Northern Devon Healthcare NHS Trust (16 010 515a)

Category : Health > Other

Decision : Upheld

Decision date : 22 Oct 2018

The Ombudsman's final decision:

Summary: Mrs T complained about the way the Council and the Trust dealt with her late father’s discharge from hospital. She also complained about the care and support he received at home after he left hospital. Mrs T said this had an adverse impact on her father’s wellbeing and caused her avoidable distress. The Ombudsmen found no fault in the way the Council and the Trust dealt with the discharge arrangements. The Council did not properly monitor the care agencies it commissioned to provide care to the complainant’s father which resulted in him receiving some poor care. The Trust did not consider completing a checklist before deciding the complainant’s father was not eligible for healthcare funding. The Council and the Trust have agreed to the Ombudsmen recommendations to apologise to the complainant and improve their procedures. The Council will pay
Mr D’s estate and Mrs T a financial remedy to acknowledge the injustice caused.

The complaint

  1. Mrs T complains about the care and support provided to her late father, Mr D, by the Council and the Trust. She complains that:
    • the Trust did not consider her father’s health needs when its occupational therapy department assessed his mobility and potential for rehabilitation;
    • the Trust and the Council did not communicate properly when planning her father’s discharge from hospital and this resulted in poor discharge arrangements;
    • the Council did not allocate a social worker to review her father’s care package and act as point of contact for the family from the date he was discharged;
    • the Council did not monitor the care agencies it commissioned to provide support and did not complete formal reviews. This resulted in Mr D receiving poor care; and
    • the Council or the Trust did not complete a checklist to determine whether her father should be assessed for healthcare funding.
  2. Mrs T said this had an adverse impact on Mr D’s wellbeing and caused her and her family avoidable distress.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
  2. 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)).
  3. 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.
  4. 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

  1. I have considered information provided by the complainant, the Council, the Trust and a third-party Trust which held Mr D’s health records but is not named in this complaint. I have also considered the law and guidance relevant to this complaint. All parties have been given an opportunity to respond to a draft decision.
  2. The responsibility for hospital where Mr D was an inpatient transferred to a different Trust on 1 October 2016. However, Northern Devon Healthcare NHS Trust remains the responsible healthcare provider for this complaint because the events complained about occurred before 1 October 2016.

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What I found

  1. Sections 9 and 10 of the Care Act 2014 require local authorities to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to all people regardless of their finances or whether the local authority thinks an individual 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.
  2. The Council must carry out the assessment over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Local authorities should tell the individual when their assessment will take place and keep the person informed throughout the assessment.
  3. Section 27 of the Care Act 2014 gives an expectation that local authorities should conduct a review of a care and support plan at least every 12 months. The authority should consider a light touch review six to eight weeks after agreement and signing off the plan and personal budget. It should carry out the review as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. As well as the duty to keep plans under review generally, the Act puts a duty on the local authority to conduct a review if the adult or a person acting on the adult’s behalf asks for one.
  4. Department of Health guidance: Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go guidance’) is the core guidance around hospital discharge. It contains ten key steps for staff to follow during discharge planning, including:
    • start planning for discharge or transfer before or on admission;
    • identify whether the patient has simple or complex discharge and transfer planning needs and involve the patient and carer in your decision;
    • involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.
  5. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
  6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: In summary, Regulation 12 says, providers must assess the risks to people's health and safety during any care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe. Care and treatment must be provided in a safe way for service users. The things that a registered person must do to comply with this regulation include:
    • assessing the risks to the health and safety of service users of receiving the care or treatment;
    • doing all that is reasonably practicable to mitigate any such risks;
    • Assessments, planning and delivery of care and treatment should:
        1. be based on risk assessments that balance the needs and safety of people using the service with their rights and preferences.
        2. include arrangements to respond appropriately and in good time to people's changing needs.
  8. The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care 2012 contains information about how organisations should screen people for healthcare funding. This says, “the first step in the process for most people will be a screening process, using the NHS continuing healthcare Checklist… A nurse, doctor, other qualified healthcare professional or social care professional could apply the Checklist to refer individuals for a full assessment of eligibility for NHS continuing healthcare from either a community or a hospital setting. Whoever applies the checklist should be familiar with, and have regard to, the content and principles of this guidance and the Decision Support Tool.”


  1. Mr D lived at home alone and had been diagnosed with prostate cancer with bone metastasis. Mr D’s daughter felt the symptoms of his diagnosis was having greater impact on his wellbeing. She contacted the Council in January 2016 because of concerns she had. The Council logged the contact for follow up.
  2. Shortly after Mrs D’s daughter contacted the Council he experienced a fall at home and fractured his right hip. He was taken to the Trust’s hospital where he remained for treatment and surgery.
  3. A few weeks later the Trust started discussing Mr D’s discharge arrangements. The discussions centred around the care package Mr D would need to enable him to leave hospital and continue living at home.
  4. The Council did not allocate a social worker to Mr D’s case and his discharge arrangements were managed by its Care Direct Plus team. This team completes assessments, helps to create a care and support plan and liaises with care providers when developing a care package. The team contacted Mr D and other family by telephone and there was no face-to-face contact.
  5. Occupational therapists working for the Trust went to visit Mr D’s home to assess what equipment he would need at home when he was discharged. The Council said it shared information with health colleagues to inform Mr D’s discharge arrangements.
  6. Mr D was discharged to a different hospital in March for rehabilitation. The Council developed a care plan using information obtained from the Trust and commissioned a homecare provider, Agency 1, to provide a morning support call of 45 minutes for when Mr D returned home. It then developed a care plan which set out the support Mr D would receive at home.
  7. The Trust contacted the Council in April with an update about Mr D’s prognosis. The record of the call confirmed Mr D had not yet been considered for healthcare funding. The Council continued to ask the Trust about a referral for healthcare funding. The records state the Trust’s officer felt Mr D would not meet the criteria for healthcare funding. However, it was noted that Mr D may need more support at home than one support call daily.
  8. Mr D remained in hospital until 11 April. The Care Direct Plus team contacted him by telephone the day after his discharge. Mr D told the team member he needed an extra visit in the evening so he had someone who could help him to bed.
  9. The Council then commissioned a different homecare provider, Agency 2, to provide a daily evening support call of 30 minutes starting from 14 April. Agency 1 continued to provide the support call in the morning.
  10. The Council’s records note from July that Mr D was feeling anxious about being left alone for long periods and wanted to go into residential care. The records indicate his daughter was concerned about the home care agencies communication. Mrs T’s concerns included the care agencies missing visits, issues around Mr D not having his medication on time and the development of a pressure sore.
  11. Mr D’s condition worsened over the next few weeks from July and the case records indicate discussions between Mr D’s family, the Council and health professionals about an increase in support. Mr D starting to receive support from a Rapid Response team shortly after these discussions. This team started to provide a lunchtime call temporarily.
  12. Mr D’s other daughter contacted the Council’s Emergency Duty Team (EDT) in July. She said she had asked the Council to place her father in residential care because of concerns about his wellbeing. The EDT told Mr D’s daughter he would need to be assessed before he could go into a residential home. Mr D’s daughter said she remained concerned because she felt the care her father was receiving was not meeting expected standards.
  13. A Community Matron went to visit Mr D near the end of July. The Community Matron telephoned the Council and said Mr D’s “pain levels are at 7/8 out of 10. He is unable to access oral pain relief as he cannot do this himself and staff cannot do it.” The Community Matron said the family had asked that the Council arrange a placement as soon as possible.
  14. The Council’s records show it agreed funding for residential and nursing care shortly after contact from the Community Matron. Mrs T told the Council she was aware of a suitable home and said she would make enquiries. She later confirmed the home had vacancies and she felt the placement would meet Mr D’s needs.
  15. Mr D moved to his preferred home on 29 July. Both his daughters were happy with the placement and the home also had links with a hospice. Mr D remained in the home until 23 August when he passed away.


Consideration of Mr D’s health needs by the Trust and communication between the Council and the Trust about discharge

  1. The Council did not get an opportunity to assess Mr D’s needs when his daughter first made contact in January 2016 because he went into hospital. Mr D’s daughter kept the Council updated with progress during the initial weeks of his hospital admission. The Council then decided not to assess Mr D and there is no fault in this decision.
  2. After Mr D moved to the second hospital for rehabilitation the evidence available shows the occupational therapy team were heavily involved in facilitating his discharge home. This involvement included arranging suitable equipment for
    Mr D’s house and speaking to Mr D’s daughter (Mrs T’s sister). Occupational therapists noted that Mr D may experience fatigue if undergoing chemotherapy and because condition was progressive. In response, they asked the Council to increase the care package. This is good practice.
  3. The Council confirms it did not allocate a social worker to Mr D’s case but says the discharge arrangements were dealt with by its Care Direct Plus team. The Care Direct Plus team arranged a care package after completing an assessment. The Council says the assessment was completed using information provided by hospital staff. This information was then used to complete a care and support plan. The evidence suggests the Council did not complete the assessment or care and support plan face-to-face with Mr D but this is not fault. The government’s care and Support Statutory guidance suggests an assessment can be carried out in various ways. On balance, the Council and the Trust had adequate communication about what services Mr D would need on discharge.
  4. The records provided show the Care Direct Plus team had discussions with the Trust about healthcare funding. The team also spoke to a nurse who confirmed she had referred Mr D to the community nurses. This shows satisfactory communication between the Council and the Trust.
  5. Discussions the Trust had with Mr D’s daughter (not Mrs T) showed it considered Mr D’s health needs including his cancer diagnosis. An occupational therapist agreed to be the main point of contact during the discharge process to better deal with the concerns and anxiety expressed by Mr D’s family. The occupational therapist also liaised with the oncology department and explained when a Macmillan Cancer Support Nurse would be involved if necessary.
  6. The Trust had discussions with Mr D’s housing provider to ensure all necessary equipment could be in place for when Mr D returned home. This is good practice and is evidence to show the Trust considered Mr D’s health needs during the discharge process. I do not find the Council or the Trust at fault in the way they dealt with Mr D’s discharge arrangements.

The Council’s decision not to allocate a social worker when Mr D was discharged

  1. In response to the Ombudsmen’s enquiries the Council said, “there was no explicit reason why a social worker would be required” for Mr D’s care and support arrangements. The Council felt the Care Direct Plus team were suitably able to arrange the care package. It also said if Mr D needed a social worker on discharge a referral could have been made to the appropriate team. The evidence available suggests Mr D would have benefitted from having a social worker once he was discharged from hospital.
  2. The Trust made the Council aware of Mr D’s prognosis just before he was discharged from hospital so the Council was aware that Mr D had a progressive illness. The hospital and the family asked the Council to arrange an evening support call visit in addition to the morning visit agreed by Agency 1 because of the increase in support needs. When the Council spoke to Agency 1 on 12 April it was unsure whether it could work with a different care agency. In any case the Council then commissioned Agency 2 when Agency 1 said it could not provide the evening visit. This meant there was greater potential for inconsistency because two different care providers were delivering one single care package.
  3. The Council spoke to Agency 2 and Mr D about 10 days after the care package had started to check how the care package was working. The Council did not speak to Agency 1 nor follow-up contact. The Council officer who spoke to Mr D told him someone would contact him in four weeks to “see how he is”. The Care and Support Statutory guidance says a review should be completed six to eight weeks after sign-off of the personal budget and plan. There is no documentary evidence to show the Council completed a review in line with this guidance. The Council is at fault.
  4. Three months after the care package had started the Council received a call from Mr D’s doctor to say he needed an increased care package. On the same day, the Council spoke to the district who confirmed Mr D’s health was worsening. There was no specific person (or social worker) for family members or other professionals to contact when Mr D had increased needs following this deterioration. This is likely to have caused avoidable distress to Mrs T and other family members.

The Council’s monitoring of Agency 1 and 2

  1. The Council did not complete a formal review in line with the government’s statutory guidance and is at fault. However, the evidence available shows it did have some contact with the care agencies while they were providing care to Mr D.
  2. Mrs T specifically complained about the care provided by the agencies between
    9 and 29 July 2016. Mr D’s wellbeing worsened during the period Mrs T complains about. The Council has no information recorded on its electronic case recording system from 22 April to 13 July. This is fault.
  3. A review of Agency 1’s daily record sheets shows that carers arrived for the morning call at times ranging between 8.05am to after 10.00am on some occasions. Although carers logged the time of arrival they did not record how long they stayed or at what time they left. This is poor practice. I cannot say on balance whether Mr D received the 45 minutes of care he needed each morning. The Council should have monitored the care agencies more closely.
  4. I cannot comment in detail on the support provided by Agency 2 because it says it did not retrieve the care records from Mr D’s property after he went into the residential home. It said arranged to collect the folder but did not do so because it had an immediate issue to deal with. This raises questions about how Agency 2 sought to protect Mr D’s personal data after it stopped providing support as it should have arranged to collect the information. On this basis, and with the absence of documentary evidence, any view is based on the evidence available and findings made on the balance of probabilities.
  5. The Council contacted Agency 2 on 22 April 2016 to check how the care package was going. However, it had no contact with Agency 1 so it could not know how this care provider was performing. Mr D did not have an allocated social worker so there were no face-to-face visits. As it commissioned two different care agencies for one care package there were likely inconsistencies from the outset. Telephone contact would not have provided the same benefit as a face-to-face visit. The evidence available shows a lack of telephone recording and failure to complete a formal review.
  6. Mrs T complained to the Council and the care agencies about the care provided. Her concerns included Mr D experiencing falls at home while unattended, carers not able to assist Mr D with taking medication, carers arriving too early or too late and on some occasions missing visits.
  7. Mrs T says her father also experienced a small stroke during this period and this is likely to have affected his independence and ability to care for himself at home. The Rapid Response Team intervened to provide extra support calls. I cannot see any evidence that before 25 July the Council acted to update Mr D’s care plan when there was a change in his needs earlier. The information provided by Agency 1 does not show it updated Mr D’s care plan. This is fault.
  8. When responding to Mrs T’s complaint Agency 2 said there was no need for it to communicate with Agency 1. It is likely that both care agencies used their own respective daily care recording system which were kept in separate folders. It is unknown how messages were passed from one care agency about any changes in Mr D’s needs and the care and support he needed. This is poor practice and the Council should have ensured Mr D’s care and support was delivered more consistently.
  9. The evidence available suggests Mr D developed a pressure ulcer, which can be an indicator of poor care. The care records provided by Agency 1 shows that
    Mr D spent a lot of time in his chair. There is no recorded assessment of pressure ulcer risk on file before or during the period of care. There are no recordings to show Mr D was helped to mobilise from the chair or assisted to turn to alleviate the risk of developing pressure ulcers. Carers did not always record when they prompted to take his medication and the medication recording sheets show some dates when medication is not signed for. The care agencies said they could not assist Mr D to take his medication from the medication organiser box when he was unable to take his medication independently. The Council had no contingency plan in place to deal with this situation.
  10. The evidence available suggests the care arrangements became inadequate after Mr D experienced the stroke and the Council should have acted quicker to respond to his changing needs and progressive illness. It is likely because of the inconsistencies and lack of recording in the daily records that the care Mr D received fell below expected standards. It is also likely the Council failed to monitor the care agencies to ensure Mr D received suitable care at all times.
  11. The faults led to Mrs T and her sister experiencing distress when witnessing some of the examples of poor care. This was set out in Mrs T’s letter of complaint to the Council and the care providers. Mr D paid towards a care package that did not always adequately meet his needs.

Consideration for healthcare funding

  1. When the Trust contacted the Council about the support Mr D needed on discharge it had not yet completed a checklist for healthcare funding. An officer from the Trust spoke to the Council on 11 April 2016 and she felt Mr D “would not meet the CHC [healthcare funding] criteria”.
  2. The Council contacted the Trust the day after to ask if it had completed a healthcare funding checklist. The Council’s record state the Trust’s officer said, “as far as he was concerned he would not meet [the criteria for healthcare funding].” There is a no evidence to show the officer completed a healthcare funding checklist before making this decision. The Trust should have completed a checklist as evidence they had properly considered Mr D’s eligibility. The Trust is at fault.
  3. When responding to the Ombudsmen the Trust said because Mr D was medically fit for discharge this was an indication he would not have met the criteria for healthcare funding. However, the threshold for being medically fit for discharge from an acute setting and the eligibility for healthcare funding in a community setting are different. CHC is not provided in an acute setting and therefore Mr D would have been medically fit for discharge even if eligible for CHC.
  4. The National Framework says, “a nurse, doctor, other qualified healthcare professional or social care professional could apply the Checklist to refer individuals for a full assessment of eligibility for NHS continuing healthcare from either a community or a hospital setting.” As such there was nothing to prevent the Council’s social work officers from completing a healthcare funding checklist. I have not seen evidence to show this happened. Ultimately, a person’s eligibility for healthcare funding is decided by the relevant health authority. Given that health professionals had said told the Council they did not think Mr D would meet the criteria for healthcare funding it is understandable why a social worker did not complete a checklist.
  5. When responding to the Ombudsman’s enquiries the Council said on reflection it could have challenged health colleagues when it was told Mr D was not eligible for healthcare funding. Given then Trust had not provided the Council with any documentary evidence to show it had properly considered Mr D’s eligibility for healthcare funding then I am inclined to agree with the Council on this point.


  1. I do not find fault with the way the Trust and the Council dealt with Mr D’s discharge arrangements. The Council did not properly monitor Mr D’s care and support arrangements and this is likely to have led to him receiving poor care when his needs changed. There is no evidence the Trust completed a healthcare funding checklist before telling the Council Mr D would not meet the criteria. The faults caused injustice to Mr D as he did not always receive the care and support he needed once discharged to the community. Mrs T experienced avoidable distress and uncertainty about her father’s eligibility for healthcare funding.

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Agreed Recommendations

  1. Within four weeks of the Ombudsmen’s final decision the Council and the Trust have agreed to the following recommendations:
    • the Council will:
        1. apologise in writing to Mrs T for the poor care her father received and arrange for £250 to be paid to Mr D’s estate via Mrs T;
        2. pay Mrs T £200 for the avoidable distress she experienced; and
        3. reflect on the findings of the Ombudsmen’s investigation to see if any lessons can be learnt from the decision not to allocate a social worker to Mr D’s case.
    • the Trust will apologise in writing to Mrs T for the uncertainty she experienced and act to improve its working practices to ensure officers complete healthcare funding checklists when considering a person’s eligibility for healthcare funding;

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Final decision

  1. The Council and the Trust have agreed to the Ombudsmen’s recommendations. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman

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