Summary: Mr C was unhappy about the time it took to move his (late) father from a residential care home into a more suitable nursing home. We did not find fault with the regards to the Council’s actions.

The complaint

1. The complainant, whom I shall call Mr C, complained to us on behalf of his (late father), whom I shall call Mr F. Mr C complained the Council should have completed a Continuing Healthcare (CHC) checklist between 5 March 2021 and 26 June 2021. He said the Council also failed to move his father to a Nursing Home following his need assessment in July 2021. Mr C complained his father did therefore not receive the level of support he needed, which was distressing.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

4. I considered the information I received from Mr C and the Council. I shared a copy of my draft decision statement with Mr C and the Council and considered any comments I received, before I made my final decision.

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What I found

Relevant background and legislation

5. The National Framework for NHS Continuing Healthcare (NHS CHC) says that screening for NHS CHC should be done at the right time and location for the individual and when their ongoing needs are known. This will help practitioners to correctly identify individuals who need a full assessment of eligibility for CHC.
6. The Discharge to Assess Scheme was introduced during the COVID 19 Pandemic to discharge hospital patients in a timely and efficient manner as soon as they no longer need hospital care.

What happened

7. In March 2021, Mr F went from hospital back to his own home within a supported living scheme. The Council’s Crisis Response Team carried out a care review in April 2021. It identified that Mr F was doing very well and passed his case to the Community Team for a three-month review.
8. Mr C says that:
• The Council said in its complaint response that his father went home from hospital in March 2021 under Discharge to Assess (D2A). However, Mr C says his father did not get the free care at that time that he should have received under D2A.
• The Council should have completed a CHC checklist between March and June 2021 (when he went back into hospital).
9. A CHC checklist is a screening tool to help identify if a person should be referred to the NHS for a full CHC assessment to determine if they may be eligible for free NHS CHC funding.
10. In response, the Council has said that:
• Under the D2A arrangements, when an individual was discharged from hospital, any extra support they would need above what they received before they attended hospital, would be free for up to 6 weeks. After Mr F went back home in March 2021, he received an extra 1.75 hours of care per week for which the Council did not charge him.
• The social worker could have completed a CHC checklist then if they, or the care workers supporting him, felt his needs merited it. It appears that, during this period, his needs did not suggest to those involved in his care that a CHC checklist would be needed.
11. Mr F had a fall and went back into hospital on 26 June 2021. He was discharged the next day into a care home, where he received free care under D2A. This meant he would receive up to six weeks of free D2A funding for his placement at the care home to complete his needs assessments etc, until 8 August 2021.
12. The Council completed a needs assessment on 3 July 2021. The record states that Mr F’s confusion and agitation had worsened recently. Further, due to a decline in his mobility, he was more at risk of falls. At the time he went into the home in June 2021, he also had pressure sores and was not eating well, needing prompts and encouragement from staff. This all suggested there had been a recent decline in his health. As such, the social worker recommended Mr F should remain in the home permanently, which was an EMI Residential Care Home. EMI stands for Elderly Mentally Infirm, which are normally people living with advanced stages of dementia. The records state staff at the home did not indicate during this assessment they could not meet his needs.
13. The Council also completed a CHC checklist on 4 July 2021 and sent this to the local NHS Clinical Commissioning Group (CCG) to consider if Mr F would meet the criteria for free NHS CHC.
14. Mr F’s care home said on 7 July 2021 that his needs would best be met in an EMI nursing home. It said that Mr F needed a higher level of care than it could provide, because he needed help with drinking thickened fluids and feeding, and he had district nurse involvement for his skin. The reason put down by the home was that: “If his dressings are to come off, they have to ring for the District Nurses to come and change them and if he was in a nursing home he would to have to wait for this to be done”.
15. The CCG decided mid-July 2021 that it would not carry out a full NHS CHC assessment. It said that to be able to accurately assess Mr F’s eligibility, the Council should carry out another CHC checklist once Mr F had moved to a nursing home and settled there for four weeks.
16. Mr C says it took too long for the Council to move his father to a nursing home who could meet his needs. He told that, if his father would have been in a nursing home, there would have been nursing staff on hand, which he said could have prevented him going into hospital again in September 2021.
17. The Council said it was difficult for the home to meet some of Mr F’s needs, including:
• Mr F had skin tears to his arms due to falls. District Nurses were visiting him every other day to dress his skin tears and monitor skin integrity. An air flow mattress was in place, and he could reposition himself during the night. Care home staff were told to check his skin areas on all interventions. The Council said that if Mr F had been in a nursing placement, he would always have nurses available immediately, if his skin integrity changed and needed intervention.
• He was generally settled with no signs of distress, although he could present as unsettled at times. When he presented in this way he would shout out and staff would give him Lorazepam. An EMI nursing placement was required to support him with these behaviours and manage his PRN medication.
18. Due to the care home’s concerns about the level of support Mr F now needed, the Council gave the case to a new social worker in July 2021 to reassess his needs. The social worker completed the reassessment on 3 August 2021, which found that Mr F needed a nursing environment. The Council provided information to Mr C in July 2021 about nursing beds and advised him to look at available homes. Mr C agreed to speak with his brother and consider the next steps. He was considering EMI Nursing placements close to him but would ideally like to keep his father within the St Helens area.
19. The records state the social worker carried out regular attempts to try and find care homes in the area, while keeping Mr C updated. However, many homes did not have available beds. Those who did were either not accepting new residents due to various reasons (including having a covid outbreak) or were unable to accept Mr F due to his level of needs.
20. The record states that Mr C said on 20 August 2021 that he understood how difficult it was to find a suitable home. He said he was happy that his father was getting the best care he can under the current circumstances. Mr C told me that he nevertheless was still unhappy that his father was still there.
21. On 23 August 2021 the Council explained to Mr C that there was a lack of beds, and it asked him if he would consider a placement outside the borough. Mr C said he would be worried going outside the area due to the impact this may have on the process for assessing whether he meets the criteria for NHS Continuing Healthcare Funding. The Council explained that the CHC checklist would be completed by the GP where Mr F’s care home would be. The Council suggested two care homes that were located outside the St Helens area.
22. The Council found a nursing home at the end of August 2021 who were willing to accept Mr F as a new resident. However, the home said Mr F would get a bed in the home’s challenging behaviour unit where he would receive one to one support 24 hours a day. The social worker discussed this with the home. However, the home was not willing to only provide 1:1 some of the time. The Council did not feel this was appropriate or in Mr F’s best interests. It said that, although Mr F could have difficult moments, it did not seem appropriate he should be on a challenging behaviour unit with 24 hour 1:1 support. Everyone agreed he had long periods of being relatively quiet. Funding was also mentioned because the placement was very expensive. However, this would not have been a determining factor, as Mr F would be self-funding.
23. Mr F went into hospital again on 3 September 2021, as he was not able to swallow food or liquids properly, with food / drinks getting into his lungs. The care home told the Council it would not be able to take Mr F back, because it had been struggling to support him.
24. While in hospital Mr C was assessed as ‘End of Life’ and he was therefore eligible to be Fast-tracked for immediate NHS CHC on discharge from hospital.
25. Mr C told me that:
• The officers involved were fantastic and tried to do everything possible to find a placement. However, there was just nothing available.
• He believes however that the officers were hindered about restrictions put on them by management in terms of funding, for instance looking for options outside the local area as they would be more expensive.
• He did not have concerns about the care provided by the staff at the home who were fantastic. The care home did all they could.
• He does not know if admission to hospital could have been avoided if he had been in an EMI home. He thinks the hospital admission was due to food in his lungs.
26. The Council says it offered the home to fund additional 1:1 support for Mr F, to manage his behaviour and needs. However, the home declined this as it was not possible to determine at what days / times he would need this, due to the unpredictable nature of the behaviour.
27. The Council says the CCG has since accepted its assessment should have taken place sooner, as Mr F had been in the home for two months, during which time he had been settled. This meant Mr F had been at the home beyond the funded time under Covid-19 discharge to assess arrangements. Mr F was therefore liable for the costs from 8 August 2021. As such, the CCG has agreed to cover the costs of the placement beyond 8 August until Mr F left the home.

Analysis

28. As required, Mr F did not have to pay for any extra care he received when he was discharged to his home in March 2021 under the DtA scheme.
29. Neither the Hospital, the Council, nor the care provider felt that Mr F’s presentation and needs warranted a CHC checklist to be completed between March and June 2021. The records show there was a deterioration in Mr C’s need before he went into the care home in June 2021, where a CHC checklist was completed. As such, there is insufficient evidence to be able to conclude the Council should have completed a CHC checklist while he was still living at home, and/or that this would have concluded he would be eligible for NHS CHC.
30. When Mr F went into the care home in June 2021, the Council completed Mr F’s needs assessment and CHC checklist within a reasonable timeframe. Although the CCG did not carry out a CHC assessment subsequently, this did not cause a delay in finding a suitable placement as these were two separate processes. One process was to find a suitable placement, the other process was to determine who should pay for it.
31. I did not find fault that the Council was unable to move Mr F into a nursing home. It persistently tried to find a placement for Mr F, some of which were not available as they were dealing with a covid outbreak amongst residents. There was no evidence to substantiate Mr C’s suspicion that the Council did not want to consider some options as they were too expensive.
32. Mr C told me he does not know if his father’s admission to hospital could have been prevented if he had been in a nursing home. While all involved acknowledge that Mr F’s care could have been even better at a nursing home, Mr C expressed that, while he would have wanted his father to be in a nursing home as per his assessed needs, he was very happy with the care he received at his father’s care home, under the circumstances. The Council also offered additional support to the care home in the interim to ensure Mr F’s needs would be met.

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Final decision

33. For reasons explained above, I did not find fault in the actions of the Council and have therefore not upheld Mr C’s complaint.

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Investigator's decision on behalf of the Ombudsman