Summary: Mr X complained about the care provided to his brother, Mr Y, by several health and social care organisations. We found fault by two councils as there was significant confusion surrounding how Mr Y’s care should be funded. We also found fault with the care provided to Mr Y when he was resident in a care home. The organisations involved agreed to apologise to Mr X and pay him a financial remedy in recognition of the impact of this on fault on him. They also agreed to take action to prevent similar problems occurring for others.

The complaint

1. The complainant, who I will call Mr X, is complaining about the care provided to his brother, Mr Y, by West Sussex County Council (WSCC), Bournemouth, Christchurch and Poole Council (BCPC), NHS Sussex Integrated Care Board (the Sussex ICB), Sussex Partnership NHS Foundation Trust (the Sussex Trust), Shaw Healthcare Group Ltd (the Care Provider), NHS Dorset Integrated Care Board (the Dorset ICB) and Dorset Healthcare University NHS Foundation Trust (the Dorset Trust).
2. Mr X complains that:

• WSCC, the Sussex ICB and the Sussex Trust failed to put an appropriate Section 117 aftercare plan in place for Mr Y. Mr X says these organisations also failed to complete regular reviews of Mr Y’s Section 117 aftercare needs;
• WSCC and the Sussex ICB failed to arrange, or provide, free aftercare services to Mr Y between 2008 and 2015. Mr X says Mr Y’s physical health needs were related to his mental health condition and that care to meet these needs should have been included in his Section 117 aftercare provision;
• Mr Y was discharged from the care of the Dorset Trust to a care home due to a dispute between WSCC and BCPC about how his care should be funded. Mr X says he was not involved in this decision, despite holding Lasting Power of Attorney for Mr Y; and
• the care provided to Mr Y in Figbury Lodge Care Home by the Care Provider was poor, resulting in him being readmitted to hospital in February 2020.

3. Mr X says Mr Y’s mental health deteriorated as a result of the failure to put appropriate Section 117 aftercare in place. Mr X says Mr Y became seriously unwell because of the inadequate care he received in the care home. In addition, Mr X says he has been caused unnecessary distress, time and trouble pursuing his complaint.

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What I have investigated

4. In his complaint to the Ombudsmen, Mr X complained about the care provided to Mr Y between 2008 and 2020. As part of his complaint, Mr X says WSCC, the Sussex ICB and the Sussex Trust failed to provide Mr Y with the free aftercare services to which he was entitled following his detention, in 2008, under Section 3 of the Mental Health Act 1983.
5. My investigation focused on the care provided to Mr X between February 2018 (when he first moved to Dorset) and February 2020 (when he was admitted to hospital from the care home).
6. As the Sussex Trust was not involved in the care provided to Mr Y during this period, I have not made any findings against it.
7. I have explained my decision not to investigate events before this date in the ‘parts of the complaint I have not investigated’ section at the end of this decision statement.

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The Ombudsmen’s role and powers

8. 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).
9. 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.
10. 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

11. In making my final decision, I considered information submitted by Mr X and discussed the complaint with him. I also considered records and documentation from the organisations Mr X complained about. I took account of relevant legislation and guidance. Furthermore, I considered comments from all parties on my draft decision statement.

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What I found

Relevant guidance and legislation

Integrated Care Boards

12. On 1 July 2022, NHS England introduced the integrated care system. This involved the formation of local NHS partnerships responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in that area.
13. As part of the integrated care system, NHS England also introduced Integrated Care Boards. These organisations are responsible for managing the local NHS budget and arranging for the provision of health services in the area. The establishment of Integrated Care Boards resulted in the closure of clinical commissioning groups.
14. West Sussex Clinical Commissioning Group shared the statutory duty to provide or arrange Section 117 aftercare services for Mr Y. That organisation has now been replaced by NHS Sussex Integrated Care Board (the Sussex ICB). The CCG’s duties and responsibilities in terms of Section 117 aftercare have now passed to the new ICB.
15. In this decision statement, for consistency and ease of reference, I have referred to the Sussex ICB throughout, rather than its predecessor organisation. I also refer to the Dorset ICB in similar terms.

Mental Health Act 1983

16. Under the Mental Health Act 1983 (the MHA), when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’.
17. Detention under Section 3 of the MHA is for the purpose of providing treatment. This section empowers doctors to detain a patient for a maximum of six months. A Section 3 can be renewed for another six months.
18. Under Section 117 of the MHA, local authorities and Integrated Care Boards have a duty to provide or arrange free aftercare services for people who have been detained under certain qualifying sections of the MHA. This includes Section 3.
19. Section 117 aftercare services must meet a need arising from, or related to, that person’s mental condition. The aim of these aftercare services is reduce the risk of the person’s mental condition worsening and thereby reduce the risk of further hospital admissions.
20. Section 117 aftercare can incorporate a wide range of services, including (but not limited to):

• Medication administration;
• Social work;
• Domiciliary care;
• Psychiatric treatment;
• Residential accommodation; and
• Supported living or extra care housing.

21. A person’s eligibility for Section 117 aftercare should be reviewed within six weeks of their discharge from inpatient services. Eligibility should then be reviewed annually thereafter. The person’s allocated care coordinator is responsible for arranging the Section 117 reviews.
22. The Department of Health produces the Mental Health Act 1983: Code of Practice (the Code of Practice) to accompany the MHA. This provides guidance for professionals on how to implement the MHA in practice.

Parkinson’s Disease

23. Mr Y had advanced Parkinson’s Disease. He was taking several medications to treat the symptoms of this disease, such as tremors and stiffness. These included Co-careldopa, Co-beneldopa and Ropinirole.
24. Mr Y was also suffering from delusional disorder and episodes of psychosis. The clinical consensus, based on the available clinical records, is that these conditions were probably side-effects of his Parkinson’s Disease medications.

Care Act 2014

25. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of any adult who appears to need care and support. They must assess anyone, regardless of their finances or whether the council thinks they have eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and, where appropriate, their carer or any other person they might want to be involved.
26. An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs and a consideration of any fluctuation in those needs. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.
27. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan in the case of a carer) detailing how a person’s eligible care needs will be met. The care and support plan may include a personal budget, which is the amount of money the council has worked out it will cost to arrange the necessary care and support for the person.
28. A council can choose to charge for non-residential care following a person’s needs assessment. Where it decides to charge, the council must follow the Care and Support (Charging and Assessment of Resources) Regulations 2014 and have regard to the Care and Support Statutory Guidance (the Statutory Guidance). (Care Act 2014, section 14 and 17)

What happened

29. Mr Y had a diagnosis of Parkinson’s Disease and associated mental health problems. These included long-term delusional beliefs and episodes of psychosis.
30. In 2008, Mr Y was detained under Section 3 of the MHA. This meant he was entitled to free aftercare services under Section 117 of the MHA. WSCC and the Sussex ICB held the statutory duty to provide or arrange these services.
31. WSCC completed a care and support plan for Mr Y in January 2016. This identified that Mr Y required two daily care visits to support him with his personal care and dressing. Mr Y remained in receipt of this care package until he was readmitted to hospital in February 2016.
32. In July 2016, while Mr Y was still an inpatient, the Sussex Trust discharged him from its secondary mental health services. However, Mr Y was not discharged from Section 117 aftercare.
33. In February 2018, Mr Y moved to the Dorset area. His GP referred him to the local Older Persons Community Mental Health Team (OPCMHT – part of the Dorset Trust) the following month.
34. In April, Mr Y was detained under Section 2 of the MHA. He remained in hospital as an informal patient pending further assessment. A social worker from the OPCMHT contacted WSCC to clarify whether Mr Y was eligible for Section 117 aftercare. WSCC officers made enquiries with the Sussex Trust and determined that Mr Y was eligible for Section 117 aftercare services.
35. The OPCMHT social worker assessed Mr Y and determined that he required two daily care visits. These were to be funded by WSCC under Section 117.
36. In the meantime, WSCC contacted Mr X with regards to outstanding care fees related to the care package provided to Mr Y in early 2016. Mr X challenged this invoice on the basis that Mr Y had been entitled to Section 117 aftercare at that time.
37. Following Mr Y’s discharge from hospital, he remained under the care of the OPCMHT.
38. In May, WSCC wrote to Mr X to confirm it held the statutory duty to provide Mr Y with Section 117 aftercare services. WSCC said this duty stemmed from Mr Y’s admission in 2008 and that Mr Y should not have been charged for any aftercare services in the intervening ten years. As a result, WSCC waived the outstanding invoice relating to care charges from early 2016.
39. On 22 May 2018, Mr Y was readmitted to hospital following a fall at home. An Occupational Therapist (OT) assessed Mr Y on the ward. The OT found Mr Y would need four care visits from two care workers per day on discharge.
40. A WSCC social worker assessed Mr Y and decided his increased needs were related to a deterioration in his physical (rather than mental) health.
41. As Mr Y now lived in the Dorset area, BCPC was the local authority with responsibility for meeting Mr Y’s social care needs.
42. Mr Y was discharged home on 25 June. A BCPC social worker visited Mr Y at home. A BCPC social worker completed a Care Act assessment. This found Mr Y required additional support with his medication. The BCPC social worker arranged two further care daily visits to commence on 9 July.
43. Mr Y was readmitted to hospital on 28 June due to problems with his medication.
44. A BCPC officer spoke to Mr X on 3 July. She explained Mr Y would need to have a financial assessment to calculate his contributions towards his care. However, Mr X was unhappy with this approach as he felt the additional care visits should be provided as part of Mr Y’s Section 117 aftercare.
45. Mr Y was discharged home the following day with a riser recliner chair and a referral for a further OT assessment.
46. In subsequent visits, care workers expressed concern that Mr Y was unable to manage his Parkinson’s Disease medication. They reported that the medication was in disorder and that Mr Y appeared to have been taking doses at the wrong times.
47. Mr Y continued to experience hospital admissions throughout the remainder of 2018 because of his poor physical health.
48. BCPC and Dorset Trust staff who visited Mr Y at home noted he increasingly preferred to spend more time in his room, BCPC officers explored whether Mr Y would like to apply for a Disabled Facilities Grant (DFG) to make adjustments to his property. However, Mr Y declined to proceed with this.
49. In October, the Dorset Trust discharged Mr Y as it concluded he had no ongoing mental health needs
50. In January 2019, a community matron from the Dorset Trust visited Mr Y at home. She noted a decline in his physical health and mobility and said Mr Y now largely stayed in his room. The matron also noted that Mr Y was not eating and drinking enough.
51. A BCPC social worker review Mr Y on 13 February. However, Mr Y did not engage with the review and declined further assistance.
52. In May, Mr Y was again admitted to hospital with chest pains. He was transferred to Alderney Community Hospital the following month for rehabilitation. Staff noted Mr Y was not always compliant with his physiotherapy and sometimes declined personal care and medication. Furthermore, Mr Y was found to be increasingly delusional.
53. During Mr Y’s admission, staff also completed a Continuing Healthcare (CHC) checklist. This determined that Mr Y required a full CHC assessment.
54. On 18 September, Mr Y was discharged to a care home to await a full CHC assessment.
55. The CHC assessment was completed on 13 November. This found Mr Y was not eligible for CHC funding.
56. In December 2019, BCPC concluded that WSCC should meet the entirety of Mr Y’s care costs as part of his Section 117 entitlement. WSCC challenged this via its legal services team. In the meantime, Mr Y remained in the care home.
57. Mr Y was reviewed by a GP on 29 January and treated for a chest infection.
58. On 10 February 2020, Mr Y was seen again by a GP. He was readmitted to hospital later that day. He was diagnosed with aspiration pneumonia and was thought to be near the end of his life. The attending ambulance crew recorded that care home staff had failed to seek medical advice when Mr Y’s condition had begun to deteriorate.
59. The ambulance crew subsequently raised a safeguarding referral with BCPC. BCPC began safeguarding enquiries.
60. In March, Mr Y was found to be eligible for Fast Track Continuing Healthcare funding. He was discharged to another care home on 25 March.
61. Mr Y died on 15 May.
62. BCPC completed its safeguarding enquiries shortly after this. These resulted in recommendations for care home staff to undergo additional training in several areas, including caring for residents with Parkinson’s Disease.

Analysis

Section 117 aftercare – February to July 2018

63. Mr X complained that WSCC, Sussex ICB and the Sussex Trust failed to put in place appropriate Section 117 aftercare services for Mr Y. Mr X said there was a lack of proper Section 117 aftercare planning and review. Mr X said he feels Mr Y’s physical health needs stemmed from his mental health problems and that his care should have been provided without charge as part of his Section 117 provision.
64. Mr Y moved to the Dorset area in February 2018 and was living alone. The clinical records show Mr Y’s GP referred him to the OPCMHT in March 2018. The OPCMHT was planning to arrange an assessment visit for Mr Y. However, on 19 March, Mr Y was detained under Section 136 and then Section 2 of the MHA.
65. In early April 2018, a social worker from the OPCMHT contacted WSCC to request confirmation that Mr Y was entitled to Section 117 aftercare services. A WSCC officer made enquiries with the WSCC legal services team and the Sussex Trust. He established that Mr Y was entitled to Section 117 aftercare.
66. In the meantime, the OPCMHT social worker arranged to visit Mr Y in hospital on 11 April to complete a Care Act assessment and Section 117 aftercare review. The social worker established that Mr Y was keen to remain independent and wanted to develop his local social support network. However, the social worker concluded Mr Y would benefit from support to monitor his medication and prepare meals. She arranged for a care package of two daily care visits. WSCC agreed to fund this care package as part of Mr Y’s Section 117 aftercare entitlement.
67. It is clear from the WSCC care records that there was some confusion around Mr Y’s entitlement to Section 117 following his move to Dorset.
68. Section 33.7 of the Code of Practice requires local authorities and ICBs to maintain a record of people for whom they provide or commission aftercare. This should include details of what aftercare services are being provided. I found no evidence to suggest either WSCC or Sussex ICB kept such as record. Had they done so, any confusion might have been avoided. This was fault.
69. Nevertheless, I am not persuaded this had a significant impact on Mr Y’s care. This is because the evidence shows local services in Dorset, including BCPC and the Dorset Trust, acted appropriately and promptly in assessing Mr Y’s care needs and putting suitable care in place for him.
70. I understand WSCC, the Sussex ICB and the Sussex Trust are currently undertaking a multi-agency review of local Section 117 aftercare policies and protocols. I am satisfied this will improve local procedures and provide greater clarity for professionals and service users.
71. Mr Y was discharged home on 23 April with two daily care visits. However, he was readmitted on 22 May due to a fall caused by a deterioration in his Parkinson’s Disease.
72. An OT assessed Mr Y during his admission. The OT found Mr Y would need a significantly increased care package on discharge. The OT recommended four daily care visits from two carers.
73. As Mr Y was in receipt of Section 117 aftercare, an officer from the Dorset Trust contacted WSCC to request a reassessment of Mr Y’s care needs.
74. A WSCC social worker assessed Mr Y in hospital on 12 June. He noted Mr Y had been admitted to hospital complaining of having experienced spasms and “searing pain” at home. He went on to record that Mr Y was “complaining of acute pain across his whole body. His speech is slurred, he is unable to feed himself. He has tremors down his whole right side. He needs turning in bed regularly. He is now doubly incontinent.”
75. The WSCC social worker found Mr Y’s mental health needs were the same as at the previous assessment in April. The social worker noted “[t]here is no evidence of psychosis, delusion severe depression, suicidal ideation”. The WSCC social worker concluded that Mr Y’s increased care needs were due to a deterioration in his physical health. He concluded that BCPC would need to complete a Care Act assessment to consider Mr Y’s wider care needs.
76. A BCPC officer spoke to Mr Y on the ward on 14 June. She noted that she informed Mr Y that he would need an assessment of his care needs and a financial assessment. However, Mr Y became "very distressed" as he felt his care should be funded by WSCC. Another BCPC officer subsequently spoke to Mr X, who reiterated the view that Mr Y’s care should be provided as part of his Section 117 entitlement.
77. The case records suggest Mr Y declined an increase in his care package as he was unwilling to contribute towards any care charges. He was discharged home on 25 June with his existing care package. An OT also arranged for a riser recliner chair to be delivered to Mr Y’s home.
78. A BCPC social worker visited Mr Y at home the following day. She recorded that Mr Y this time consented to an increased package of care and a financial assessment. The social worker’s assessment found Mr Y required a further two daily care visits to support him with medication, personal care and food preparation. The social worker arranged for this support to commence on 9 July.
79. The Code of Practice explains that Section 117 aftercare services must meet a need arising from, or related to, a person’s mental health condition. The purpose of these services is to reduce the risk of a deterioration in the person’s mental health condition and the need for that person to be readmitted to hospital.
80. The case records show the funding of Mr Y’s care package, and whether this should be included in his Section 117 provision, was a matter of dispute between Mr X and the professionals involved in Mr Y’s care.
81. The clinical records show Mr Y suffered from long-standing psychosis and delusional disorder. The clinical consensus appears to have been that these conditions were likely associated with his Parkinson’s Disease medications. Mr X argued that Mr Y’s physical and mental health needs were therefore so closely linked it was impossible to separate them. On that basis, he argued that the entirety of Mr Y’s care should be funded by WSCC and the Sussex ICB as part of his Section 117 aftercare provision.
82. Mr Y’s care needs were evidently very complex. Nevertheless, any decisions about the funding for Mr Y’s care were a matter of professional judgement for the BCPC and WSCC officers who assessed Mr Y in 2018.
83. I have reviewed the WSCC assessment from June 2018. I am satisfied that the social worker based his decision on an appropriate consideration of the available evidence. This included input from Dorset Trust and BCPC officers. I find no fault in respect of this matter, albeit I appreciate Mr X does not agree with the decision.

Section 117 aftercare – August 2018 to June 2019

84. Once the decision had been made that Mr Y’s increased care needs were related to his deteriorating physical health, BCPC were required to complete an assessment. The assessment determined that Mr Y had eligible care needs under the Care Act and required two additional care visits per day.
85. The Care Act gives local authorities the power to charge for care they provide or arrange. A local authority choosing to charge for care must complete a financial assessment to calculate the amount a service user can afford to contribute towards their care.
86. BCPC completed a financial assessment and determined that, from 9 July, Mr Y would contribute £3.60 per week towards his care.
87. The care records show Mr Y was admitted to hospital again in August 2018. Following his discharge, BCPC arranged for Mr Y to have two further visits per week (of two hours each) to support him with social engagement. In total, Mr Y was receiving:

• two daily care visits funded by WSCC as part of his Section 117 entitlement;
• two daily care visits arranged by BCPC; and
• two weekly two-hour care visits arranged by BCPC.

88. Mr Y experienced another short hospital admission on 27 September after he fell at home.
89. On 1 November, an OT and social worker visited Mr Y at home. The OT was concerned that Mr Y’s property required adaptations to make it more accessible. However, Mr Y declined to apply for a DFG.
90. Mr Y was admitted to hospital again on 12 January 2019 due to decreased mobility caused by his ongoing neuropathic pain.
91. A community matron from the Dorset Trust visited Mr Y at home later that month and noted “a large decline in his physical health and mobility” since she had last seen him in September 2018. The matron made a referral to BCPC for a review of Mr Y’s care needs.
92. A social worker visited Mr Y on 13 February. Mr Y was reluctant to speak to the social worker but advised that he was happy with his care arrangements and did not want any additional care services. The social worker also attempted to discuss the possibility of Mr Y attending a day centre to increase his opportunities for socialising. However, Mr Y was not interested in pursuing this.
93. An OT from BCPC visited Mr Y at home on 15 May following his discharge from hospital. She found Mr Y was experiencing “extremely severe” tremors and reported being unable to move from his chair. However, he declined food or other assistance.
94. Mr Y was readmitted to hospital on 22 May 2019 with chest pains and muscle spasms related to his Parkinson’s Disease. He remained in an acute hospital until 26 June when he transferred to Alderney Community Hospital for rehabilitation.
95. The care records show the professionals supporting Mr Y reviewed him regularly between August 2018 and February 2019. This led to an increase in his daily care visits and the introduction of two weekly socialisation visits. Although Mr Y continued to display some delusional behaviours, there is no evidence to suggest a deterioration in Mr Y’s mental health during this period that would have warranted an increase in his Section 117 aftercare. Rather, Mr Y’s frequent hospital admissions were related to his declining physical health and mobility.
96. The evidence I have seen suggests the support provided by BCPC, WSCC and the Dorset Trust during this period was appropriate. I found no fault by the organisations concerned.

Funding dispute

97. In his complaint to the Ombudsmen, Mr X said Mr Y was discharged to the care home in September 2019 because there was an ongoing dispute between BCPC and WSCC as to how his care should be funded. Mr Y said nobody discussed Mr Y’s care with him even though he held Lasting Power of Attorney (LPA) for Mr Y’s health and welfare.
98. On 7 August 2019, while Mr Y was still an inpatient in the acute hospital, an elderly care clinician reviewed him. She noted concern that Mr Y’s mental health was deteriorating and that his delusions had become more severe.
99. The care records show Mr Y was discharged to the care home on 18 September to await a full CHC assessment and for a period of rehabilitation. I was unable to find any evidence to suggest the discharge was discussed with Mr X.
100. The first point to clarify is that, while Mr X did hold LPA for Mr Y’s health and welfare, this was not directly relevant. This is because Mr Y was considered to have capacity to make decisions about his own care at that point.
101. I note the BCPC records contain an email from a hospital social worker to a colleague in which she recorded that she had spoken to a ward sister at Alderney Community Hospital and that Mr Y “did not want his brother involved in CHC/Discharge planning. Therefore we don’t have consent to speak to the brother.” It seems likely this was the reason nobody from the Dorset Trust or BCPC discussed Mr Y’s discharge with Mr X.
102. I found no contemporaneous note of this conversation in the records of either organisation. Nor was this recorded in the referral to the care home, which listed Mr X as Mr Y’s next of kin. While I have no reason to doubt that this conversation took place, Mr Y’s decision should have been clearly recorded. This was a significant omission and represents fault by BCPC and the Dorset Trust.
103. However, I found no fault with the decision of care staff not to involve Mr X in planning for Mr Y’s discharge as this was in keeping with Mr Y’s wishes at that time.
104. On 13 November, Dorset ICB completed a CHC assessment. This found Mr Y was not eligible for CHC funding. The BCPC social worker who was present at the assessment identified that Mr Y would need a further Section 117 review. Another BCPC officer contacted Mr Y’s social worker at WSCC to arrange this. However, the WSCC officer suggest a further review by BCPC under the Care Act to determine whether Mr Y’s increased needs were related to his physical or mental health.
105. A BCPC social worker assessed Mr Y on 21 November. She found Mr Y had eligible care needs in several areas, including mental health, transfers, nutrition, medication, toileting and pain related to his Parkinson’s Disease. The BCPC social worker recommended an additional two daily care visits. This was a total of six daily care visits, with two of these funded by WSCC as part of Mr Y’s Section 117 entitlement. In addition, Mr Y would continue to receive two weekly socialisation visits.
106. However, when the BCPC social worker discussed Mr Y’s case with her manager, the manager concluded that his care should be funded entirely by WSCC as part of Mr Y’s Section 117 entitlement. The BCPC records contain a brief note of this discussion n which the social worker recorded that her manager “was of the view that West Sussex should have continued with the increase previously or discharged the S117 after care funding altogether”. The social worker noted that her manager would discuss the case with senior managers. I found no note of that conversation in the BCPC records.
107. On 9 December, the care provider who had been providing Mr Y’s Section 117 care visits in the community contacted the WSCC social worker. The care provider said it had been informed by BCPC that it had closed Mr Y’s case and that all care would now need to be funded by WSCC.
108. The WSCC social worker requested a copy of the BCPC review on 10 December. However, the BCPC social worker instead wrote to Mr X. She noted “I do not believe it is my place to share the assessment with [the WSCC social worker]” and advised Mr X that he could share this if he wished.
109. The BCPC care records show the BCPC social worker spoke to Mr X several times. This included a conversation on 7 January 2020 in which she reiterated that it would be down to Mr X to share the review with WSCC. The BCPC social worker noted that “there [was] no mental health deterioration within the assessment and this may give West Sussex evidence to discontinue the S.117 funding.”
110. Mr X told the BCPC social worker that Mr Y had been visited by police at the care home as he had been sending emails suggestive of delusional beliefs. The BCPC social worker told Mr X that her assessment was now no longer relevant and that she had closed Mr Y’s case. She told Mr X that BCPC would consider Mr Y’s needs again once WSCC had put a package of care in place for Mr Y under his Section 117 entitlement.
111. On 13 January, the WSCC legal services team wrote to WSCC. WSCC said it continued BCPC’s decision to withdraw care under the Care Act “unreasonable”. WSCC said this decision was made without consultation. WSCC asked BCPC to reinstate Mr Y’s care to facilitate his discharge from the care home.
112. BCPC was still formulating a response to WSCC when Mr Y was admitted to hospital on 10 February.
113. The case records show that the funding dispute began in November 2019. This was when a BCPC manager decided that Mr Y’s care should be funded in its entirety by WSCC as part of his Section 117 entitlement. This decision appears to have been made without proper consultation with WSCC and I was unable to find a clear rationale for it in the records.
114. The records show BCPC staff and managers thought Mr Y’s care needs should be met either by WSCC (under Section 117) or BCPC (under the Care Act). This was incorrect and suggests BCPC staff misunderstood the provisions of Section 117 of the Mental Health Act 1983. As WSCC correctly explained in its letter to BCPC of 13 January, Section 117 aftercare is intended only to meet a need arising from or related to a person’s mental disorder. This means it is possible for part of a person’s care to be funded under Section 117, with other parts provided under the Care Act. Indeed, this arrangement had been in place in Mr Y’s case for almost two years by this point.
115. It was not appropriate for BCPC to withdraw funding for Mr Y’s care without further consultation with WSCC and, if necessary, a further mental health assessment. This was fault.
116. The evidence shows this decision led directly to the funding dispute with WSCC. This in turn delayed Mr Y’s discharge from the care home. The situation was compounded when the BCPC social worker decided not to share a copy of her November 2019 assessment with WSCC. She did not explain this to WSCC and the care records show a WSCC social worker was still trying to obtain a copy in January 2020, almost two months later.
117. The case records show Mr Y was increasingly frail by November 2019. As a result, I am unable to say whether Mr Y’s hospital admission would have been avoided even if he had returned home with a package of care. However, the delay caused Mr Y distress. It also left Mr X with uncertainty as to whether the outcome of Mr Y’s care might have been different if he had been discharged home.

Care Home

118. Mr X complained that the Care Provider failed to provide Mr Y with appropriate care during his time as a resident in the care home. Mr X said staff were not trained to care for people with Parkinson’s Disease. He said this resulted in Mr Y being admitted to hospital following a choking incident.
119. There has been considerable dispute surrounding the funding of this placement with both BCPC and Dorset ICB denying having funded it. Based on the evidence I have seen, I consider it likely, on balance of probabilities, that this was a health placement funded by the Dorset ICB.
120. I have addressed what I consider the most significant aspects of Mr Y’s care in the care home below.

Care home - Nutrition

121. When Mr Y was admitted to the care home in September 2019, staff completed a care plan. This noted Mr Y was mostly independent with eating and drinking but required an ‘easy to chew’ diet (soft or tender foods) as he had some difficulty swallowing.
122. The care records for November and December show Mr Y appeared to be relatively stable. However, his appetite was variable and he sometimes refused meals. Mr Y’s weight on 16 December was recorded as 91.5kg. This was only slightly below Mr Y’s admission weight of 92.7kg.
123. On 29 January, Mr Y began a course of antibiotics for a chest infection. Care home staff attempted to weigh Mr Y again on 31 January as he continued to refuse meals. However, Mr Y declined to be weighed. This was part of a historic pattern of behaviour for Mr Y, who often refused care interventions.
124. On 2 February, staff completed an up-to-date nutritional care plan for Mr Y. This noted that Mr Y was not thought to be at risk of malnutrition but that he sometimes declined meals and refused to be weighed.
125. However, when care home staff were eventually able to weigh Mr Y on 9 February, his weight had dropped to 78.1kg. This was significantly below Mr Y’s admission weight. This prompted care home staff to request a GP visit. A GP visited Mr Y the following day and he was subsequently admitted to hospital.
126. It is important to note that Mr Y was considered to have capacity to make decisions about his care and so was entitled to refuse nutrition. Indeed, he had a history of declining care interventions and often refused meals. The care home took appropriate action to review Mr Y’s nutritional needs shortly after he refused to be weighed. His weight (as recorded in December 2019) was normal, and he was not considered to be at risk of malnutrition. However, once it became apparent Mr Y had lost weight, the care home sought clinical input from a GP to explore whether there was an underlying health problem.
127. Taken as a whole, I am satisfied the nutritional care provided to Mr Y by the care home was appropriate and in keeping with good practice.

Care home - Medication

128. The care records suggest Mr Y was content to take his medication with support from staff.
129. On 2 February, the care home completed a risk assessment for Mr Y relating to his medication. This emphasised the importance of ensuring Mr Y received his Parkinson’s Disease medication at specific times to keep his condition stable. The risk assessment noted that Mr Y “is very compliant with all his medications and likes to take them all in one go using a spoon. [Mr Y] likes hot chocolate or orange juice to help him swallow his medications.”
130. By this point the care records suggest Mr Y had become frailer. This meant he was at greater risk of developing further swallowing problems. Despite this, the risk assessment did not consider the impact of Mr Y’s swallowing difficulties on his ability to take medication safely. In my view, this was a potentially significant omission and means the risk assessment was incomplete. This represents fault by the Care Provider.
131. On 9 February, the care home again requested a GP visit. Care home staff reported that Mr Y was declining all personal care and repositioning and had lost weight. A GP visited Mr Y on 10 February and noted a “slow deterioration”.
132. That evening, a care worker noted Mr Y “was in bed, eyes very red. Looks really unwell.” Around an hour later, the care worker attempted to assist Mr Y to take his medication but noted he was struggling to swallow and began to choke. The care worker recorded that Mr Y was coughing and appeared to stop breathing briefly. The care worker called 999.
133. An ambulance attended Mr Y at the care home shortly afterwards. The ambulance crew found Mr Y’s condition had deteriorated significantly. Mr Y appeared dehydrated and could not tolerate fluids or medication. The crew transported Mr Y to hospital.
134. In my view, it is not possible to say whether this choking incident would have been avoided even if care home staff had completed a more thorough risk assessment. Nevertheless, the failure to do so placed Mr Y at greater risk. This was understandably distressing for Mr X.
135. I note the ambulance crew that transported Mr Y to hospital on 10 February subsequently submitted a safeguarding referral to BCPC. The referral noted that Mr Y’s condition had deteriorated significantly and queried why care home staff had not sought medical advice sooner.
136. This led BCPC to undertake safeguarding enquiries. These enquiries identified significant shortfalls in record-keeping and care planning in Mr Y’s case. The Care Provider arranged further training for staff in several areas, including recognising deterioration in residents. In addition, the Care Provider put in place a new system to ensure improved recording of input from other professionals (such as GPs).
137. In my view, these measures should minimise the risk of similar problems occurring for other residents.
138. However, one recommendation arising from the BCPC safeguarding enquiries was that care home staff should undergo additional training on caring for people with Parkinson’s Disease. It is unclear whether this happened. This is addressed below.

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Agreed actions

139. I identified fault by WSCC, the Sussex ICB, BCPC, the Dorset Trust and Shaw Healthcare. These organisations will now complete the agreed actions set out below.

Within one month of my final decision

WSCC and the Sussex ICB

140. WSCC and the Sussex ICB will write to Mr X to apologise for:

• their shared failure to maintain a clear record of Mr Y’s entitlement to Section 117 aftercare services and his aftercare needs. This caused unnecessary confusion when Mr Y moved to the Dorset area.

BCPC and the Dorset Trust

141. BCPC and the Dorset Trust will write to Mr X to apologise for:

• their failure to properly document Mr Y’s wishes with regards to the planning for his discharge from hospital in September 2019.

BCPC

142. BCPC will write to Mr X to apologise for:

• its decision to withdraw funding for Mr Y’s care in December 2019 without proper consultation. This led to a funding dispute that delayed Mr Y’s discharge from the care home; and
• its failure to share relevant information with WSCC, which further contributed to the delay. These events were distressing for Mr X, who was keen for Mr Y to be discharged home in accordance with his wishes.

143. BCPC will pay Mr X £200 in recognition of the impact of this fault on him.

Shaw Healthcare

144. Shaw Healthcare will write to apologise for:

• its failure to adequately assess the impact of Mr Y’s swallowing difficulties on his ability to safely take his medication orally. This fault placed Mr Y at greater risk and caused Mr X significant distress.

145. Shaw Healthcare will pay Mr X £300 in recognition of the impact of this fault on him.

Within three months of my final decision

BCPC and the Dorset Trust

146. BCPC and the Dorset Trust will write to the Ombudsmen to explain what action they will take to:

• ensure they have clear procedures in place for recording the wishes of patients/service users with regards to their care and treatment; and
• ensure they have robust communication protocols in place that provide for the timely sharing of relevant information with the families and carers of patients/service users.

BCPC

147. BCPC will write to the Ombudsmen to explain what action it will take to:

• ensure it has a robust process in place for resolving funding disputes with partner agencies that does not disadvantage service users. This should include an escalation process to ensure disputes are resolved in a timely fashion; and
• ensure there is a clear process in place for the sharing of relevant information with partner agencies.

148. BCPC should also explain what action it will take to ensure relevant staff are aware of these processes.

Shaw Healthcare

149. Shaw Healthcare will write to the Ombudsmen to explain what action it will take to:

• ensure staff at Figbury Lodge are appropriately trained in the completion of risk assessments as part of the care planning process; and
• ensure staff at Figbury Lodge have received appropriate training to care with residents with Parkinson’s Disease.

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Final decision

150. I found fault with the failure of WSCC and the Sussex ICB to maintain a clear record of Mr Y’s Section 117 aftercare needs and how these were to be met.
151. I found fault with the failure of BCPC and the Dorset Trust to properly record Mr Y’s wishes with regards to discharge planning.
152. I found fault by BCPC with regards to its decision to withdraw funding for Mr Y’s care without proper consultation as well as its failure to share relevant information with WSCC.
153. I also found fault with the care provided to Mr Y by Shaw Healthcare when he was resident in the care home.
154. In my view, the actions these organisations have agreed to complete represent a reasonable and proportionate remedy for the injustice caused to Mr X by the fault I identified.
155. I have now completed my investigation on this basis.

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Parts of the complaint that I did not investigate

156. As I have explained in paragraphs four to six of this decision statement, my investigation has focused on events occurring from February 2018. I have not investigated Mr X’s concerns about the care provided to Mr Y between 2008 and 2017. Specifically, Mr X is concerned that Mr Y did not receive the free Section 117 aftercare to which he was entitled during this period.
157. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
158. A long time has now passed since many of the events Mr X is complaining about occurred. For example, it is now over 14 years since Mr Y was first discharged from section in 2008. The passage of time significantly hampers our ability to complete a robust investigation. This is because law and guidance changes, the recollections of professionals involved in a person’s care fade and, in some cases, records are no longer available.
159. The evidence I have seen suggests Mr X first became aware of problems with Mr Y’s historic Section 117 aftercare arrangements in April 2018 further to contact with WSCC and BCPC officers.
160. Mr X did not approach the Ombudsmen until December 2020. This was over two years later. In my view, it would have been reasonable to expect Mr X to bring his concerns about Mr Y’s historical Section 117 aftercare to the Ombudsmen’s attention sooner than he did. I can see no good reason to investigate these matters at this late stage.
161. For this reason, my investigation focused on the care provided to Mr Y following his move to the Dorset area in February 2018.

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Investigator's decision on behalf of the Ombudsman