Summary: Mr X complained the Council should not have accepted his son into a care home as it was not able to meet his needs. We found the care home care was a suitable placement. However, there was fault as the Council failed to conduct a needs assessment to properly determine Y’s needs. We recommended an apology, and a review of the Council’s procedures.

The complaint

1. Mr X’s son, (who I refer to as Y in this statement) suffered a brain injury. Mr X says health professionals told him it could take five years for Y to reach his maximum recovery potential. He says health professionals recommended that he received cognitive rehabilitation and therapy.
2. At the end of October 2019 Y was placed in a care home. Mr X complains the Council was at fault for accepting Y into this care home. This was because Y was spending most of his time in bed and he received no cognitive therapy. He complains the care home was not able to meet the needs that NHS health professionals stated Y had, so the placement was hampering his recovery.

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The Ombudsman’s role and powers

3. 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)
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 spoke to Mr X and considered the information he provided. I asked the Council for information and I considered its response to the complaint.
6. Mr X and the Council had an opportunity to comment on my draft decision. I considered the comments received before making a final decision.

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What I found

Care Act 2014

7. Section 9 of the Care Act 2014 states, where it appears to a council that an adult may have need for care and support, it must carry out a needs assessment to establish what (if any) needs they have and what these needs are. A needs assessment must include:
• The impact of their care and support needs;
• What outcomes the person wishes to achieve in day to day life;
• To what extent provision of support will contribute to meeting these outcomes.

Mr X’s complaint

8. Mr X’s son, Y suffered a brain injury in March 2019. After a period in several hospitals Y was admitted to a specialist Brain Injury Rehabilitation Centre in June 2019. A report on 5 August noted Y was benefiting from specialist therapy and a further period of treatment was agreed.
9. Correspondence from the Council states that the Rehabilitation Centre sent an email to make a referral for a social worker on 29 August. The email was wrongly addressed and was not received by the Council through no fault on its part.
10. A multi-disciplinary meeting was held on 25 September to review Y’s progress. The notes of the meeting stated Y had engaged well with therapy sessions. However, his significant cognitive impairment, and difficulty learning new information, meant that he had been unable to make significant functional gains.
11. The summary stated “[Y] has significant care needs and requires support to complete daily activities and maintain his personal safety. Therefore, returning to living in his previous property is highly unlikely at the moment. As such we would be recommending [Y] be discharged to a supported residential unit, ideally with experience in managing complex cognitive needs”.
12. The NHS Clinical Commissioning Group (CCG) followed up the earlier referral with the Council’s Social Care Department on 27 September 2019. The correspondence noted that Y’s estimated discharge date was 7 October and 14 days after that (21 October) the CCG would begin charging the Council a daily rate for Y’s placement because his NHS funding would cease at that point. I have seen correspondence confirming the Council negotiated an extension to funding to ensure sufficient time for discharge planning.
13. On 15 October, two social workers met Y’s parents and discussed Y’s situation with staff at the rehabilitation centre. The Council records noted Y had engaged well with therapy but, unfortunately, the September review determined Y had no further rehabilitation potential. The notes stated health professionals considered Y needed to be discharged to a service where he could initially receive 24-hour support. The Council noted Mr X was concerned that Y was not getting any further therapy and that progress he had made to date could decline.
14. On 16 October a social worker discussed the situation with Y’s wife. There were concerns that she could not support Y while also returning to work full-time. The notes stated the social worker had been in discussion with a care home (referred to as Care Home A in this statement). This was stated to be for respite, and to move Y back to the area to allow time to consider future options.
15. The social worker emailed Care Home A on 16 October asking if they had availability for a period of respite. Care Home A was a reablement/respite facility. Although it also has an ‘Acquired Brain Injury Reablement Unit’, the NHS found Y ineligible for funding for this part of the home.
16. On 22 October the manager of Care Home A visited Y at the rehabilitation centre and carried out an assessment to decide if the home could meet Y’s needs. A social worker told Y’s wife that the care home manager felt it would be a suitable step down from the Rehabilitation Unit.
17. The care home manager emailed the social worker on 25 October noting Y had no further reablement potential but he stated “important to use our reablement paperwork to identify capabilities so this information can be obtained so you can determine future care needs and hold discussions with person/family about where to live in the future.” The email also noted Y’s personal circumstances, that he required prompting and it noted reports of poor road safety.
18. A clinical assessment of Y was carried out before he left the Rehabilitation Centre. The assessment noted Y’s abilities and difficulties in some detail and that Care Home A had been identified as an appropriate placement. It stated Y could “be supported by staff to complete his daily activities and encourage him to remain as independent as possible.” It stated the intention was for Y to remain at Care Home A “for a period with on-going assessments and support whilst longer term options are considered”. Y was discharged to Care Home A on 31 October 2019.
19. The Council kept a conversation record of actions taken as a ‘rolling’ short term plan for Y. It did not complete a full care assessment. It says this was because Care Home A was seen as a short-term placement to enable a timely discharge from the rehabilitation centre and to allow Adult Social Care to fully assess Y’s needs outside the hospital environment.
20. The Council says, as a respite service Care Home A were asked to provide support with daily tasks in a manner that maintained Y’s independence as much as possible while ensuring his safety. It stated the placement was temporary with no reablement needs identified.
21. In December 2019 an occupational therapist (OT) observed Y and noted that he had difficulties with cognition. He needed significant verbal prompting for all tasks and he would be unable to manage safely or independently. This was support the OT expected to be needed long term.
22. In December Mr X raised a complaint. The complaint included Y’s discharge to Care Home A and whether Y’s needs were being met there. It also referenced two outpatient appointments and communication issues.
23. At a multi-disciplinary meeting on 7 January Y’s family stated they had been told to expect Y to need five years of therapy, so they were concerned he had been discharged after two months. They felt Care Home A did not meet Y’s cognitive needs because of a lack of activities and cognitive input. They felt Y’s cognition would deteriorate.
24. The notes indicate these concerns were discussed and action points were taken to establish what was included in the price being paid for Y’s place at Care Home A and to discuss the situation with Care Home A. There was also an action to consider what future cognitive therapies may be appropriate. The Council stated it was still looking for a placement for Y and it agreed also to discuss Y returning home with support.
25. On 13 January, following the meeting, the Clinical Lead Therapist sent an email to the Council. She agreed Y would not benefit from specialist therapy at this time. However, she questioned if Care Home A was currently meeting Y’s needs. She stated Care Home A should be able to meet Y’s needs; she had seen the home do this well with other patients. However, she felt the home may not have properly interpreted the package of care required. i.e. interpreted it as respite. She stated the input required from Care Home A was around structure, repetition, stimulation and time. Not so much therapy but more about maintaining Y’s ability to be the best he could be.
26. On 14 January a meeting took place to discuss the concerns Y’s family had raised. The meeting involved the family, council officers, and staff at Care Home A.
27. A note on Care Home A’s records stated Y’s needs were discussed. The staff explained they prompted Y’s morning routines, getting up, showering, getting breakfast etc. The notes included reference to Mr X stated he had been happy with Y’s progress.
28. A note on the Council’s records set out an action plan to address what had been discussed.
29. On 16 January 2020 the Council responded to Mr X’s complaint. The Council explained the NHS Rehabilitation Centre had been clear that Y would not be eligible for funding for further specialist rehabilitation and that a rehabilitation placement was not required. The Council stated its role was to find a social care placement to enable Y’s discharge from NHS care.
30. The Council commented that it had agreed additional time with the NHS to find a suitable placement. However, it told Mr X because the discharge from the Rehabilitation Centre needed to be achieved in a short timeframe it was agreed that Y should access a short-term respite placement at Care Home A.
31. In terms of Y’s care, the Council stated the Clinical Lead Therapist advised that Y would not benefit from intense, specialist rehabilitation at this time. It stated Y’s needs did not need health funding or specialist input, they could be met through social care provision. The Council noted there had been regular contact between professionals and the family during the discharge process and that the family had been involved in discussions about Care Home A, so it did not agree that the placement at Care Home A had been inappropriate. It stated the adult social care team had been transparent as to the reasoning for the placement.
32. In May, after discussion with Y’s family, he returned home with a package of care. The Council provided a copy of a support plan. The support plan sets out various care visits to support Y and his family. The Council says this was based on ensuring Y’s activities of daily living were being met and to provide routine. Although the plan sets out some care provision it does not set out what his needs were. The section of the plan recording Y’s needs is blank. Following discussions with Y’s wife the support has since been changed to better suit the family and their routine. The Council stated Y’s care worker was reviewing the situation regularly.
33. The Council carried out a needs assessment in October 2020 during our investigation.

Was there fault by the Council

34. The Care Act states a council must conduct a needs assessment where it appears that an adult may have need for care and support. It was clear Y had support needs. I note the Council kept a ‘conversation record’ showing actions it took when it became involved and placed Y in Care Home A. But it did not carry out an assessment his needs. This was fault.
35. In its complaint response the Council indicated, unfortunately, it only had a short timescale to find a placement when Y was leaving the Rehabilitation Unit. However, this was not through fault on the Council’s part. It also agreed extra time to mitigate this.
36. There is evidence in the discharge report from the Rehabilitation Centre and in comments made by a clinical psychologist that Care Home A was a suitable placement and one that could meet Y’s needs.
37. However, while it is clear that Care Home A had the capability to meet Y’s needs, there is some doubt about whether Care Home A was clear about what needs to meet and what role it should perform. I say this because the Council’s initial enquiry email to Care Home A asked if it could provide “respite”. The Council also told Y’s wife that it was a “respite placement” that was being arranged while options were considered. After Y’s family raised concerns in January, the lead therapist questioned if the care home had properly interpreted the package of care required. She indicated Care Home A was suitable; it had the skills and experience to meet his needs. However, she asked if it had misinterpreted what was required ‘as respite’. She stated the input required from Care Home A was around structure, repetition, stimulation and time. This was to help Y be as much as he could be.
38. It is clear that the NHS considered Y had been unable to make significant functional progress and recommended no further therapy at the point of his discharge. However, I found that the failure to complete a basic needs assessment led to a lack of clarity and communication about what Y’s specific needs were. Had a needs assessment been completed, it seems likely that this would have been avoided.
39. There is some evidence available to set out what medical professionals believed Y’s needs would be. These referred to support to complete daily activities, maintain safety and remain as independent as possible. In January a clinical psychologist stated he needed structure, repetition, stimulation and time. The aim of support being to enable Y to maintain his abilities.
40. Despite the lack of clarity, there is some evidence that routine prompting to carry out daily activities – getting up, preparing meals etc were provided by Care Home A. So, any lack of clarity did not result in all of Y’s needs not being met. It does not seem that the impact to Y was significant as it is clear that formal therapy was not to continue. However, there is some uncertainty about whether, had his needs been properly assessed, Y may have received more structured support during his stay at Care Home A. The lack of clarity was also frustrating for Y’s family.
41. When Y returned home, it seems the Council still did not carry out an assessment of Y’s needs. This was further fault.
42. I recognise Care Home A provided support and that the Council provided support to the family at home after May 2020. However, without a proper assessment and understanding of Y’s needs, it is difficult to see how the Council satisfied itself in both instances that his needs were being met fully until a needs assessment was later carried out.

Agreed action

43. Within eight weeks the Council agreed to:
44. apologise to Y’s family for the failure to carry out a proper needs assessment and the uncertainty about whether Y’s needs could have been better met at Care Home A and at home had this been done.
45. review why a needs assessment was not conducted in Y’s case in line with the Care Act. It should take any steps necessary to ensure that this situation is not repeated for other people.

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Final decision

46. There was fault. The Council agreed to remedy the complaint, so I have completed my investigation and closed my file.

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Investigator's decision on behalf of the Ombudsman