Summary: Mr A has complained about a council and an integrated care board in relation to a lack of carer support for him, a poor transition between services, and a lack of adequate safeguarding action. He said this caused him and his son distress, and he suffered financial loss. We found fault with a lack of carer support provided to Mr A. The council and integrated care board agreed to our recommendations to address the issues Mr A had suffered.

The complaint

1. Mr A has complained about Hampshire County Council (the Council) and NHS Hampshire and Isle of Wight Integrated Care Board (the ICB) about the lack of carer support provided to him and a lack of care provided to his son, Mr B, between 2020 and 2023.
2. Specifically, Mr A complains about:

inadequate carer assessments and carer support,

a badly handled transition for Mr B from children to adult services by the Council and the ICB and;

a lack of adequate safeguarding by the Council.

3. Mr A says this lack of support has affected him financially with him having to employ people to keep his business afloat.
4. It has also affected him mentally causing anxiety and suicidal thoughts.
5. Mr A would like some form of financial compensation and for the question of who is responsible for meeting his needs as a carer to be answered.
6. He would also like a formal apology.

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The Ombudsmen’s role and powers

7. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18Z The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA). The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended). The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)). A)
8. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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. As part of my investigation, I considered evidence from the Council and ICB including social care records and complaint correspondence. I also considered evidence from Mr A provided in writing and in a telephone call.
12. I also considered the relevant legislation and guidance.
13. I considered comments on my draft decision from all parties before making this final decision.

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What I found

Background

14. Mr B has learning difficulties and lives at home with Mr A. Mr B turned 18 in late 2020 and so was eligible for adult social care. Also, when he turned 18, after being assessed, Mr B was eligible for Continuing Healthcare (CHC) funding and his care and support funding came from the ICB. Before this the Council had funded Mr B’s care and support.
15. Mr A first complained in 2021 about his son’s care and the lack of support he had as his carer. After going through the complaint with the Council and ICB, Mr A approached the Ombudsmen.

Guidance and legal background

Continuing Healthcare

16. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’.
17. The Department of Health’s National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (November 2012 (Revised) and updated in July 2022) (the National Framework) is the key guidance about Continuing Healthcare. It states that where an individual is eligible for Continuing Healthcare funding the ICB is responsible for care planning, commissioning services and case management.

Care Act - safeguarding

18. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.

Carer’s Assessment

19. Where an individual provides or intends to provide care for another adult and the carer may have any needs for support, local authorities must carry out a carer’s assessment. Carers’ assessments must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself. This includes the practical and emotional support the carer provides to the adult.
20. Where the local authority is carrying out a carer’s assessment, it must consider the carer’s potential future needs for support. Factored into this must be a consideration of whether the carer is, and will continue to be, able and willing to care for the adult needing care. (Care and Support Statutory Guidance 2014)
21. The Care Act 2014 makes clear the local authority may meet the carer’s needs by providing a service directly to the adult needing care. In these cases, the carer must still receive a support plan which covers their needs, and how the Council will meet them. The carer’s personal budget must be an amount that enables the carer to meet their needs to continue to fulfil their caring role. It must also consider what the carer wishes to achieve in their day to day life. Part of the planning should be to agree the way the carer will use the personal budget to meet his or her needs. (Care and Support Statutory Guidance 2014).

Carer’s assessment and support

22. Mr A said after the Council assessed his needs as a carer, it did not provide any carer support for him. For example, it provided no training for him in behavioural techniques including safe restraint as Mr B could become aggressive at times. In addition, he was not given support at home so he could go out and maintain his business. He had to hire workers to help with his business, but this created financial pressure. In addition, Mr A said his mental health suffered due to not having breaks from looking after his son.
23. The Council said it carried out two carer’s assessments, in 2019 and 2021. Both these assessments identified Mr A had needs under the Care Act and Mr A would benefit from breaks from his carer’s role. This would be in the form of help from a personal assistant to support Mr B while Mr A took a break.
24. In 2020 there were carers who helped Mr A in caring for Mr B, however Mr A was still struggling to maintain his business and independence due to what he felt was a lack of carer support.
25. In 2021, the Council said the personal assistant support was provided by the ICB. It said it was the ICB’s responsibility to ensure the personal assistant support was enough to allow Mr A breaks to sustain his role as carer. The Council said this was part of his support plan.
26. The Council, in its final response to the complaint, agreed it had a responsibility to ensure it met Mr A’s needs as a carer and if Mr A wanted a new carer’s assessment, he should contact the Council.
27. The ICB outlined what support it gave Mr A in the form of Mr B attending placements during the day to give Mr A time to himself. It also said he had some weekend respite.
28. Mr A said that he still had to do all the domestic chores and hire people to help run his business as he did not have enough time.

Analysis

29. The 2019 carer’s assessment stated that Mr A was the primary carer for Mr B. It went on to say Mr A’s business needed to be open at certain times to ensure an income to support him and Mr B.
30. It stated Mr A needed support in these times when he was working. It went on to say he receives little other support.
31. The assessment assumed that Mr A had enough support from a carers' hub and a care package. This included personal assistance support, day service support when Mr A had to work, and monthly respite.
32. Mr A said, in reality, the Council did not put this support in place.
33. The 2019 assessment stated that Mr A had until recently underestimated the respite support he needed to give him time to himself and a break from his caring role.
34. The assessment did not put any extra personal assistance support in place and said that Mr A had mental health needs which could be addressed by his GP and support from his carers’ hub.
35. On respite care the Council’s carer’s assessment said this should be provided to give Mr A regular breaks.
36. The carer’s assessment of 2021 portrayed a worsening situation in that Mr A’s mental and physical health had suffered since the last assessment and Mr B’s behaviour was becoming hard to manage.
37. Mr A had to do all the household tasks such as cleaning, cooking and laundry. In addition, although his son attended a placement from 10am to 4pm every weekday, this involved intensive preparation and for Mr A to transport him there and back.
38. Mr A also struggled to find time to attend appointments for himself such as his doctor and dentist.
39. Mr A had one weekend a month respite, but the carer’s assessment identified that two weekends would be more suitable for his needs and that he should not have to pay for this. There was a suggestion of a rolling allowance to support him to have these two weekends respite.
40. Mr A was also paying a manager of his business through direct payments but there was a lack of clarity from the Council about the system of direct payments.
41. The carer’s assessment also said that Mr B had been assessed as needing two support workers but that he was not getting them, so Mr A was providing all Mr B’s support at home. He wanted direct payment support to get these carers. The carer’s assessment said the health budget his son was entitled to from CHC should provide for this respite support for Mr A.
42. This 2021 carer’s assessment stated that Mr A was entitled to support under the Care Act to prevent risks to his health and economic wellbeing.
43. The Council has told the Ombudsmen that in the period in question, 2020 to 2023, it provided support in the form of signposting and advice. It said that overnight respite become the responsibility of the ICB after Mr B’s care transferred to the ICB.

Analysis

44. If a carer is assessed as having needs that are eligible for support, the Council has a legal duty to meet these needs on request from the carer. It must also draw up a support plan with the carer, setting out how to meet these needs.
45. The Council is correct in stating that overnight respite is the responsibility of the ICB.
46. The carer assessments outlined needs which Mr A had as a carer. With regard to him having support which allowed him to have breaks and to manage his business, the Council did not provide this support during this period, despite it being part of the carer’s assessment. Mr A did get more support from the ICB when it arranged for Mr B to go on daytime placements, but the Council did not provide any further support to Mr A to allow him breaks or to meet his needs as a carer. This was fault and it left Mr A without support, and his physical and mental health as well as his business, suffered.
47. In addition, the CHC National Framework says the ICB may need to provide additional support to care for an individual whilst the carer has a break from his or her caring responsibilities and will need to assure carers of the availability of this support when required.
48. This could take the form of the ICB providing the cared-for person with additional services in their own home or providing the necessary support to enable them to spend a period away from home (e.g. in a care home). The ICB should also give consideration to meeting any training needs that the carer may have to carry out their caring role.
49. Therefore, it was the duty of the ICB and the Council to collaborate to meet the needs of Mr A as the main carer of his son. Regarding his needs relating to work and leisure which fell outside what could be provided under Continuing Healthcare, the Council was responsible for meeting those needs.
50. However, the ICB could also have considered funding some training to Mr A in relation to how to care for his son and deal with his aggressive episodes, something he had asked for. It was fault that the ICB did not consider this.

Transition from children to adult services and CHC

51. Mr A said that the same issues he had with his son’s care remained, and in some ways got worse, after he turned 18. In addition, he criticised the ICB and Council for the way the transition to CHC was handled.
52. Mr A said there was a difficulty in providing carers who were sufficiently highly trained and able to follow the behavioural programmes and techniques which sustained Mr B when he was at school.
53. Mr A said this revealed a lack of familiarity with his son’s needs and triggers, flaws in the transition process and a lack of predictive crisis planning.
54. Mr A also pointed out that his son was unsettled by change and new things could increase his aggression and hard to manage behaviours. Therefore, his deterioration, through fighting and running away, could have been predicted and prevented. Mr A said this would have been the case if Mr B had carers qualified in behavioural techniques similar to those which the staff at his school had.
55. Mr A said although a transition process took place between the Council and Health (the ICB), the care package provided was inadequate in terms of quality and anticipated increase in need for carer support and respite.
56. The Council said its Childrens Services Directorate made an appropriate and timely referral to Independent Futures Team (Transition) when Mr B was 16, to support his transition between services.
57. The Council said Mr B had an allocated social worker who remained involved after he became an adult in late 2020.
58. The Council went on to say this social worker had multiple meetings and reviews which Mr A attended. The social worker completed three social care assessments and a carer’s assessment in 2021.
59. The Council said it agreed a personal budget for support Mr B would receive after turning 18. It went on to say the support planning was commenced in a timely way and a decision was made five months ahead of him turning 18.
60. The Council also said the social worker made appropriate referrals and had discussions with partner agencies such as Children and Adolescent Mental Health Services and social prescribers.
61. When Mr B became eligible for CHC the Council said it ensured robust case and financial handover between Council and ICB and remained involved for some time following handover.
62. The Council said it also made a referral to the Intensive Support Team who deal with learning disabilities when Mr B’s behaviour deteriorated in February 2021.
63. Mr A felt that this support should have been part of the transition rather than a reaction to the situation.
64. The Council admitted the complexity of the case would have benefited from a more coordinated approach.
65. However, the Council said at the time adult services and the ICB were under extreme COVID-19 pressure trying to manage hundreds of calls and doing additional vulnerable adult checks. The Council said it was trying to learn from the pandemic and how better to manage in the future.
66. The ICB said it did not receive a handover or care plans from the Council when Mr B made the transition to CHC.
67. The ICB outlined the attempts it made to provide Mr B with adequately qualified carers. There were difficulties in sourcing the appropriate agency until 2022.

Analysis

68. NICE Guidance on Transition (NG43) from children’s to adults’ services covers both health and social care. It emphasises the importance of using person-centred approaches to transition support. It also recommends health and social care services in children’s and adults’ services working together in an integrated way, to ensure a smooth and gradual transition.
69. There is evidence the Council made efforts to ensure a smooth transition from children’s to adult services. There is also evidence the Council passed on information to the ICB to ensure a smooth transition, despite the ICB stating it did not receive the information.
70. However there was a difficulty in finding specialist carers.
71. I do not find fault with the ICB’s provisions of care as it made several attempts over the following months to resolve the matter and there was difficulty with providing specialist carers.

Safeguarding

72. Mr A felt there was a lack of safeguarding action by the Council in this period to safeguard both him and his son. He said this led to the associated deterioration in his son’s behaviour and the resulting impact on Mr A.
73. The Council outlined several safeguarding referrals it received in this period and how it handled these. The Ombudsmen look at whether there was fault in the way an organisation made a decision. If there was no fault in how the decision was made, we cannot question the outcome of that decision-making process.
74. On each of these occasions the Council sought evidence from the people involved in Mr B’s care. It used this evidence to decide what action to take to ensure Mr A and Mr B’s safety. Therefore the Council followed the safeguarding process appropriately and we do not find fault in this aspect of the complaint.

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Recommendations

75. The lack of support provided to Mr A by the Council and ICB in relation to his needs as his son’s main carer was fault, leading to the impact I have described above. Due to this I recommend that by 9 December 2024, the Council:

• writes to Mr A apologising for the mental, physical and financial distress he suffered due to the faults in relation to carer support,
• pays Mr A £2000 in recognition of the impact this lack of support had on him from 2020 to 2023,
• reminds social care staff of their responsibility under the Care Act and National Framework to provide support to all carers assessed as needing it, whether or not the person they are caring for is receiving CHC funding; and

And the ICB:

• writes to Mr A apologising for the impact that a lack of training had on Mr A while caring for his son,
• reminds staff of the need to consider under the National Framework if family members as carers have training needs it can meet

76. The organisations should provide us with evidence they have complied with the above actions.

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Final decision

77. I found fault with the Council and ICB relating to carer support which led to distress for Mr A. I do not find fault with the Council or ICB regarding transition and safeguarding.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman