the level of costs he would have incurred, there is some uncertainty about whether the outcome would have been different if the communication had been better.
13. We therefore asked the Council, and it agreed, to pay Mr X £300 to recognise the uncertainty caused within one month of the date of this decision. It has already apologised and taken steps to improve its services.

Refund due

14. The health body agreed to backdate its contribution to the cost of the one-to-one carer to November 2023. Therefore, Mr X says the Council refunds the entire costs of that one-to-one carer, which Mrs Y funded until her death in March 2024. This amounted to £26,799.
15. The Council initially said it would refund £7,914.14 without explaining how it had calculated this. In its complaint response it provided a breakdown. It explained that the health funding meant Mrs Y’s capital would have remained above £23,250 until her death. Therefore, she would have had to fully fund her adult social care throughout and it calculated the refund due, after adjusting for that.
16. The Council has provided evidence of the sums used in its calculation, and I can confirm its calculation of the refund due was correct. It provided the breakdown within one month of calculating the refund due. Although this caused some frustration to Mr X, there is not enough injustice to warrant further investigation.

Communications

17. The records show Mr X sent a number of emails about the refund due after the appeal meeting. The officer was not able to provide the information he was seeking because they were waiting for another team to address the finance aspects. In its complaint response, the Council accepted Mr X did not get the information he wanted in that period, for which it apologised. It said it would use the feedback from this complaint to inform staff training.
18. We will not investigate this further because there is insufficient injustice caused to justify our involvement.

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Final decision

19. We have upheld this complaint because the Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused.

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Investigator's decision on behalf of the Ombudsman