Summary: There was no fault in the way the Council decided Ms B’s care plan and its provision of care.

The complaint

1. Ms B complained that the Council had not properly assessed her needs for care and support and that her care plan did not meet her needs. She also said she was not receiving appropriate care and complained about a debt she owed to the Council for unpaid care charges.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
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 have spoken to Ms B and I have considered the information that she and the Council have provided and the relevant law, guidance and policies.

What I found

Law, guidance and policies

5. The Care Act 2014, the Care and Support Statutory Guidance 2014 set out the Council’s duties towards adults who require care and support and its powers to charge. The Council also has its own policies.
6. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan.
7. The threshold for eligibility is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing. Council must consider whether:
• The adult’s needs arise from a physical or mental impairment or illness.
• As a result of the adult’s needs the adult is unable to achieve 2 or more of the specified outcomes.
• As a consequence of being unable to achieve these outcomes there is a significant impact on the adult’s wellbeing.
8. The outcomes are:
• Managing and maintaining nutrition
• Maintaining personal hygiene
• Managing toilet needs
• Being appropriately clothed
• Being able to make use of the home safely
• Maintaining a habitable home environment
• Developing and maintaining family or other personal relationships
• Accessing and engaging in work, training, education or
• Making use of necessary facilities or services in the local community
• Carrying out caring responsibilities for a child.
9. The local authority must take all reasonable steps to agree with the person how the person’s needs will be met in the care plan, before the authority signs off the plan.
10. If the plan cannot be agreed with the person, or any other person involved, the local authority should state the reasons for this and the steps which must be taken to ensure that the plan is signed-off. If a dispute still remains, and the local authority feels that it has taken all reasonable steps to address the situation, it should direct the person to the local complaints procedure. 
11. If a person has substantial difficulty in being involved in the assessment process, and if there is nobody else to support the person, then the Council should appoint an independent advocate to support the person in the process.

Charging for care

12. A council can choose to charge for non-residential care following a person’s needs assessment. Where a council decides to charge, it must carry out a financial assessment to decide what contribution a person can afford to pay.

What happened

13. Ms B has a mental health diagnosis and an underlying condition which affects her mobility. She receives support from the Community Mental Health Team and the Council’s Adult Social Care Team. Ms B was admitted to a mental health hospital in August 2023 and remained there until December 2023.
14. On 5 October 2023, an occupational therapist assessed Ms B and stated the following in his report:
• Ms B mobilised with a Zimmer frame. She had been observed to mobilise independently without the Zimmer frame. She had been assessed by Physiotherapy as being independent in transfers and had a noted weakness in her left leg. It was recommended, during a physiotherapy review that Ms B should try to walk with a stick to increase her independence.
• Ms B was able to dress and feed herself independently.
• Ms B said she was incontinent and used pads. She had declined support to find out the cause of this to enable her to move towards greater independence in this area.
• Ms B had significant anxiety around her self-efficacy and skill level, particularly around concentration, planning, attention and initiation.
• Ms B said she needed an extensive care package of 7.5 hours per day but this level of support would be the equivalent to supported accommodation/residential living, which Ms B did not want.
• As Ms B had shown a capacity to develop and consolidate occupational performance, a package of care of 7.5 hours was not recommended as it would lead to further de-skilling.
• Ms B would benefit from a package of support of two daily 45 minutes visits and one weekly 90 minutes visit. This should consist of a morning and evening visit with personal care in the morning, if required, and a once weekly visit to support with food and basic shopping. A referral to the Council’s Mental Health Integrated Network Team and Occupational Therapy was recommended to support with skill and function building.
15. The Council carried out a review assessment of Ms B’s needs in the hospital on 6 December 2023 and it completed Ms B’s mental health care plan which said:
• Because of Ms B’s mental health conditions, she was often distressed, agitated and sometimes verbally aggressive when working with professionals.
• It was difficult to obtain the necessary information to assess Ms B’s care needs.
• Ms B needed support in personal care and continence.
• Ms B needed support in keeping her home environment tidy such as changing the bed, cleaning, laundry and removal of rubbish.
• Ms B needed support in food shopping and food preparation. She had declined online delivery of food and did not want prepared food that could be heated up.
• The daily care package consisted of one morning visit of 60 minutes and two further visits of 30 minutes for personal care, showering, administration of creams, food preparation and domestic chores and one weekly visit of 45 minutes for food shopping.
• The Council also offered a one-off clean of Ms B’s property.
• The plan was due to be reviewed in February 2024, once Ms B was discharged from hospital.
16. The social worker contacted Ms B on 19 February 2024 to start the review of the care plan. Ms B said she was not in the frame of mind to do so. She complained that there were not enough hours in the care package and that the care workers were too slow. The social worker explained to Ms B that it was important that there was a formal review, but Ms B did not engage. Ms B was adamant that she would not financially contribute to her care package (she had a large debt to the Council of unpaid contributions.)
17. The manager of the care agency which was supporting Ms B contacted the Council and said Ms B had been allocated a fourth care worker as she had refused three previous care workers. Ms B was not complying with the care plan as she did not use the personal care element but used the care package mainly for shopping and cleaning. The care agency did not know whether it would be able to continue to provide support because Ms B’s aggressive behaviour towards staff.
18. Ms B complained to the Ombudsman on 15 March 2024 and said the Council failed to properly assess her needs for care and support when she was discharged from hospital and had failed to support her. The Council was pursuing a debt for the care provision that she was unable to pay and she wanted an advocate. The Ombudsman told Ms B that her complaint was premature as she had not complained to the Council so we referred her complaint back to the Council.
19. The care agency gave notice on 21 March 2024 but continued to provide care during the notice period, until 29 April 2024.
20. On 27 March 2023 the Council made referrals to advocacy agencies to support Ms B.
21. On 9 April 2024 the Council held an internal meeting about Ms B. The attendants noted that the social worker had been unable to complete a review of Ms B’s care plan and Ms B had been challenging with the care providers. Ms B refused to make a financial contribution to her care package and had a debt of almost £38,000 to the Council. The Council agreed to cancel this debt.
22. The Council responded to Ms B’s complaint on 12 April 2024 and said:
• The Council had based its assessment of Ms B’s needs on professional judgement and this included the professionals involved with Ms B. It said that the most successful needs assessments and care packages happened when the customer engaged with the process so it encouraged Ms B to engage with the process of assessment going forward.
• The Council had made a referral to advocacy agencies.
• The Council had written off the debt.

Analysis

23. It is not the Ombudsman’s role to assess Ms B’s needs or to say what her care plan should be. The Ombudsman only considers whether the Council’s actions were in line with its duties.
24. The Council had a duty to assess Ms B’s needs, to provide a care plan if the assessment showed that she had eligible needs and to provide the care as set out in the care plan.
25. I find no fault in the way the Council assessed Ms B. It carried out an assessment on 6 December 2023 and considered Ms B’s needs in line with the outcomes set out in the CASS Guidance.
26. The social worker noted the difficulty in assessing Ms B as it was difficult to engage Ms B in the assessment. Ms B was also of the view that her needs were greater than the needs identified by the social worker. The social worker took into consideration the views of Ms B, but also the views of the professionals, including the Mental Health Integrated Network Team, the consultant psychiatrist and the occupational therapist who assessed Ms B while she was in hospital.
27. The social worker took all the factors into consideration when formulating the care plan so I find no fault in that respect. The care package was more extensive than the package proposed by the occupational therapist. I also note that the social worker tried to review the care plan in February 2024, but Ms B did not want to engage in the review.
28. In terms of the care provision, I find no fault. The agency tried, as much as possible to provide the care in line with the care plan but this was difficult as Ms B disagreed with the care plan and the care workers said she was verbally abusive towards them. I accept that the Council and the agency had to balance the duty to provide a care package to Ms B with its duties towards its employees.
29. The Council made referrals for advocacy for Ms B and it cancelled the substantial debt that Ms B owed so I find no fault in that respect.

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Final decision

30. I have completed my investigation and have not found fault by the Council.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman