Summary: We found fault by the Council as it delayed in arranging a multidisciplinary team meeting to reach a consensus on Miss Y’s care needs and how they should be met. The Council will now make a retrospective decision as to whether a profiling bed was an appropriate means of meeting Miss Y’s night-time care needs. We found no fault by a Trust that was also involved in Miss Y’s care.

The complaint

1. The complainant, who I will call X is complaining about the care and treatment provided to his daughter, Miss Y, by North Tyneside Metropolitan Borough Council (the Council) and Northumbria Healthcare NHS Foundation Trust (the Trust).
2. Mr X complains that the Community Learning Disabilities Team (CLDT) failed to reassess Miss Y when her nighttime care needs changed. In addition, he complains that social workers failed to complete carer’s assessments and that professionals repeatedly ignored his concerns when he raised them.
3. Mr X says he was left with no choice but to purchase a profiling bed using Miss Y’s Direct Payments as neither the Council nor Trust had taken action to support the family. Mr X says this caused him and his wife significant distress and anxiety and placed the family at risk of harm.

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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. 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

7. In making my final decision, I considered information provided by Mr X and discussed the complaint with him. I also considered relevant records and information from the Council and Trust. Furthermore, I took account of relevant legislation and guidance. I invited comments from all parties on this draft decision statement and considered the responses I received.

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What I found

Relevant guidance and legislation

Care Act 2014 - Assessment

8. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and, where suitable, their carer or any other person they might want involved.
9. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.

Care Act 2014 – Carer’s assessment

10. Where somebody provides or intends to provide care for another adult and it appears the carer may have any needs for support, the council must carry out a carer’s assessment. A carer’s assessment must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself. This includes the practical and emotional support the carer provides to the adult.
11. As part of the carer’s assessment, the council must consider the carer’s potential future needs for support. It must also consider whether the carer is, and will continue to be, able and willing to care for the adult needing care. This is set out in the Care and Support Stautory Guidance (the Statutory Guidance) that accompanies the Care Act 2014.

Care Act 2014 - Review

12. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met.

Background

13. Miss Y has complex care needs. In 2022, Miss Y was living at home with Mr and Mrs X, who act her main carers. Miss Y attended a day centre five times per week. She also received two care visits per day, and 24 nights of care per year. Miss Y receives support from the Trust’s Community Learning Disabilities Service (CLDT) and the Council’s Whole Life Disability Team (WLDT).
14. In September 2022, Mr X contacted the Council to request a review of Miss Y’s support. He reported that her behaviours had increased and that she was sometimes sick at the day centre. This meant she had to go home and could not attend again for 48 hours. This in turn meant Mr or Mrs X needed to leave work to cover. In addition, Mr X said Miss Y was also sometimes sick at night because of lying flat on her back.
15. A social worker agreed to visit the family to carry out a review of her support needs. In the meantime, she agreed to make a referral to the Council’s Community Occupational Therapy (OT) service to see if Miss Y would be suitable for a hospital profiling bed.
16. In early October, the social worker was advised by the Community OT service to make a referral to the Trust’s CLDT OT instead. This was because Miss Y’s sickness appeared to be behavioural in nature.
17. On the same day, the social worker visited Mr X at home. Mr X told the social worker Mrs X would benefit from a carer’s assessment as she did most Miss Y’s personal care and he was often away with work. Mr X also raised queried whether Miss Y might be eligible for Continuing Healthcare (CHC) funding.
18. The following month, Mr X spoke to the social worker regarding Miss Y’s allocation of night care. Mr X said he felt the family needed and increase to 36 nights as they were exhausted.
19. On 20 December, the social worker discussed Miss Y’s care with a CLDT OT. The OT told the social worker she would need more information from Miss Y’s GP regarding her episodes of sickness. The OT said it was unlikely a profiling bed would be offered as Miss Y was mobile and these are usually used people who require hoisting.
20. The social worker contacted Miss Y’s GP on that day. The GP advised that the vomiting was behavioural. The GP explained that Miss Y was trying to cough to clear her throat. However, the GP said that problems with Miss Y’s cough would cause her to vomit instead. The GP said Miss Y would not tolerate being propped up with pillows and refused to lie in any other position than flat on b her back.
21. The CLDT OT queried whether Miss Y needed a Speech and Language Therapy (SALT) assessment to look at her swallowing and reflexes. The OT advised that the CLDT OT team would not need to see Miss Y. This was because, although her vomiting was behavioural, the vomiting itself was a physical need and did not require a CLDT assessment. The OT advised the social worker to make a further referral to the Community OT service. The OT also queried whether Miss Y needed a nursing referral.
22. In early January, Mr X spoke to a duty social worker. He again raised the possibility of a profiling bed, which he said the GP had recommended. The next day Mrs X also spoke to a duty social worker to request further support.
23. On 12 January, Miss Y’s social worker spoke to the CLDT again and was advised to make a SALT referral to examine Miss Y’s swallow and her continued vomiting. The social worker submitted the referral that day.
24. In mid-January, the Community OT Service again declined the referral. The screening OT said that, if the vomiting was a medical problem, Miss Y would need to be seen by the district nursing service. However, if it was a behavioural issue, she would need to be seen by CLDT OT.
25. Later that month, following discussion with her manager, the social worker decided to arrange a meeting involving the GP, family and a CLDT health representative.
26. On 13 February, Mrs X spoke to the social worker. She explained that family was still struggling. She also asked again whether Miss Y could have a profiling bed. The social worker explained that the OT services did not feel this would be appropriate for Miss Y. The social worker told Miss X that she was considering further referrals for Miss Y.
27. The Council convened a virtual multidisciplinary team meeting. This was attended by social workers, a psychologist, representatives from Miss Y’s day centre and respite placement and Mrs X. The meeting agreed Miss Y would need some additional waking night care as her behaviours were becoming more challenging.
28. A social worker completed a carer’s assessment for Mrs X shortly after this. This led to an increased respite allocation and additional fortnightly support at the weekends.
29. In early April, Mr X purchased a profiling bed for Miss Y using her Direct Payments. This led the Council to suspend the Direct Payments as this expenditure had not been authorised and the need for a profiling bed was not included in Miss Y’s care plan. The Council advised that Mr X would need to reimburse the cost of the bed.
30. Mr X approached the Ombudsmen shortly after this.
31. In May 2023, Mr X told a community nurse that Miss Y’s sickness had reduced since she had been sleeping in the profiling bed.

My analysis

Needs assessments

32. In his complaint to the Council, Mr X explained that he had been trying to deal with the problems relating to Miss Y’s night-time sickness since October 2022. He said this had not resulted in any meaningful support from the Council and that he therefore felt justified in purchasing the profiling bed when he did in April 2023.
33. In response, the Council said that public funds can only be used to meet a person’s assessed needs as set out in their care and support plan.
34. The evidence I have seen shows Mr X first raised concerns about Miss Y’s night-time care needs with a social worker in September 2022.
35. The case records show there was significant confusion surrounding the source of Miss Y’s night sickness. Between October 2022 and January 2023, the social worker made several referrals to the Community OT service and CLDT OT service. The Community OT service declined all referrals on the basis that Miss Y’s sickness was reported to be behavioural in nature and so related to her learning disabilities.
36. However, the CLDT OT service also declined the referrals. This was because, although the sickness was thought to be related to Miss Y’s behaviour, the service considered it to be a physical health need.
37. The situation appears to have been further complicated as both Mr X and Miss Y’s GP felt she would benefit from a profiling bed. Neither OT service shared this view.
38. By late December, referrals had been refused by both OT services. This should have led the social worker to arrange a multidisciplinary team meeting to discuss Miss Y’s care. This would have allowed the professionals supporting her to establish a clear picture of her needs and how they could best be met. This did not happen until March 2023. This was six months after Mr X first approached the Council for help. This represented fault by the Council.
39. While I appreciate this delay caused Mr X significant frustration, I am presently unable to say whether events would have proceeded differently even if the meeting had taken place in December 2022.
40. It is clear from the records that the Council did not authorise the purchase of the profiling bed. Mr X’s decision to purchase the bed therefore amounted to a misuse of Miss Y’s Direct Payments. This means the Council is entitled to recover the cost of the bed from Mr X.
41. However, there is some evidence to show that Miss Y benefited from the profiling bed and that her night sickness was reduced as a result. I have addressed this further in the ‘agreed actions’ section of this decision statement below.

Carer’s assessments

42. Mr X complained that social workers failed to complete carer’s assessments for hm and Mrs X.
43. The case records show a social worker visited Mr X in early October 2022 to discuss various aspects of Miss Y’s care. In her note of the visit, the social worker recorded that “I asked whether [Mr X] would need a carers [sic] assessment and I explained this to him, he feels that this would be better for his wife as she is the one that does the personal care at times for his daughter.”
44. I found no fault by the Council with regards to the fact that it did not complete a carer’s assessment for Mr X. This is because the evidence shows Mr X did not request a carer’s assessment.
45. The Council did complete a carer’s assessment for Mrs X in March 2023. This represents a delay of over five months from the point that the Council recognised a carer’s assessment was needed. The records suggest this delay was caused in part by the fact that the family’s allocated social worker changed during this period. I accept this delay would have been frustrating for Mr and Mrs X. However, I am satisfied a social worker did complete an appropriately thorough carer’s assessment for Mrs X that was in keeping with the requirements of the Care Act 2014.

Trust

46. The evidence I have seen shows that the Trust’s CLDT had only limited involvement in Miss Y’s care. Rather, it was the Council’s WLDT service that was responsible for ensuring Miss Y’s needs were properly assessed and care provided to meet them. For this reason, I have not made a finding of fault against the Trust.

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Agreed actions

47. Further to the recommendations set out in my draft decision statement, the Council has:

• written to Mr X to apologise for the frustration caused to him by its failure to arrange a timely multidisciplinary meeting to clarify Miss Y’s needs and how these should be met; and
• arranged a multidisciplinary meeting to discuss Miss Y’s care. The multidisciplinary team will make a retrospective decision on whether the profiling bed was an appropriate means of meeting Miss Y’s night-time care needs and reducing her risk of choking.

48. If the Council concludes the bed successfully met Miss Y’s night-time care needs and promoted her wellbeing, it will arrange a retrospective payment to fund the cost of the bed.
49. The Council will provide us with evidence it has complied with the above actions.

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Final decision

50. I identified fault by the Council as it delayed in arranging a multidisciplinary team meeting to discuss Miss Y’s care needs and how they should be met.
51. I am satisfied the actions the Council is undertaking represent a reasonable and proportionate response to the injustice caused to Mr X and Miss Y by the fault I identified.
52. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman