Summary: The Ombudsmen do not agree Haringey Clinical Commissioning Group should have commissioned a day care centre to meet Q’s needs during the holiday period. The Ombudsmen do not consider there was fault in the way London Borough of Haringey carried out Mr and Mrs P’s carers assessments. However, it should have completed them when it was aware Q’s care package would significantly change.

The complaint

1. Mr and Mrs P complain about the actions of London Borough of Haringey (the Council) and Haringey Clinical Commissioning Group (the CCG).
2. Mr and Mrs P say the CCG failed to provide their son, Q, with suitable care during the holiday period. The Council and the CCG did not robustly assess whether a day care centre could meet their son’s needs and did not identify alternative day care provision. Therefore, they must care for Q at home, which will be worse when his college placement ends. As a result, Q’s needs are not being met during the holiday period.
3. Mr and Mrs P say the Council did not robustly assess their needs as carers. It did not properly explore their ability and willingness to act as full-time carers for Q, or their need for respite. The Council’s lack of support has caused them distress and inconvenience.
4. Mr and Mrs P would like the Council and CCG to provide care that meets their son’s assessed needs and offer support to them as carers.

Back to top

The Ombudsmen’s role and powers

5. 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).
6. 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.
7. The Ombudsmen 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. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
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)

Back to top

How I considered this complaint

9. I have considered the complaint information Mr and Mrs P provided to me. I have asked all organisations to comment on the complaint and provide supporting documentation. I have taken the relevant law and guidance into account. I have also written to Mr and Mrs P, the Council and the CCG with my draft decision and considered their comments.

Back to top

What I found

Key facts

10. Q lacks mental capacity, has autism and complex health and social care needs. As a result, he receives continuing healthcare (CHC). The Council provided Mr and Mrs P with a personal budget of £300 to manage their needs as carers. The CCG also funded 28 days respite per year for Q.
11. Before September 2016, the CCG funded Q’s support at college during term and holiday period. In July, Mr P told the Council the CCG was going to stop Q’s support during the holiday period in September. In its place, the CCG commissioned a care agency (Agency 1) to provide 2:1 support to Q at home during the holiday period.
12. In April 2017, the Council held a carer review for Mr and Mrs P. Mr and Mrs P wanted Q to attend a specific day centre (the Day Centre) during the holiday period, which would provide them with the respite they needed. The Council said the existing personal budget, and Q’s respite agreement with the CCG, would still provide them with the support they needed.
13. At the same time, the CCG asked the Council to review the suitability of the Day Centre for Q’s needs. In May 2017, the Council told the CCG the Day Centre could not meet Q’s needs.
14. On 4 August 2017, the CCG met with the Council and Mr and Mrs P, whose solicitors had sent the CCG a letter before action. Mr and Mrs P were unhappy with the Council’s decision in May. The CCG agreed to review its decision.
15. On 11 August 2017, the CCG held a review of Q’s CHC care package. Agency 1 said Q had settled well with his care team.
16. In September 2017, the Council and CCG told Mr and Mrs P the Day Centre was not suitable for Q’s needs.

The Day Centre and alternative care provision

17. The Department of Health’s National Framework for NHS Continuing Healthcare and NHS‑funded Nursing Care (November 2012 (Revised)) (the National Framework) is the key guidance about Continuing Healthcare. It states that where an individual is eligible for Continuing Healthcare funding the CCG is responsible for care planning, commissioning services and case management.
18. Paragraph 172 of the National Framework says: “Where a person qualifies for NHS Continuing healthcare, the package to be provided is that which the CCG assesses is appropriate to meet all of the individual’s assessed health and associated care and support needs. The CCG has responsibility for ensuring this is the case and determining what the appropriate package should be. In doing so, the CCG should have due regard to the individuals wishes and preferred outcomes...”.
19. In response to Mr and Mrs P’s complaint, the Council said the CCG was responsible for commissioning the Day Centre. The Council worked with the CCG to assess the suitability of the Day Centre. Also, the CCG said Q’s care package met his needs during the holiday period.
20. Mr P is unhappy with the CCG’s decision not to commission support at the Day Centre, or any other service during the holiday period. The Ombudsmen are not a right of appeal against the CCG’s decision. My role is to review how the CCG made its decision to commission Agency 1 to provide support to Q after September 2016.
21. I have reviewed the CCG’s assessment of Q’s needs and his care and support plan from August 2016. The care and support plan found Q wished for:
• Care at home with his parents, and carers who understand his autism and behaviour, and can manage his health needs and administer medications.
• Access the community in the holiday period.
• His parents would assess the standard of Agency 1’s care on Q’s behalf.
• A planned timetable of activities to ensure he received the support to meet his needs in the holiday period.
22. I have also reviewed Agency 1’s ‘Support Guidelines’ from August 2016, which state: “At the weekends and non-college days, it is important to plan at least one activity outside the home (and to have a driver scheduled in order to facilitate this)”.
23. The CCG’s assessment and support plan were in line with the National Framework. The CCG included Q’s views and wishes, identified Q’s complex health and associated social care needs and addressed how Agency 1 will support those needs in the holiday period. Agency 1’s ‘Support Guidelines’ also show how it understood its responsibilities for Q in the holiday period.
24. I do not consider there was fault in the way CCG decided how it would meet Q’s needs after September 2016. The CCG’s decision to commission Agency 1 to provide that support was a matter of professional judgement.
25. In April 2017, the CCG considered Mr P’s concerns about Q’s care package and asked the Council to assess the suitability of the Day Centre.
26. I consider the CCG was responsible for commissioning the Day Centre placement only if it could meet Q’s needs. While the CCG asked the Council to assess the Day Centre, only the CCG could provide the placement.
27. I have reviewed the Council’s May 2017 assessment of the Day Centre. The assessment found:
• The Day Centre did not have the staff capacity to meet Q’s needs.
• It cannot provide an allergy free space to prepare food for Q.
• It would struggle to provide support between activities and the toilet, or for his wider extensive personal care needs.
• The shared dining room at the Day Centre would not be suitable for Q’s eating needs because he needs lots of space. It could not provide a private room for him to eat in.
• Q can only manage communicating with other service uses for 20 minutes. It cannot provide space for Q as he needs isolation.
• It could not meet Q’s transport needs as he cannot share with others or use the minibuses with his care staff which it provides.
28. I have also considered the Council’s review of the May 2017 assessment, which considered comments from Mr P. The review found:
• Q could not fully engage in activities because of his unpredictable pain.
• Q could only interact with others for 30 minutes which would impact the service.
• It could not provide a space for just Q throughout the day.
• Q’s toileting needs would impact the shared use of the toilet which could disrupt the service.
• Q will need extra staff to support him (2:1) which will make the environment more crowded. That could impact service users who do not like crowded spaces.
• Even if the CCG made reasonable adjustments to the service, it could not offer Q a place at the Day Centre.
29. After the Council’s review, the CCG decided it could not safely meet Q’s needs at the Day Centre. The Council had completed a robust assessment and a comprehensive review of that assessment. The review considered Mr P’s comments about the assessment. The Council considered Q’s needs in relation to the Day Centre’s activities, other service users and staff capacity.
30. The CCG was willing to make reasonable adjustments to support Q at the Day Centre. If the placement was suitable for Q it would have funded it as part of the CHC. However, the Day Centre could not safely manage Q’s complex needs. Therefore, it could not accept him. Therefore, I do not consider the CCG was at fault in the way it decided the Day Centre was not suitable for Q’s needs.

The carer assessments

31. Where an individual provides or intends to provide care for another adult and it appears the carer may have any needs for support, councils must carry out a carer’s assessment. Carers’ assessments 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.
32. Where a council is carrying out a carer’s assessment, it must include in its assessment a consideration of the carer’s potential future needs for support. Factored into this must be a consideration of whether the carer is, and will continue to be, able and willing to care for the adult needing care. (Care and Support Statutory Guidance 2014)
33. Mr and Mrs P stated a desire for the Council to use their powers under the Care Act to provide a day centre placement for Q’s need. That would also provide the respite they need as carers.
34. In response to Mr and Mrs P’s complaint, the Council said it assessed their support needs as carers and provided them with a direct payment. The direct payment would help them choose how to break from their caring roles. Mr and Mrs P indicated they wanted to continue caring for Q at home. Also, as Mr P was in discussions with the CCG about a day centre placement, it did not consider that as part of the carer’s assessment.
35. I have reviewed the Council’s social care record, including the assessments of Mr and Mrs P’s needs as carers.
36. In April 2017, the social worker reviewed Mr and Mrs P’s needs. The social worker acknowledged their views, considered them and decided the direct payment and 28 days respite would still meet their needs as carers. The social worker recognised how Mr and Mrs P’s needs had changed since September 2016. However, the support the Council already provided met their needs as carers. I do not consider the Council carried out the carer assessments with fault.
37. However, the Council missed the opportunity to complete a review of Mr and Mrs P’s needs when Q’s circumstances changed in September 2016. The Council should have completed a reassessment when Mr and Mrs P’s needs may change because Q would be based at home during the holiday period, rather than college. Mr P made the Council aware of the changing care packing in an email in July 2016. This was fault.
38. I do not consider this caused Mr and Mrs P a significant injustice as the subsequent assessment in April 2017 identified Mr and Mrs P’s carers’ needs were being met by the package already in place. However, it was still a missed opportunity and the Council should take further action to avoid similar fault occurring to others.

Back to top

Recommendations

39. Within eight weeks the Council should ensure that it has a process in place to ensure it completes carer assessment reviews when they are aware someone’s package of care will change significantly.

Back to top

Final decision

40. The Council’s assessment of the Day Centre was robust and could not meet Q’s needs. The CCG was not at fault for not commissioning the Day Centre or any other service to meet Q’s needs. It had already completed an assessment of Q’s needs in August 2016 and detailed how Q’s needs would be met at home by Agency 1.
41. I do not consider the Council carried out the carer assessment reviews in April 2017 with fault. However, the Council should have completed them in September 2016 when Q’s care package changed significantly.

Back to top

Investigator's decision on behalf of the Ombudsman