Summary: Mrs E complained that the Council took to long to agree to a residential care placement for her mother Mrs F (now deceased) despite her expressed wish to do so due to loneliness, isolation and anxiety over carer visits. We found some fault with the actions of the Council. The Council has agreed to pay Mrs E £300 and improve its procedures for the future.

The complaint

1. Mrs E complained that Leeds City Council (the Council) unreasonably delayed in agreeing to a residential care placement for her mother Mrs F (now deceased), despite her and Mrs E’s expressed wishes to do so, because Mrs F was lonely, isolated and struggling with her appetite. She also found the carer’s visits stressful when the people and timings changed. This delay has caused Mrs E significant distress and uncertainty over whether an earlier move would have been beneficial to Mrs F.

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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 significant injustice, or that could cause injustice to others in the future 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 have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. Mrs E and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Assessment

5. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
6. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.

Council guidance: Residential and Nursing Care – Establishing Need

7. This guidance says that residential care will be considered appropriate for people who meet at least one of the following criteria:
• Cannot carry out essential daily living tasks and these tasks cannot be completed by carers.
• Are unable to guard against common dangers and cannot reasonably be supervised by carers.
• Are causing unacceptable stress to a carer that cannot be relieved by community care services.
• Are at risk of physical or emotional abuse and no other means of protection are available.
8. In addition, the following criteria should also be considered:
• Situations where rehabilitation has been unsuccessful.
• Need assistance with a number of daily living tasks such as eating, drinking, walking and toileting on a 24 hour basis.
• Are unable to be supported at home with a care package.
• Have a history of falls which pose an unacceptable risk.
• Telecare has been explored and discussed.
• The person has agreed to try residential care and mental capacity has been addressed.

What happened

9. In August 2023 Mrs F was in hospital. Prior to this Mrs F lived in her own flat in a retirement complex with care from Mrs E and a small package of care visits. The Council held a multi-disciplinary meeting to review her care needs and decide where she should go after discharge. Mrs E wanted her to go into a care home as she had concerns about whether Mrs F could look after herself properly, particularly around nutrition and Mrs E said she could no longer cope being Mrs F’s main carer. Mrs F wanted to return home and retain her independence.
10. The Council agreed she should go home with a package of care involving three visits a day. This started at the end of September 2023. Mrs E expressed concerns about the care provider within a couple of days. The Council reviewed the care in early October. Mrs E had cancelled the lunchtime call as it was always too late and created too short a gap between lunch and tea, so Mrs F was not hungry and didn’t eat in the evening. The Council agreed to look for a new care provider.
11. The Council reduced the package of care to two visits a day and found a new care provider (CP).
12. Towards the end of October Mrs E told the Council she was estranged from Mrs F and she could no longer provide care due to the impact on her mental health. She requested an assessment with a view to Mrs F going into a care home. Mrs E was unhappy with the new carers and said they were always ringing her. Another family member had taken over Mrs E’s caring duties temporarily. Mrs E said Mrs F agreed that she should go into a care home. The Council said residential care was not the only option and arranged a visit in a couple of days’ time.
13. A new social worker (SW) visited Mrs F and Mrs E. Mrs E said the family wanted Mrs F to move into residential care. SW suggested increased care visits, but Mrs E did not think this would work as Mrs F was not coping with the current visits and they were causing her anxiety. SW recognised that Mrs F was underweight and frail, but she felt the CP had only been in place for a week and it was reasonable to give them more time to settle in. Mrs E said she could not help anymore. Mrs F said she wanted to go into residential care: she said she was lonely and was not managing her meals.
14. SW checked with the CP: they felt the visits were working well and Mrs F was eating.
15. In response to emails from Mrs E who said Mrs F was depressed the Council said SW was completing the assessment, with a view to increasing the length of care visits to compensate for Mrs E stopping her care. In respect of the concerns over Mrs F’s nutrition the CP was going to have additional time to sit with Mrs F while she eats to provide stimulation and encouragement.
16. Mrs F refused to speak to SW without daughter present. But she said she did not want her care increased. SW was worried that Mrs F was in a vulnerable position now without family care. She spoke to the manager of the accommodation who felt Mrs F was isolated and not so independent now.
17. SW contacted Mrs F’s GP. They had visited Mrs F and felt she was safe where she was. The GP did not have any concerns and said she had gained some weight but did not know her weight back in August when she was in hospital. They said the district nurse service could monitor Mrs F’s weight.
18. SW visited Mrs F at the beginning of November 2023. Mrs F again said that she felt residential care was best for her. She was struggling with carers coming in and changes of staff/late arrival increased her anxiety. SW said there were eligibility criteria for going into a care home but if the care package was not working the Council could consider where her needs would be best met. Mrs F said she was happy to see how things worked out in the meantime and SW would try and improve the timeliness and consistency of carers.
19. SW increased the care visits to include a two hour laundry and shopping call once a week. Mrs E made a complaint that the Council and CP were still contacting her even though she was unable to provide care any longer. The Council acknowledged the complaint. SW accompanied Mrs F to a medical appointment and made a referral to a befriending service. Mrs F said she wanted things to work out as she liked living in the flat. SW offered Mrs E a carer assessment, but she declined saying she was getting help from her GP.
20. In mid-November SW noted that carers were missing the extra slot for laundry and shopping and there were constant problems with safely arranging Mrs F’s medication.
21. On 4 December 2023 SW visited Mrs F at home. She said she still wanted to go into a care home. She said she felt anxious about the carers coming in and not being on time or doing things she didn’t like.
22. SW completed the assessment on 8 December 2023. They concluded it was best for Mrs F to stay at home with a package of care. SW noted Mrs F had capacity to make decisions about her care and that she and Mrs E wanted her to go into a care home. SW concluded the situation for Mrs F may not be any better in a care home. The assessment is not signed off by a more senior member of staff.
23. SW raised concerns about Mrs F’s weight loss with the medical team. An Occupational Therapist visited Mrs F and felt she was doing well.
24. In early January 2024 SW note that Mrs F had lost 5 kg in two months. They referred Mrs F to the GP and spoke to the carers who felt Mrs F was eating well, but acknowledged she did not eat lunch. Mrs F told SW she was very unhappy and did not want to live like this. SW visited Mrs F who again said she was lonely in her accommodation. She had refused the lunch call and the befriending scheme because she was worried about getting on the bus. SW again contacted Mrs F’s GP as she was concerned about her weight loss.
25. On 9 January 2024 the Council responded to Mrs E’s complaint and sent her a copy of the assessment. It said:
• Not all the community based options for Mrs F had been considered: it could increase care visits and look at community activities.
• There had been medication problems, but SW had been very proactive in resolving these contacting both the GP and the pharmacy.
• It upheld her complaint about the failure to give the CP Mrs F’s telephone number so they could call ahead if they were running late.
• The extra laundry and shopping call was working well despite initial teething problems.
• There was no delay in the time SW took to complete the assessment.
26. Mrs F again refused the befriending service due to concerns that she could not get on the bus to get there. The service leader agreed that she would struggle with this. Mrs F said she didn’t want a telephone call, she wanted a face-to-face visit. She said her niece was helping her look for residential care.
27. On 23 January 2024 Mrs F’s GP called SW to say that Mrs E and the rest of the family wanted Mrs F to go into residential care. SW said they could not make that decision, but all options were being considered.
28. The CP and SW reviewed Mrs F’s care plan Mr F said she felt isolated and wanted to move. She missed going out in the car with Mrs E and wanted carers to do that. SW explained that was not possible and again offered the befriending service with help to get on the bus. Mrs F refused, saying she was not eating because she was unhappy where she was living.
29. Mrs E escalated her complaint to stage 2 of the complaints procedure.
30. In mid-February 2024 CP withdrew the laundry and shopping visit as Mrs F was not keeping to time and making unreasonable demands. Mrs F was also subject to some complaints from other residents in the retirement complex and she declined a hearing and sight assessment.
31. SW asked a manager for assistance. They suggested carrying out a mental capacity assessment and considering a period of residential respite. SW visited Mrs F on 19 February 2024. She was very unhappy and liked the sound of the respite option. On 26 February 2024 the Council agreed to three weeks of respite care. Mrs F’s GP said she was very lonely and isolated and wanted to move to a care home for social reasons. The Council’s Head of Service approved the respite care on 5 March 2024, as it was in Mrs F’s best interests particularly in terms of nutrition and weigh loss.
32. The Council responded to Mrs E’s complaint on 6 March 2024:
• It was the health service’s responsibility to monitor weight loss. SW had made a referral to the dietician, but this was still outstanding. SW had tried to restore the lunchtime call, but Mrs F had refused. The support plan put in place by SW was not the cause of Mrs F’s weight loss.
• SW had undertaken an appropriate capacity assessment and Mrs F was able to make her own decisions about her care and support needs.
• Mrs F has eligible care and support needs which the Council considers can be met in her own home.
• Although it was right to give Mrs F time to get used to a package of care. It was now the right time to trial a respite residential care placement.
33. On 19 March 2024 Mrs F’s weight had increased and was now considered normal. On 21 March 2024 Mrs F went into respite care for four weeks with a view to a permanent placement. A permanent placement was agreed on 11 April 2024.
34. Mrs F died on 22 April 2024.

Analysis

35. When Mrs F was discharged from hospital in September 2023 it was clear she wanted to go home, and this could be safely managed with a package of care plus support from Mrs E. The situation changed at the end of October 2023 when Mrs E said she could no longer provide care due to a breakdown in her relationship with Mrs F and the impact on her own mental health.
36. SW was allocated to the case and undertook a very detailed assessment with in approximately six weeks. They met with Mrs E and Mrs F on several occasions. They also kept in touch with Mrs F very regularly and carried out numerous tasks for her. They also pursued all the options available to enable Mrs F to stay in her home, including extra care visits, more timely care visits, extra care housing, befriending services and day centres.
37. Although Mrs F said at this point, she wanted to go into residential care because she was lonely and isolated and struggling to manage the carer visits, I have not found fault with SW’s actions to help Mrs F stay in her own home with additional support from carers and voluntary services, now Mrs E could not support her. SW also checked with the GP and CP who both thought Mrs F was managing well at home. I note that at the beginning of November 2023, although Mrs F still said she wanted to go into residential care, she did agree to see how things went with the SW input and a few days later said she wanted to stay in her flat if things worked.
38. A month later when SW completed the assessment, Mrs F was still saying she wanted to go into a care home and expressing concerns about anxiety over the carers and loneliness. SW noted Mrs F had capacity to make her own decisions about care but concluded that Mrs F was better off remaining at home because the situation may not be any better in a care home. I do not consider the reasons for this decision were adequately justified in the assessment. SW did not properly explain Mrs F’s reasons for wanting to go into residential care or explain how these could be effectively addressed to enable Mrs F to stay at home. It was clear Mrs E could not provide support, Mrs F was struggling with depression, anxiety and loneliness and had lost a significant amount of weight. Furthermore, none of the many things SW had tried had eased these concerns. I am also unclear of the evidence SW had to say that residential care would not be any better given that Mrs F would be able to have more regular contact with other people, both residents and carers, in a care home setting.
39. I also note the assessment was not signed off by a more senior member of staff. The Council has assured me that managers were involved and consulted at all stages and the stage one complaint response from a senior manager made clear that all community options had not yet been considered. However, I consider evidence of this should be clear in the case records and the assessment document itself.
40. SW had concerns about Mrs F’s weight and mental state as they referred the matter to Mrs F’s medical team, arranged an OT assessment and suggested again to reinstate the lunchtime call, which Mrs F refused as she could not cope with any more care visits. This suggests that Mrs F could not properly manage her eating (a daily living task) and due to her mental condition, the community care option was not working. Looking at the Council’s guidance on residential care it is arguable Mrs F met the first criterion at this point:
• Cannot carry out essential daily living tasks and these tasks cannot be completed by carers.
41. By early January 2024, Mrs F had lost more weight. I acknowledge that SW responded properly to this situation buy referring her again to the GP and asking CP to monitor food and fluid intake. But CP also said Mrs F was not eating lunch and needed a lunchtime call. SW was aware that Mrs F would not accept a lunchtime call, so there was no immediate solution to address this key issue.
42. Mrs F again said to SW that she was very unhappy and didn’t want to live in the flat anymore as she was lonely. SW offered the befriending service, but Mrs F refused this due to concerns about getting on the bus, which were supported by the service manager. This also indicates Mrs F’s mental health was suffering and there was no workable solution.
43. I note the stage one complaint response said that not all community-based options had been considered as the Council could increase carer visits and look at community activities. But looking at the interactions with Mrs F it is clear by this point she had already refused those options.
44. By the end of January 2024, the GP contacted the Council to say Mrs F and her family wanted her to try residential care and Mrs F said she was not eating because she was not happy with where she was living.
45. By mid-February 2024 Mrs F was experiencing problems with other residents in the block and refused support with hearing and sight loss. SW again consulted a manager who suggested a mental capacity assessment and residential respite care. Mrs F was very keen on this proposal and wanted to go into a care home for company. However, respite care took another month to arrange. Once she did move in, she was happy there and the Council agreed to the placement as a permanent arrangement.
46. I have not found fault with the efforts made by the SW and the Council to address Mrs F’s needs. They were thorough and persistent and offered a service more akin to a personal assistant than a social worker. However, I do think the Council took too long to suggest a period of residential respite: Mrs F consistently said after early December 2023 that she wanted to go into residential care and refused all options to improve the situation at home. By the end of January her GP also agreed with this. I consider the Council should have looked for residential respite care at this point. It is likely Mrs F would then have been able to move by the end of February 2024, approximately a month earlier than she did.
47. I am unable to reach a view as to whether the delay in Mrs F moving to residential care contributed to her death, but Mrs E was caused avoidable distress raising her concerns about Mrs F for longer than she should have done.

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Agreed action

48. In recognition of the injustice caused to Mrs E I recommended the Council within one month of the date of my final decision:
• Apologises to Mrs E and makes a symbolic payment to her of £300; and
• Reminds social work staff of the importance of reaching a balanced decision regarding care placements, taking into account all the information provided about a person’s eligible care needs.
49. The Council has agreed to my recommendations and should provide us with evidence it has complied with the above actions.

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Final decision

50. I consider this is a proportionate way of putting right the injustice caused to Mrs E and I have completed my investigation on this basis.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman