Summary: We have upheld Mrs Y’s complaints about the way Surrey County Council (the Council) and NCH Surrey Heartlands Integrated Care Board (the ICB) dealt with her brother Mr X’s care and communicated with her family. We have recommended remedies for Mrs Y and four family members. We have also recommended service improvements to prevent similar faults affecting others. The Council and ICB have accepted our recommendations, so we have completed our investigation.

The complaint

1. Mrs Y complained about matters affecting her brother (Mr X), herself, their sister (Mrs S) and their parents (Mr and Mrs P). She complained about the actions of Surrey County Council (the Council) and NHS Surrey Heartlands Integrated Care Board (the ICB). Mrs Y complained that:
1. the Council and ICB failed to provide adequate support to Mr X and his family from May 2022, and insensitively advised the family to call the Police. She said the support that was eventually offered was inappropriate because live-in carers would not be able to safeguard Mrs P from Mr X’s behaviour;
2. the Council and ICB’s communication with the family was flawed; and
3. the organisations’ complaint handling was flawed.
2. Mrs Y said this caused the following injustice:
• stress and upset for the whole family;
• Mrs P received daily injuries which could have been avoided had Mr X been accommodated in residential care;
• the family felt forced into making Mr X homeless because having him at home with his parents was no longer safe;
• the family feels ripped apart, broken, and let down. They feel that Mr X has been treated as if he did not exist; and
• Mrs Y needed 12 weeks of counselling to come to terms with what happened.
3. The complainants requested financial remedies and service improvements.

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The Ombudsmen’s role and powers

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen 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).
5. If it has, they 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.
6. The Ombudsmen may investigate complaints made on behalf of someone else if they have given their consent. The Ombudsmen may also investigate a complaint on behalf of someone who cannot authorise someone to act for them if the Ombudsmen consider them to be a suitable representative. (Health Service Commissioners Act 1993, section 9(3) and Local Government Act 1974, sections 26A(2) and 26A(1), as amended)
7. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
8. 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

9. I have considered:
• information provided by the complainant in writing and by telephone;
• responses from the Council and ICB to my enquiries, including answers to my questions and copies of records; and
• relevant law, guidance and policy.
10. Mrs Y, the Council and the ICB have had an opportunity to comment on this draft decision. I took their comments into account before reaching a final decision.

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What I found

Background summary

11. Mr X has a rare genetic condition that causes severe physical and learning disabilities. He also has diagnoses of autism, anxiety and mood disorder. His behaviour can become aggressive if he is unhappy or agitated. This poses a risk of harm to himself and others. He needs help and support with dressing, personal care, meals, and some support at night. He takes prescribed psychiatric and physical health medication. He cannot make his own decisions about medication or care.
12. Until 2022, Mr X’s care and support was organised by the Council under its duties under the Care Act 2014. In early 2022, the ICB started considering whether Mr X’s care and support should be provided through the NHS. The ICB decided in June 2022 that it should be. It then backdated Mr X’s entitlement to NHS care to January 2022. However, the Council remained responsible for his care until the ICB issued its decision in June 2022.
13. Until September 2022, Mr X lived with his parents, Mr and Mrs P, and attended a day centre five days a week. Mr and Mrs P worked as well as being Mr X’s main carers.

What happened

14. This section sets out the key events in this case and is not intended to be a detailed chronology.
15. The following is a summary of key events in May 2022.
• Mrs S contacted the Council stating the family was getting increasingly concerned with Mr X’s behaviour and aggression, lack of an appropriate wheelchair, lack of adaptations in the home, and medication issues. She said that if things did not improve at home, the family needed to start looking for a residential care place for Mr X. She said this would be despite it being an emotionally difficult thing to do for the whole family.
• In late May 2022, Mrs S contacted the Council social care email again to chase a response to her earlier email. She said Mr P needed emergency surgery and, when he returned home from hospital, Mrs P needed to care for him as well as Mr X. She also raised concerns about Mr and Mrs P struggling to care for Mr X, care workers failing to turn up and being late. She said Mr X was becoming more agitated.
16. The following is a summary of key events in June 2022.
• The ICB told Mr X’s family and the Council that Mr X was eligible for NHS Continuing Healthcare (CHC) early that month.
• Mrs S chased the Council for support twice in mid-June. This was around five weeks after her original request for support.
• A few days later, the ICB allocated a case manager and contacted the Council to arrange a handover. The same day, the Council told Mrs S that the NHS was now responsible for Mr X’s care and gave her the ICB’s contact details. The Council also emailed the ICB with information about Mrs S’s concerns.
• A day after these communications about a handover between the Council, Mrs S and the ICB, Mrs S emailed the ICB with urgent concerns about her parents coping and requesting residential care for Mr X.
• At the end of the month, the ICB tried to contact Mrs P, Mrs S and Mrs Y. The ICB could only get in touch with Mrs S, who explained her concerns again. The ICB’s officer asked the ICB’s placement team for advice.
17. There was a gap of about two and a half weeks, where neither the Council nor the ICB have evidence of acting on the family’s concerns. The following is a summary of key events from mid-July 2022.
• Mrs S emailed the ICB about residential care and problems with the current home care service. The ICB forwarded this email to various ICB officers, seeking advice.
• About two weeks later, the ICB called Mrs S to discuss the type of care Mr X needed.
18. The following is a summary of key events in August 2022.
• In early August, Mrs Y emailed the ICB with further serious concerns about Mr X’s aggression causing a car accident and injuries to Mrs P. She was also concerned about the home care agency cancelling visits. Mrs Y said the family wanted Mr X to go into supported living [where a person lives in their own house or flat and gets support there]. Mrs Y also gave the ICB details of a supported living home the family liked. One of Mrs Y’s emails, sent to the Council and ICB, was titled “OFFICIAL COMPLAINT”.
• Between 9 and 22 August, the ICB contacted the residential care home four times, trying to establish whether it was suitable for Mr X.
• The ICB replied to Mrs Y’s complaint on 12 August. On 16 August the Council closed Mrs Y’s complaint and advised her the ICB was responsible for dealing with it.
• On 23 August, the home told the ICB it could not meet Mr X’s needs. The ICB told Mrs Y and asked her for the family’s preferred areas for permanent and respite residential care. It also asked her if the family needed a respite placement while waiting for a permanent one. Mrs Y told the ICB the family would like a permanent residential place for Mr X that was up to 45 minutes’ drive away from the family home. She also asked for respite every weekend, Fridays to Mondays.
• Mrs Y spoke to the ICB on 25 August and emailed it after the conversation. She chased the ICB for a list of placements she says it had promised a week ago. She also said Mrs P could not cope and that care for Mr X in the family home would not resolve the problems. The ICB contacted another two placements and one immediately said it was full.
• On 26 August, Mrs Y emailed the ICB again to say Mr X had attacked Mrs P again while she was driving him and carers were unable to deal with his behaviour the previous night. She said he needed respite care now. On the same day, the other placement told the ICB it was full. The family managed to place Mr X in a short break respite care home for the following week. However, this care home had no spaces after 4 September so Mr X would need to return home then if there was no other residential care home for him to go to.
19. The following is a summary of key events in September 2022.
• On 9 September, Mrs Y emailed the ICB saying Mr X was refusing care from their parents and attacking them. The ICB asked whether Mr and Mrs P would accept care in the home while waiting for a residential place to become available. Mrs P refused this as they had tried this in the past and it did not work. The ICB advised the family to contact the Police in an emergency.
• On 12 September, Mr X’s day centre told the Council that Mrs P had left him there but could not pick him up at the end of the day. This was because she was unable to cope with him as he had been assaulting her regularly. The Council told the day centre that the ICB was responsible for supporting Mr X and the Council would look at any safeguarding issues. The Council told the ICB what had happened. The ICB asked the Council for help sourcing emergency placements. The organisations placed Mr X in his usual respite care home for the time being. He stayed there until 23 September.
• On the same day, the Council started a safeguarding investigation. It decided that Mr X had experienced and was at risk of neglect because Mrs P would not allow him to return to the family home. It decided that the following needed to happen to safeguard Mr X: a best interests meeting; moving Mr X to a permanent residential care home; and offering carer support to Mrs P who “has reached breaking point”.
• On 22 September, the ICB held a best interests meeting, attended by Mr X’s family and the Council. The attendees decided moving to a specialist residential care home would be in Mr X’s best interests.
• Mr X moved to his current, permanent residential care home shortly after.
20. In late October 2022, Mrs Y complained again to the Council about care and support for Mr X and his family. The Council and the ICB discussed this in early November and agreed the ICB would take the lead in responding to Mrs Y, while the Council contributed to the response. The ICB sent the complaint response to Mrs Y in mid-December 2022.

Relevant law, guidance and policy

Care Act 2014 – assessment, care and support

21. Local councils have duties under the Care Act 2014 to:
• assess adults’ and their carers’ needs for social care and support;
• if a carer is involved in supporting an adult, consider:
1. the sustainability of the caring role;
2. the carer’s potential future need for support;
3. whether the carer is likely to continue being able and willing to support the adult in the future;
• meet an adult’s and carer’s ‘eligible needs’ for care and/or support, as defined by the Care Act 2014 and associated Regulations;
• produce care plans showing how their eligible needs will be met; and
• reassess the person’s or their carer’s needs and revise their care plan if circumstances have changed in a way that affects their care plan.
22. Councils cannot provide or organise services that are clearly the responsibility of the NHS (Care Act 2014, section 22(1)).

Transfer of care responsibility between council social care and NHS Continuing Healthcare (CHC)

23. The key guidance for CHC is in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (the National Framework).
24. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. A person’s local Integrated Care Board (ICB) is responsible for arranging and funding the person’s health and social care.
25. An ICB may decide to assess whether a person who receives care and support from their council is eligible for CHC. While the person is waiting for the ICB’s decision, the council should continue to provide or arrange their care and support.
26. If the ICB eventually decides the person is eligible for CHC, the ICB becomes responsible for their care from that point. The local council remains responsible for supporting their carers’ eligible needs.
27. The ICB becomes responsible for planning the person’s care, commissioning services and case management. This should be person-centred and reflect the person's preferences where possible. It should deal openly with risk.
28. CHC case management includes:
• reviewing and assessing the person’s needs;
• monitoring the quality and suitability of the person's care and support arrangements; and
• responding without delay to any difficulties or concerns about them.
29. According to the ICB’s CHC operational policy:
• a case manager is “a named professional who is responsible for ensuring each patient who is eligible for CHC has a care plan, maintaining contact with the patient, their representatives and relevant professionals, monitoring and reviewing the needs of the patient and assessing the suitability of the package of care”;
• the care provided “should meet the patient’s health and associated social care needs as identified in their care plan”;
• the care plan “should set out the [CHC] services”.
30. The National Framework says ICBs and councils should have local protocols for handling transfers of care. This should include risk management.
31. Regulation 22 of The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 says ICBs must have “due regard to the need to promote and secure” the continuity of care for people who were getting Council social care when they became eligible for CHC.
32. The NHS Constitution establishes the principles and values of the NHS in England. Section 5 says that the NHS works jointly with council services “to provide and deliver improvements in health and wellbeing”.
33. The Care Act 2014 and The Care and Support (Provision of Health Services) Regulations 2014 say that:
• councils and ICBs must co-operate with each other; and
• councils must have “due regard to the need to promote and secure the continuity of appropriate services” for people whose support changes from social care to CHC.

Mental capacity and best interests

34. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves.
35. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity, must be in that person’s best interests. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.

Safeguarding

36. Councils’ and ICBS’ responsibilities on safeguarding are set out in the Care Act 2014, the Government’s Care and Support Statutory Guidance (CSSG), their own policies, and their local safeguarding adults boards’ policies.
37. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves (section 42, Care Act 2014).
38. CSSG says:
• “it is important to recognise that abuse or neglect may be unintentional and may arise because a carer is struggling to care for another person. This makes the need to take action no less important”;
• “no professional should assume that someone else will pass on information which they think may be critical to the safety and wellbeing of the adult. If a professional has concerns about the adult’s welfare and believes they are suffering or likely to suffer abuse or neglect, then they should share the information with the local authority”;
• “if a carer experiences intentional or unintentional harm from the adult they are supporting, or if a carer unintentionally or intentionally harms or neglects the adult they support, consideration should be given to [whether]… support can be provided that removes or mitigates the risk of abuse”;
• councils and ICBs “should ensure that they have the mechanisms in place that enable early identification and assessment of risk through timely information sharing and targeted multi-agency intervention”; and
• “abuse or neglect must be reported whatever the source of harm is”.
39. The Surrey Adult Safeguarding Board’s policies and procedures follow the Government’s Care and Support Statutory Guidance (CSSG). The ICB’s safeguarding policy and procedure says staff must act in accordance with the Surrey Adult Safeguarding Board’s policies and procedures and be mindful of their responsibility to safeguard adults. It also says staff must report safeguarding concerns immediately to a manager. This includes concerns arising from an observation of the behaviour of the adult.

Complaint procedures

40. Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 say that:
• councils and NHS organisations should have clear procedures to deal with health and social care complaints;
• where a complaint is about more than one “responsible body”, each organisation must co-operate when handling the complaint. They must decide who will lead the process, share relevant information and give the complainant a coordinated response;
• the Regulations do not say how long a complaint investigation should take. But they do say an expected timescale must be explained at the start and the organisation must keep the complainant informed of progress.

Was there fault causing injustice?

A – Support for Mr X and his family

41. The Council was responsible for Mr X’s care and support and supporting his parents’ needs as carers while awaiting a decision on Mr X’s eligibility for CHC. It took no practical action in response to Mrs S’s concerns in May 2022, even though it was still responsible for Mr X’s care at the time. For example, it failed to consider if it should review and revise Mr X’s care and his parents’ support plans in light of the information from his sister.
42. Mr X needed care and support. He was also at risk of unintentional neglect because of unsustainable care arrangements. Because of his needs, he could not protect himself from this. Yet the Council also failed to consider whether the information provided by Mrs Y in June about Mr and Mrs P not coping, and in early August 2022 about Mr X’s aggression being a risk to Mrs P and himself, amounted to:
• safeguarding concerns; and/or
• indications that Mr and Mrs P needed fresh carers’ assessment or a review of their support plans.
43. The Council’s actions were contrary to sections 27 and 42 of the Care Act 2014 and associated CSSG chapters. These were faults.
44. There was no co-operative working by the Council and ICB in preparation for the responsibility for Mr X’s care being transferred from the Council to the ICB. Even though the Council:
• knew about the CHC eligibility assessment and took part in it; and
• was aware of escalating problems with Mr X’s current care in May 2022;

it did not share this information with the ICB until the following month. This was contrary to the Care Act 2014, the National Framework, and the 2014 Regulations. It was fault by the Council.

45. When the ICB became aware of the concerns in June 2022, it did not consider whether it needed take urgent action. Although it had decided in early June 2022 that Mr X was eligible for CHC, it did not assess his needs or produce a care plan between June and September 2022. This was contrary to the National Framework and fault. It was a lost opportunity for the ICB to have clear insight at an early stage into Mr X’s increasingly challenging behaviour and the strain this was placing on his care arrangements, as well as his family.
46. Despite several contacts from Mr X’s sisters between June and September 2022 about the increasingly untenable situation at home for Mr X and the risks from his behaviour, the ICB did not consider:
• whether the family’s concerns amounted to safeguarding concerns which the ICB should report to the Council;
• Mr X’s capacity to make decisions about his care and where he lives, and what would be in his best interests if he could not make these decisions for himself;
• whether it should take urgent case management action to review Mr X’s needs, issue a care plan that addressed the needs and risks, and step up its search for more appropriate and sustainable care; and/or
• whether it should ask the Council for help in sourcing emergency or long-term care when its own searches took too long or were unsuccessful.
47. The ICB offered Mrs P extra hours of home care for Mr X as an interim solution. The ICB made its offers either direct or through Mrs P’s daughters. The ICB’s records say Mrs P rejected more home care because she did not think it would help as Mr X would still be in the family home, his challenging behaviour putting them both at risk. Again, there is no evidence the ICB considered Mr X’s ability to make his own decisions about more care in his own home, and what would be in his best interests if he could not. The ICB also failed to follow this up with a written care plan specifying what additional care it was proposing. This means that it would have been difficult for Mrs P to make informed decisions about the ICB’s offer. Given the ICB also decided that Mr X should go into residential care, it is unlikely that more home care would have made much of a difference to Mr X or his parents.
48. These were faults by the ICB. This is because the ICB’s actions were contrary to the National Framework, its safeguarding duties under the Care Act 2014, safeguarding guidance as set out in CSSG, as well as local safeguarding and CHC operational policies.
49. Collectively, the ICB and the Council allowed concerns about the sustainability of Mr X’s care at home, and potential safeguarding issues, to drift until Mr X’s family reached a crisis point and felt they had no choice but to refuse to collect Mr X from his day centre.
50. The Council’s and ICB’s faults, taken together, have caused the following injustice to Mr X and his family.
• Had the Council and ICB acted without fault at an early stage, it is more likely than not that Mr X would have had a more orderly and less distressing transition from living with his parents to living in residential care. The situation of Mrs P feeling she had no option but to leave her extremely vulnerable son at a day centre with no plans for him from that evening onwards, most likely would not have happened, had the Council and ICB acted without fault.
• Based on what Mrs Y told me and the organisations’ records, what happened caused Mr X avoidable distress, which is a particularly severe injustice given his vulnerability. It also placed Mr X and Mrs P at increased risk of physical harm from Mr X’s aggression, for example the car accident that happened when he attacked Mrs P as she was driving him.
• Mr X spent longer than necessary receiving care in a way that was no longer suitable for him.
• Mrs P was in an unsustainable, stressful and dangerous caring role for longer than she should have been.
• Mr X’s parents and sisters also suffered significant avoidable distress as a result of what happened. In Mrs Y’s own words, the family feels ripped apart, broken, let down, and that Mr X has been treated as if he did not exist.
51. We have therefore made recommendations at the end of this decision statement.

B – Communication with family

52. The Council’s communication with the family is characterised by delay. For example, it:
• did not respond urgently to concerns of aggression and not coping the family sent in May 2022, despite Mrs S chasing the Council twice;
• did not check in at all with Mr X, his parents or the agency it had commissioned to provide Mr X’s care;
• did not communicate with Mrs S until 1 June 2022, and then failed to communicate with her again until 20 June, after Mrs S chased it twice; and
• informed Mrs S it would not be involved in care issues on 20 June, despite knowing of the CHC decision two weeks earlier.
53. The ICB first became aware of the family’s concerns on 20 June 2022. But it did not reach out to the family until 28 June, a week after Mrs S emailed it with more urgent concerns on 21 June. There were further delays and flaws in the ICB’s communication with Mr X’s family, for example:
• there was no communication with the family between 28 June and 15 July, and the ICB only contacted the family after a chaser sent by Mrs S;
• there was no further contact with Mrs S for another 12 days; and
• the ICB did not ensure it communicated directly with Mr and Mrs P, despite the serious concerns raised by Mrs S.
54. The ICB’s communication with Mr X’s family became more regular for about a week after their complaint of 5 August. It stopped again after 12 August, until Mrs Y chased it on 22 August. The ICB’s communication became more regular after then.
55. Overall, the Council and ICB did not communicate regularly or quickly enough with the family when Mr X’s sisters were telling them of the escalating problems with caring for Mr X at home. This was fault.
56. Mr X’s family is very upset by the advice the ICB gave them in early September 2022 to call the police in an emergency if Mr X’s behaviour escalated. It is understandable that the family would feel upset by the idea of calling the police to deal with a distressed response by a vulnerable disabled person whom they love. While the ICB’s advice was upsetting, it was also appropriate in the situation. This is because the police were realistically the only service that could help in an emergency if aggression by Mr X put him or anyone else in danger. But, for the reasons set out in section A above, it is also my view that the situation is unlikely to have arisen, if the Council and ICB had acted without fault from the outset.
57. There is no evidence the ICB contacted Mr X’s family to discuss how he was settling into life at his new residential care home when he first moved there. This was contrary to the ICB’s CHC operating policy which talks about case management involving maintaining contact with patients and their representatives.
58. The faults in the Council’s and ICB’s communication with Mr X’s family have added avoidable uncertainty to the family’s avoidable distress. The faults have also caused Mrs S and Mrs Y the avoidable frustration of having to chase the two organisations for responses and updates.
59. We have therefore made recommendations at the end of this decision statement.

C – Complaint handling

60. The Council did not deal with or input into the ICB’s response to Mrs Y’s first complaint of August 2022, despite the complaint including a period when Mr X was under the Council’s care. It simply closed the complaint and told Mrs Y the ICB was now responsible for her brother’s care. This was contrary to the 2009 Regulations and fault. It caused Mrs Y avoidable frustration.
61. The ICB’s complaints procedure says it should respond to complaints within 25 working days. It replied to Mrs Y’s complaint within a week. We have found no fault in the way the ICB dealt with the first complaint.
62. The Council and ICB’s records indicate they received Mrs Y’s second complaint a few days apart from each other, either at the end of October or the beginning of November 2022. The Council sought consent from Mrs P before starting to deal with the complaint. This was appropriate given the nature of the complaint and that Mrs Y did not have legal power of attorney for her brother. Once it had consent from Mrs P, the Council discussed the complaint with the ICB. The Council and ICB agreed the ICB would respond on behalf of both organisations. This was in accordance with the 2009 Regulations and not fault. According to its complaints policy, the ICB should have sent a response to Mrs Y by the end of November. However, there was a delay. The ICB sent Mrs Y a holding email about the delay in early December, issuing a final response in mid-December. While the ICB took longer than its policy to respond to Mrs Y, it acted in accordance with the 2009 Regulations by keeping her informed about the delay and ensuring she received a co-ordinated response from both organisations. I have therefore not found fault in the way the organisations dealt with Mrs Y’s second complaint.

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Agreed actions

63. Our recommendations are in line with the Ombudsmen’s published guidance on remedies.

Remedies for the complainants

64. Within one month of our final decision on this complaint, the Council and ICB will write to Mrs Y, Mrs S, Mrs P and Mr P individually with meaningful apologies for the faults we have identified through our investigation and the impact those faults have had on them.
65. Within three months of our final decision, the Council and ICB will make the following symbolic payments in recognition of the injustice caused by their faults.
• The Council and ICB will each pay £500 to Mrs P for her to use for Mr X’s benefit. This is in recognition of the organisations’ faults causing avoidable distress and risk of harm to Mr X, as well as causing him to spend longer than necessary receiving unsuitable care.
• The Council and ICB will each pay £500 to Mrs P in recognition of the organisations’ faults causing her avoidable distress and risk of harm, and her having to act as a carer in unsustainable and dangerous circumstances for longer than necessary.
• The Council and ICB will each pay £250 to Mr P in recognition of the organisations’ faults causing him avoidable distress.
• The Council and ICB will each pay £350 to Mrs Y in recognition of the organisations’ faults causing her avoidable distress, as well as frustration through poor communication.
• The Council and ICB will each pay £350 to Mrs S in recognition of the organisations’ faults causing her avoidable distress, as well as frustration through poor communication.

Service improvements

66. Within one month of our final decision, the Council will review its handling of Mrs Y’s first complaint of August 2022 and the family’s communications that indicated safeguarding concerns. The Council will then share any lessons learned from the review in anonymised format with the appropriate teams.
67. Within three months of the date of our final decision, the ICB will take the following steps to prevent similar problems affecting others.
• Ensure all staff are aware of, and know how to implement, its safeguarding policy, the local safeguarding adults board policy and the ICB’s safeguarding duties under the Care Act 2014. This should include appropriate record-keeping.
• Ensure all relevant staff are aware of and know how to put into practice the ICB’s duties and responsibilities as set out in the Mental Capacity Act 2005 and associated guidance. This should include appropriate record-keeping.
• Review and if necessary update its procedures to ensure people who become eligible for CHC have an appropriate CHC care plan in place, when the ICB takes over responsibility for their care.
• Review and if necessary update the systems it has in place for dealing with breakdowns in care provision and sourcing emergency care.
68. Within three months of the date of our final decision, the ICB and Council will jointly review, and if necessary update, the systems and protocols they have in place for transferring care responsibilities from one organisation to another. This should include risk management and information sharing both at the point of transfer and during any lead-in or transition period. We are pleased to note that the ICB and Council have already started work on this.
69. The organisations will provide us with evidence they have complied with the above recommendations for personal remedies and service improvements.
70. The ICB will send copies of action plans resulting from our recommendations to the complainant and its NHS England local area team.

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Final decision

71. We have upheld Mrs Y’s complaints. The Council and ICB have accepted our recommendations. We have therefore completed our investigation.

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Investigator's decision on behalf of the Ombudsman