The Investigation

The complaint

1. Ms X complained the Council:

• delayed completing a social care assessment, care and support plan and agreeing a direct payment; and

• did not deal with her request for rehousing into an accessible property.

2. Ms X says as a result she struggled to meet her basic care needs, was housebound, isolated and neglected herself.

Legal and administrative background

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we 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. We 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)

Relevant law and guidance

4. A local housing authority must have an allocation scheme setting out how to assess and prioritise applications for housing. An allocation scheme must give 'reasonable preference’ to people who need to move on medical or welfare grounds. (Housing Act 1996, section 166A(3))

5. The allocation scheme should set out how groups will be given reasonable preference. Under the Council’s allocation scheme, applicants receive points for housing needs factors and these are added together. Applicants get:

• 100 points for living in the borough for five years; and

• medical points due to unsuitable housing because of a disability or medical condition. There are three categories:

  • A (200 points). The applicant has a progressive or life-threatening condition seriously affected by their housing;

  • B (80 points). Where housing conditions are having a major adverse effect on the applicant’s condition; including where a person is housebound and cannot access essential facilities in their home and there are critical concerns about their safety; and

  • C (40 points). Where housing conditions are having a moderate effect on an applicant.

6. Intermediate care is a structured programme of care provided for a limited time to help a person maintain or regain the ability to live independently. Reablement is a type of intermediate care which has a focus on helping the person regain skills and reducing their needs through providing services in the home. (Care and Support Statutory Guidance paragraphs 2.9 and 2.10)

7. A council must carry out an assessment for any adult ‘with an appearance of need for care and support’. (A social care assessment) (Care Act 2014, section 9)

8. An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs. Councils should give the person an indicative timescale and keep them updated. (Care and Support Statutory Guidance 2014, paragraph 6.24)

9. The Care Act spells out the duty to meet eligible needs (needs which meet the eligibility criteria). (Care Act 2014, section 18)

10. An adult’s needs meet the eligibility criteria if they arise from or are related to a physical or mental impairment or illness and as a result the adult cannot achieve two or more of the following outcomes and as a result there is or is likely to be a significant impact on wellbeing.

• Managing and maintaining nutrition

• Maintaining personal hygiene

• Managing toilet needs

• Being appropriately clothed

• Making use of the home safely

• Maintaining a habitable home environment

• Accessing work, training, education

• Making use of facilities or services in the community

• Carrying out caring responsibilities.

(Care and Support (Eligibility Criteria) Regulations 2014, Regulation 2)

11. The Care Act explains the different ways a council can meet eligible needs by giving examples of services that may be provided.

• Accommodation in a care home or other premises

• Care and support at home

• Counselling and social work

• Information advice and advocacy (Care Act 2014, section 8)

12. If a council decides a person is eligible for care, it should prepare a care and support plan which specifies the needs identified in the assessment, says whether and to what extent the needs meet the eligibility criteria and specifies the needs the council is going to meet and how this will be done. The council should give a copy of the care and support plan to the person. (Care Act 2014, sections 24 and 25)

13. The care and support plan must set out a personal budget. A personal budget is a statement which specifies the cost to the local authority of meeting eligible needs, the amount a person must contribute and the amount the council must contribute. (Care Act 2014, section 26)

14. There are three ways in which a personal budget can be used.

• As a managed account held by the local authority with support provided in line with the person’s wishes.

• As a managed account held by a third party with support provided in line with the person’s wishes.

• As a direct payment (a direct payment is money a person gives to a council to meet agreed needs).

15. There is no defined timescale for completion of the care and support planning process. The plan should be completed in a timely fashion and it should not unduly delay needs being met. (Care and Support Statutory Guidance paragraph 10.84)

16. The duty to meet eligible needs is not discharged because the person has another entitlement to a different service which could meet those needs which they are not using. (Care and Support Statutory Guidance, paragraph 10.25)

17. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. Abuse may include self-neglect. (Care Act 2014, section 42)

18. The Council told us, at the time of the events in this investigation, it did not have a written policy for prioritising adults who have requested or been referred for an adult social care assessment. The Council said senior staff discuss the allocation list each week and must prioritise some cases over others due to high risk, complexity, staffing capacity and availability.

How we considered this complaint

19. We produced this report following the examination of relevant files and documents.

20. Ms X and the Council had an opportunity to comment on a draft report. We considered their comments before finalising the report.

What we found

What happened

21. Ms X has physical and mental health conditions. She has several long-term conditions affecting her ability to complete most activities of daily living.

Adult Social Care

22. A hospital sent the Council’s adult social care access team a referral (marked as a safeguarding concern) in March 2023. The referral said Ms X was a vulnerable adult who needed an urgent social care assessment and package of care. It went on to say Ms X also needed a referral to the mental health team for support to manage stress. The access team referred this information to the NHS mental health team. The access team took no further action.

23. Ms X’s GP practice asked the Council what was happening in May; explaining Ms X was self-neglecting and needed help. The access team replied saying it had referred the case to the NHS mental health team. It said if Ms X needed a social care assessment, a referral would need to be completed.

24. In June an occupational therapist (OT) from the NHS mental health team asked the Council to prioritise Ms X’s case for a social care assessment. A senior practitioner from the Council said there was no capacity to prioritise Ms X’s case. Ms X emailed the Council at the start of July asking what was happening. A manager replied saying her case was awaiting allocation, but there was a waiting list.

25. In October Ms X emailed the Council saying she had not had a bath or shower since October 2022 and was housebound. She summarised her physical and mental health problems and said she was scared the Council would leave her to die.

26. A manager allocated Ms X’s case to a social worker (a senior practitioner) and they visited Ms X within a week.

27. In November, the OT chased the Council for an urgent assessment stating Ms X’s condition had declined and she could not get out of bed. A physiotherapist also raised a safeguarding concern.

28. The social care assessment was completed in December. It set out Ms X’s health problems and noted she was bed bound. She had input from an OT in the NHS mental health team. The social care assessment concluded Ms X was eligible for social care under six of the eligibility outcomes (see paragraph 10.) Her estimated personal budget was £479 a week. The social worker recommended reablement care for Ms X, which she declined. Ms X wanted a package of care and a direct payment. The next steps were to draw up a care and support plan, present the case at the Council’s internal quality assurance meeting (IQAM) and set up a direct payment.

29. The social worker emailed Ms X in the middle of November and said he would aim to get her care package approved by the following week. The social worker made an internal referral to the finance team for them to assess Ms X’s care contribution. The notes said Ms X was eligible for a package of care.

30. The social worker offered Ms X reablement care again. Ms X responded saying she did not want this; she did not like having strangers in her home and she wanted control over her care because of a mental health condition.

31. There was a gap of three weeks in December with no progress on the case. The social worker and Ms X met shortly before Christmas and completed a checklist for NHS continuing healthcare. The social worker said he was asking the IQAM for four daily visits for personal care, weekly shopping, domestic support and five hours a week of community support. Ms X said she wanted a direct payment and had a friend in mind to ask to be her Personal Assistant (PA).

32. The IQAM’s decision was to refuse the social worker’s recommendation of

25 hours a week care and support. The record said “not agreed with suggestion… OT and reablement required so her care needs are clarified as well as her equipment to make sure her needs can be explained to the carers in detail.”

33. The social worker emailed Ms X to let her know the IQAM’s decision. Ms X said she wanted a copy of the decision and intended to complain about the delay.

34. The social worker and Ms X spoke at the start of January 2024; she said she was upset and frustrated. The social worker spoke about reablement again; Ms X said this was not suitable as her condition was permanent.

35. The social worker told Ms X that her case was closed to him in the middle of January (as he worked in a short-term team). The closure note said Ms X was at potential risk of self-neglect if not supported with her care needs and also potentially at risk of social isolation and malnutrition.

36. Ms X complained to the Council in January about the same issues she has raised with us.

37. The Council’s first response did not uphold Ms X’s complaints. It said:

• a hospital made a safeguarding referral in March 2023. The GP chased this in June. The same day, an OT from the mental health team advised they were allocated and asked for a joint visit with a social worker;

• a senior officer from the first contact team advised her in July that her case was awaiting allocation and there was a waiting list;

• referrals are prioritised to ensure the Council deals with urgent needs;

• it did not uphold the complaint because the safeguarding referral “was processed and forwarded to the mental health team which is not part of the Council’s adult social care service”; and

• Ms X had care and support needs. She had refused a reablement package. Direct payments took a while to set up, she had advised she was happy to wait. The advice was she should engage with the reablement service to get her personal care needs met.

38. There were safeguarding concerns raised by the GP and a hospital in February. The fire brigade raised a further concern describing poor conditions in the home, including storage of urine and faeces on the bedside table, Ms X being bed bound and appearing unkempt. The Council’s records indicate Ms X’s case was “referred to the complex needs team”.

39. One of Ms X’s friends raised another safeguarding concern at the end of March, saying she was worried about Ms X’s health and wellbeing.

40. Ms X was unhappy with the Council’s first response to her complaint and asked for a review. The Council’s second response reached the same conclusions as the first response. Ms X complained to us in April.

Events since the complaint to us

41. The social worker was re-allocated Ms X’s case at the start of May. He emailed her to say he would take her case back to the IQAM and “try to get the budget approved.”

42. The following day, the IQAM agreed 23.5 hours of care. The social worker told Ms X and noted she was happy.

43. The social worker completed a care and support plan at the end of May. The plan said Ms X was eligible for long term support from the Council. It described her eligible needs. In summary, she needed support with:

• housework

• meal preparation

• putting away on-line supermarket shopping

• dressing

• personal care

The care and support plan set out Ms X’s personal budget and the direct payment funding for 23.5 hours a week of care and support.

44. The social worker referred Ms X to the direct payment team for setting up payments and support managing them.

45. Ms X went into hospital in June. The Council told us it had set up a direct payment with a backdated start date at the end of May. It also said it would commission care and support if Ms X could not find a PA when she left hospital.

Information from the Council

46. We asked the Council why it took from March 2023 to May 2024 to undertake and complete Ms X’s social care assessment, care and planning and agree and put in place direct payment funding. The Council said:

• Ms X received a copy of the assessment at the end of November 2023 and returned it the following month;

• a continuing healthcare assessment checklist took until the end of January 2024; and

• the IQAM recommended twice that Ms X had reablement which Ms X declined.

Housing

47. Ms X applied for rehousing in October 2022. She included a medical form, but no supporting medical evidence. The Council decided to award no priority for rehousing on medical grounds.

48. Ms X sent the Council a medical form for rehousing at the end of January 2023 and supporting evidence from her doctor. The Council awarded 100 points.

Ms X asked for a review, which the Council completed in February. The points remained the same. The medical officer asked for a report about the lift in Ms X’s block of flats.

49. In May 2023, Ms X complained about the delay in receiving the lift report. The report was available shortly after her complaint. It said the lift had broken 14 times in the previous year.

50. The outcome at this stage was no further points would be awarded.

51. In November 2023, Ms X’s GP and the NHS submitted letters in support of rehousing. The letters said Ms X’s mobility had declined, she was bed bound and could not move about in her home in a wheelchair. And another organisation which was supporting Ms X, asked for the Council to consider rehousing her on medical grounds. The Council sent out a new medical form in November 2023 and received the completed form at the end of February 2024. The Council awarded Ms X 80 medical points with a recommendation for wheelchair access, level access and feasibility for adaptations for a wet room. The Council sent Ms X a letter in March 2024 explaining she could start bidding for wheelchair access accommodation.

52. The Council told us it had not received any bids from Ms X.

Conclusions

Was there fault?

The Council delayed completing a social care assessment, care and support plan and agreeing a direct payment

53. The NHS referred Ms X for an urgent social care assessment in March 2023. The Council did not allocate the case to a social worker until November of the same year and they did not complete the assessment until December. While there are no timescales for completing a social care assessment, statutory guidance says they should be completed within a reasonable timeframe, depending on the urgency of needs. Even routine, non-urgent cases should not take nine months to assess. The information the Council had on file indicates Ms X’s case was not routine and may be urgent: she was described as having no support and the GP said she was self-neglecting. The delay in assessing Ms X was fault.

54. Once the Council had decided Ms X was eligible for care and support, there was an additional failure to complete a care and support plan in a timely manner and without causing undue delay in meeting needs. This was not in line with statutory guidance and was fault.

55. The Council offered reablement care in December 2023; this was potentially a way of meeting Ms X’s care needs at least for the short-term and was not fault. When Ms X declined reablement, there should have been a prompt reconsideration of the case as her care and support needs remained unmet. Yet the case was closed in January 2024, with no resolution or care and support plan. And it remained unallocated for five months despite Ms X’s complaint and other contacts expressing dissatisfaction. This was not in line with statutory guidance which emphasises the importance of seeking an agreement with the person about their care. Closing Ms X’s case was also not in line with statutory guidance (Care and Support Statutory Guidance paragraph 10.25) which stresses the duty to meet eligible needs is not discharged because the person has another entitlement to a different service which could meet those needs. The needs remain unmet and so the Council remains under a duty to meet them. Instead of seeking to reach an agreement or offering Ms X alternative care and support, there was no action on the case between January and May 2024, despite numerous concerns about Ms X’s health and welfare being raised by the GP, OT, physiotherapist, hospital, a friend and by Ms X herself.

56. The IQAM reconsidered the case at the start of May. The only new information available to it since the previous consideration was Ms X had refused reablement care, which she had communicated to the social worker at the outset. The IQAM then agreed the package that it had refused six months earlier. There was no change in need and the reconsideration was based on the same social care assessment.

57. Taking six months to complete a care and support plan after an assessment concluded Ms X had eligible unmet needs for care and support was fault: it was not timely and not in line with the Council’s legal duty to meet Ms X’s eligible, unmet care and support needs.

The Council did not deal with the request for rehousing into an accessible property

58. The Council considered Ms X’s application for rehousing based on information available; awarded her time in borough points (100) and medical points (80) based on medical evidence she provided and decided she needed an adaptable property. This is in line with its published allocation scheme and so there is no fault.

Did the fault cause injustice?

59. The delay in assessing Ms X’s social care needs was fault causing avoidable distress and uncertainty and a potential loss of or a delay in accessing a service to which she had a legal entitlement.

60. The failure to reconsider the case after Ms X refused reablement care and the delay in completing a care and support plan and agreeing funding caused Ms X the injustice of not having her eligible care needs met from December 2023 to May 2024.

Recommendations

61. The Council must consider the report and confirm within three months the action it has taken or proposes to take. The Council should consider the report at its full Council, Cabinet or other appropriately delegated committee of elected members and we will require evidence of this. (Local Government Act 1974, section 31(2), as amended)

62. In addition to the requirements set out above, the Council has agreed to:

• apologise to Ms X for the avoidable distress and frustration caused by the delay described above. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology;

• pay Ms X £3,000 to recognise the avoidable distress, frustration and loss of care and support. This is an exceptional case and the recommended payment reflects significant avoidable delay and the impact on Ms X who requires significant care and support to enable her to complete activities of daily living;

• devise and implement written guidelines for prioritising cases for social care assessments; and

• instruct staff to offer clients with unmet eligible care and support needs an interim care package to meet their needs before closing a case and/or before resubmitting it to the IQAM.

63. The Council should provide us with evidence it has complied with the actions in the previous paragraph.

Decision

64. There was delay by the Council in assessing Ms X’s social care needs, completing a care and support plan and arranging funding for care. This caused avoidable frustration, uncertainty and distress. We recommend an apology, payment and changes to procedures to minimise the risk of recurrence. The Council has accepted our recommendations.

Print this page