Summary: Mrs A complained about the care Somerset Council and Somerset NHS Foundation Trust provided to her daughter, Miss B, before her death. She complains the Council and Trust refused to provide funding for 24-hour care which Miss B needed, could not find Miss B a suitable care agency and tried to force the family to accept direct payments. Based on the evidence reviewed, we found no fault with the actions of the organisations.

The complaint

1. Mrs A complains about the care provided to her daughter, Miss B, now deceased, by Somerset Council (the Council) and Somerset NHS Foundation Trust (the Trust). Miss B’s care was jointly funded.
2. Specifically, Mrs A complains;
• The Council found Miss B a bungalow on a supported living site with on-site carers. After Miss B moved there, the Council said she could not receive support from the on-site team because she did not meet the eligibility criteria. The Council did not explain this to her family before she moved or explain why it thought the bungalow would be suitable for Miss B.
• The Council told the family aids and adaptations would be made before Miss B moved there, but these were not done. Her wheelchair could not fit through the door, and she also fell twice and was hospitalised.
• While Miss B was in hospital, the Council said it was going to reduce the care hours it paid for. The Council offered to fund seven hours a day and a carer to sleep in at night. Mrs A says this was not enough to keep Miss B safe. She had complex needs which needed a 24-hour care package. Mrs A complains the Council refused to reassess Miss B’s needs, despite the family’s insistence the proposed care hours were not enough.
• The Council pressured Miss B to take direct payments so she could manage her own care. Mrs A told the Council the care agency they wanted to use, but the Council refused to contact them, saying they were unsuitable.
3. Mrs A said the Council did not help with a difficult situation. Miss B had to spend a long time in hospital before she sadly died, and Mrs A believes this was because the Council refused to provide adequate and safe care. The Council refused to recognise Miss B’s complex physical and learning disabilities and has provided no explanation to the family to why it thought its actions were suitable.
4. Mrs A would like an apology and service improvements which will ensure others are not placed in a similar situation.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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). If it has, we 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.
7. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. 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, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. When investigating complaints, if there is a conflict of evidence, we 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. 
9. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our 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

10. I have considered information Mrs A provided in writing and by phone. I considered documents and comments on the complaint from the Council and the Trust. I also considered relevant law, policies and guidance.
11. Mrs A and the organisations had the opportunity to comment on the draft decision.

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What I found

Background

12. Miss B had Emotionally Unstable Personality Disorder (EUPD), autism and Functional Neurological Disorder (FND). She was previously cared for at home by Mrs A before moving to independent accommodation, supported by the Council.
13. Miss B had complex needs and found it difficult to communicate with care workers whose first language was not English. These difficulties led to several care companies not being able to work with her.
14. After a fall, Miss B went into hospital for treatment. The Council had difficulties finding a new care company and this meant she stayed in hospital for a long time, even when she was medically well enough to leave.

Bungalow placement by the Council and decrease in care hours

The complaint

15. Mrs A complains the Council found Miss B a bungalow on a supported living site with on-site carers. In May 2024 Miss B moved there but the Council said she could not receive support from the on-site team because she did not meet the eligibility criteria. Mrs A does not understand why the Council felt the bungalow was suitable for Miss B if she could not access the on-site support.
16. Mrs A also complains the Council reduced Miss B’s funded care hours shortly after she moved into the bungalow. Mrs A says the reduced hours were not enough to keep Miss B safe, she needed 24-hour care. Mrs A says the Council refused to reassess Miss B’s needs and did not do enough to find a new care company.

What happened

17. I asked the Council to explain why it felt the bungalow was suitable for Miss B, and why she could not access the on-site support team.
18. The Council assessed Miss B under the Care Act 2014. She had eligible needs, including mobility issues and issues with personal care such as showering. The Council’s occupational therapy team assessed the bungalow and found it could meet Miss B’s mobility needs and there was a wet room.
19. The Council explained it spoke to the onsite support provider about whether it could help Miss B with personal care. The provider said because Miss B’s primary diagnosis was mental health related, under the terms of the provider’s Care Quality Commission registration, it could not offer any support to Miss B. 
20. The Council had a meeting with the provider to discuss this further in April 2024. It asked them to reassess as Miss B had a diagnosis of autism. The provider explained it could not support Miss B at night because the staff on-shift were commissioned to support other residents. The provider worried whether, especially at first, Miss B would need night support, so the Council agreed to consider this before Miss B moved into the property.
21. I have reviewed the Care Act assessment from January 2024. This says Miss B has a high-level of needs, but nowhere in the assessment does it state she needs 24-hour care.
22. Although the on-site support team could not help Miss B, the Council wanted to ensure her safety so it agreed to fund a 24-hour live-in carer temporarily. This was to allow Miss B to adjust to her new home and so the Council could assess her longer-term needs. The Council agreed funding for up to four weeks.
23. In this time, Miss B found it difficult to have someone around all the time and wanted more independence. Mrs A explains Miss B told her this was because Miss B found the staff hostile and they showed her no respect. Miss B asked to reduce the number of hours a care worker was there for, and the Council reduced the care hours to seven hours a day.
24. In summary, even without the support of the on-site team, the bungalow was suitable for Miss B. The 24-hour care funding was only ever agreed temporarily and it was Miss B who asked for the reduction in care hours to promote her own independence. Miss B’s Care Act assessment did not state she needed 24-hour care. I am satisfied that the Council arranged suitable care to meet Miss B’s eligible needs in relation to mobility and personal care. I can find no fault.

Changes to bungalow and equipment orders

25. Mrs A complains the Council told the family it would make changes to the bungalow before Miss B moved there. When she did, the family found many of the adaptations were not complete.
26. Miss B moved to the bungalow on 22 May 2024. I asked the Council to explain what changes had to happen to make the bungalow safe for her. I also asked it to explain if it needed to order any specialist equipment.
27. The day Miss B moved into the bungalow, an occupational therapist was present. They assessed her access to the bungalow and reviewed the equipment which had been ordered based on her Care Act assessment. The occupational therapist found Miss B’s wheelchair could not fit through the front door, but she could enter through the back door. Mrs A disputes this explaining the floor was uneven so Miss B could not self-propel through the door but the Council’s notes do not show this being raised as a concern at any time.
28. The door into the living space was also not wide enough and her wheelchair could not fit through. The Council made a referral to the specialist wheelchair team for them to assess Miss B’s wheelchair and decide what could be done about the door width.
29. The Council ordered the following equipment for Miss B before she moved into the bungalow:
• Ceiling Track Hoist, to help Miss B stand up as she struggled to do this without help
• Wash/Dry Toilet and a Tilt-in-Space Shower Chair to aid with independent showering
• Bariatric riser recliner chair
• Electric wheelchair
• Wheeled commode
• Bed, rails and specialist mattress
• Slide Sheets, to help care workers move Miss B
30. I have reviewed the purchase orders and receipts for the items. I have also reviewed the occupational therapist’s notes from the day Miss B moved into the bungalow.
31. The Council said the delivery of the ceiling track hoist was delayed, and it did not arrive until two weeks after Miss B moved in. I have seen evidence the Council ordered the equipment on 26 April. The order was marked urgent and chased by the Council with the supplier. The issue with delivery was because it was coming from Europe. This was outside the Council’s control.
32. In the short-term, the Council provided a mobile hoist to help care workers with Miss B. On her move in date, the delivered hoist was faulty so a replacement was ordered and delivered the same day.
33. A couple of days after her move, two occupational therapists visited to check how the equipment was working, and if there was anything else Miss B needed. The care workers explained some equipment was not suitable for Miss B and asked the Council to find an alternative while they waited for the missing order. The occupational therapists agreed to this, and gave advice to care workers on how to help Miss B.
34. The Ceiling Track Hoist was installed in Miss B’s bedroom on 30 May 2024, eight days after she moved into the bungalow.
35. On 14 June 2024, Miss B had her wheelchair assessed and discussions about widening the doors. On 16 June, the Council applied for a Disabled Facilities Grant to cover the cost of widening the doors and adaptations to her bathroom.
36. On 23 July, the Council’s records say Miss B fell in her bathroom after trying to self-hoist to the mobile shower chair. Mrs A disputes this, saying she fell when she tried to self-hoist to lock a door to stop care staff from returning. In whichever case, Miss B knew it was not safe for her to self-hoist and had previously been told not to try to do this without help. Miss A had to go to hospital.
37. While I appreciate these matters would have been distressing for Miss B and Mrs A, I am satisfied the Council did all it could to speed up the order for the missing equipment. It put in a works request to get the door frames resized in the bungalow so Miss B’s wheelchair could fit through. It ensured Miss B was safe with alternative equipment and 24-hour care on a temporary basis and she could access the property through the back door. I can find no fault.

Direct payments

38. Mrs A says the Council pressured Miss B to take direct payments so she could manage her own care when she came out of hospital. Mrs A told the Council about the care agency they wanted (Care Agency A), but the Council refused to contact them, saying they were unsuitable.
39. Mrs A sought legal advice and her solicitor contacted the Council. The letter explained why the family did not want to accept the direct payments and again asked the Council to contact the care agency the family wanted.
40. I asked the Council to explain what had happened after the relationship with the care agency broke down, which resulted in Miss B going into hospital.
41. The Council said because Miss B’s behaviour could be unpredictable, this had caused several care agencies to refuse to work with her. There are six suitable companies in the area, and Miss B had already worked with three. The other three refused to consider helping Miss B because of the previous difficulties she had had with workers whose first language was not English.
42. It said if Mrs A and Miss B had direct payments from the Council, they would have more control over her care. Taking the Council’s involvement out of the process could make things easier for them and prevent any further disagreements with the Council.
43. It also said as soon as it knew the last care agency had served notice, it put a request out to tender to all suitable companies in the area, but there was no response.
44. When Mrs A suggested Care Agency A, the Council contacted it in August 2024 to explain the funding it was providing for Miss B, and the care she needed. Care Agency A explained this was different to what the family had explained, and agreed it was not a suitable agency to provide support to Miss B.
45. In October 2024, the Council explained to Mrs A it would not fund 24-hour care for Miss B and explained the reasons. It wrote to her and encouraged the family to accept direct payments so they could then handle Miss B’s care how they felt was best. This was when Mrs A contacted a solicitor, and the solicitor wrote in response to the Council in November 2024 explaining it could not force Mrs A to accept direct payments.
46. The Council responded to Mrs A’s solicitor on 24 December 2024. It explained since Miss B had been in hospital, it had “explored all commissioned mental health providers in their search to find a new provider … but have been unsuccessful.” The letter then discussed Care Agency A, and explained that at first, the views of Care Agency A and the assessed needs by the Council did not align so the agency refused the commission. On 23 December the Council had met with Care Agency A to explain its position and to ask the agency to reconsider, as they remained the first choice of Miss B and her family. The outcome of the meeting was Care Agency A agreed to work with the Council to get Miss B out of hospital and back into her bungalow. Miss B’s hospital discharge was provisionally arranged for 27 January 2025. Before this could happen, Miss B sadly died in hospital.
47. In the same letter, the Council explained it had offered direct payments as this was a consideration under the Care Act 2014. It explained it was not an ultimatum, but the Council saw it as a means of helping Miss B and her family manage her care. Mrs A explained she did feel it was an ultimatum and this caused her a lot of distress.
48. The Care Act 2014, section 31, states four conditions which must be met before a Council can offer direct payments. These include:
• the adult has capacity to make the request for a direct payment
• the local authority is satisfied the adult can manage direct payments, either on their own or with whatever help is available to them
• the local authority is satisfied that making direct payments (either to the adult or someone nominated) is an appropriate way of meeting the needs for care and support.
49. Miss B met these conditions and as there was a difference in opinion about her care needs, it was suitable for the Council to offer direct payments to the family.
50. I understand the events which led up to the offer of direct payments were difficult for Mrs A and Miss B. Mrs A’s priority was the safety of her daughter, and the differing views about her needs would have added extra difficulties. However, I have not found fault with the Council’s actions. It contacted the available providers in the area, including Care Agency A as it was the family’s choice. When none of this worked and the Council had been unable to find a care agency to support Miss B, the Council offered direct payments to the family as a way of trying to help them manage a difficult situation.
51. I do not find fault with the actions of the Council. The evidence has shown it did what it could to help find Miss B a new care provider, and it offered direct payments as it felt this might help address the difficulties in getting a suitable care package in place.

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Decision

52. I do not uphold this complaint. I found no fault in the areas of Miss B’s care that are the subject of the complaint I have investigated.

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Investigator's decision on behalf of the Ombudsman