Summary: We found fault with the care and support provided to Mr Y by the Council as it failed to properly assess his needs in the community. This caused Mr Y’s daughter, Mrs X, significant frustration and distress. The Council will apologise to Mrs X and pay her a financial remedy. The Council will also take remedial action to prevent similar problems occurring for other people.

The complaint

1. The complainant, Mrs X, is complaining about the care provided to her father, Mr Y, by Norfolk County Council (the Council) and Norfolk and Norwich University Hospitals NHS Foundation Trust (the Trust).
2. Mrs X complains that:

• the Council failed to provide the family with support from July 2023 when she first approached it for assistance as her mother, Mrs Y, was struggling to care for Mr Y;
• the Council and Trust failed to complete a timely Continuing Healthcare (CHC) checklist for Mr Y, despite his rapidly deteriorating condition;
• the Council and Trust discharged Mr Y from hospital without putting appropriate palliative care services in place for him; and
• the Council delayed in allocating a social worker to Mr Y’s case and this prevented a proper assessment of his needs in the community.

3. Mrs X says these failing meant Mr Y did not receive the care and support he needed in the months leading up to his death. She says the delayed CHC process meant the family incurred significant care home fees for a placement that should have been funded under that framework. Furthermore, Mrs X says these events were greatly distressing for her.

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The Ombudsmen’s role and powers

4. 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).
5. 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.
6. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
7. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we can complete our 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

8. In making my final decision, I considered information provided by Mrs X and discussed the complaint with her. I also considered relevant information and records from the Council and Trust. Furthermore, I took account of relevant legislation and guidance. I shared my draft decision statement with all parties for comment and considered the responses I received.

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What I found

Relevant guidance and legislation

Care Act 2014

9. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of any adult who appears to need care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and, where appropriate, their carer or any other person they might want to be involved.
10. An assessment should be carried out over an appropriate and reasonable timescale. The assessment should take into account the urgency of the person’s needs and consider any fluctuation in those needs. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.

Hospital discharge

11. In April 2022. the Department of Health and Social Care issued statutory guidance entitled ‘Hospital discharge and community support guidance’ (the Discharge Guidance). This guides NHS bodies and local authorities on discharging adults from hospital.
12. Section 10 of the Discharge Guidance concerns discharge arrangements for people considered to be at the end of life. This emphasises the importance of ensuring these individuals’ needs are anticipated and planned as part of the discharge process. This may include ensuring the person has access to suitable medication, equipment and care.
13. The Trust produces a ‘Standard Operating Policy regarding Discharge from Hospital’. This sets out the local discharge process. The policy identifies four discharge pathways:

• Pathway 0 (D2A0) - for people able to return home with little or no support;
• Pathway 1 (D2A1) – for people able to return home with new or additional support;
• Pathway 2 (D2A2) – for people requiring short-term, bed-based care for the purposes of rehabilitation or further assessment; and
• Pathway 3 (D2A3) – for people with complex care needs who need ongoing 24-hour, bed-based care.

End of life care

14. In 2019, the National Institute for Health and Care Excellence (NICE) issued the clinical guideline ‘End of life care for adults: service delivery [NG142]’. This provides guidance health and social care professionals on organising and delivering end of life care services. The guideline deals with providing care and support in the final weeks and months of life and the planning for this. It aims to ensure people have access to the care they want and need in all care settings. It also includes advice on services for carers.

Continuing Healthcare (CHC)

15. 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’. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. The threshold for meeting the CHC Checklist is set low.
16. The Department of Health and Social Care’s ‘National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (July 2022)’ (the CHC Framework) is the key guidance about the CHC process.
17. The CHC Framework says individuals with rapidly deteriorating conditions, who may be entering a terminal phase, may require ‘fast tracking’ for provision of CHC funding. It sets out a Fast Track Pathway that should allow professionals to ensure these individuals are provided with CHC without the need for the standard assessment process.
18. The CHC Framework makes clear that terms such as ‘rapidly deteriorating’ and ‘may be entering a terminal phase’ should not be interpreted narrowly.

Background

19. In 2023, Mr Y was living at home with Mrs Y. He was receiving one daily care visit in the morning to help him get up and washed.
20. Mrs X contacted the Council on in July 2023 to report that Mrs Y was struggling to cope with the Mr Y’s increasing needs. Mrs X explained that she felt Mr Y needed some additional equipment at home.
21. The Council arranged an urgent Occupational Therapy (OT) assessment. This took place the following day. The OT arranged for Mr Y to have some equipment (such as a toilet frame) delivered. Mr Y’s family arranged for additional equipment.
22. Mrs X also remained in contact with the Council. She reported that Mr Y’s condition had stabilised slightly after he recovered from an infection. However, she said he remained without a care plan. In a call on 31 July, Mrs X said Mrs Y was satisfied with one care visit per day but that some flexibility would be helpful.
23. Mr Y was admitted to hospital with pneumonia on 4 August.
24. On 7 August, Mrs X informed the Council that the hospital had discharged Mr Y. She again said that Mrs Y was struggling to cope with Mr Y. Mrs X declined any additional support during the day but said Mrs Y would benefit from a break in her caring role as Mr Y was waking at night.
25. Mrs X contacted the Council again on 22 August. Mrs X explained that Mr Y was weak and malnourished and was experiencing increasing continence issues. Mrs X was unhappy the case had not been allocated to a social worker and felt nothing was being done. The duty officer agreed to make a further OT referral.
26. Mrs X called again the following day. She said the care provider could not offer any support after 8pm.
27. The Council allocated the case to a social worker on 11 September. A duty worker spoke to Mrs X the following day. Mrs X reported that Mr Y had entered a respite placement. However, on the first day he experienced two unwitnessed falls and cut his hand. This required hospital admission. Mrs X said the respite care home would not have him back due to his dementia care needs.
28. As Mr Y was in hospital, the Council reallocated his case to the hospital social work team on 15 September. The referral noted that Mr Y would require 24-hour care and that he may be suitable for CHC funding.
29. The Trust assessed Mr Y on 21 September. The assessment concluded Mr Y would not be suitable for a D2A3 placement.
30. A Council practitioner completed a Care Act Assessment on 25 September. The assessment noted that Mrs Y felt unable to cope with Mr Y at home due to his increased care needs. The practitioner recommended a short-term residential placement so Mr Y’s needs could be considered in further detail.
31. On 6 October, the social worker completed a capacity assessment for Mr Y. The social worker concluded that Mr Y lacked capacity to make decisions about his care. On the same day, a Council practitioner noted Mr Y’s family had arranged a self-funded placement at a care home.
32. The Trust discharged Mr Y to a permanent bed at the care home on 9 October.
33. Mrs X contacted the Council on 7 November to report that nobody had assessed Mr Y since his transfer to the care home. This was followed by several further calls later that month in which Mrs X expressed her frustration with the lack of support. Mrs X reported being passed back and forth between the hospital and the adult social care team. She said Mr Y had lung cancer and heart failure and was doubly incontinent.
34. Mr Y’s case was allocated to a social worker on 1 December.
35. The social worker visited Mr Y at the care home on 6 December. Mrs X was also present. However, Mr Y was experiencing an erratic pulse and breathlessness. The care home called an ambulance and Mr Y was admitted to hospital. Mrs X again raised the issue of CHC funding. The social worker explained that it would be possible to complete a CHC checklist once Mr Y’s condition had stabilised. The social worker advised Mrs X that, if Mr Y was at end of life, a fast track assessment would need to be completed.
36. On 8 December, Mrs X told the social worker Mr Y was now being treated as end of life. The social worker contacted the care home to ask it to arrange a fast track assessment by a GP. The social worker later contacted the GP directly to arrange this. The local Integrated Care Board (ICB) accepted the fast track CHC application later that day.
37. Mr Y died on 9 December.

My analysis and findings

Lack of support

38. Mrs X says she first approached the Council for help in July 2023 as Mrs Y was struggling to cope with Mr Y’s increasing needs. Despite this, Mrs X complains the Council failed to provide the family with support.
39. The Council acknowledged receiving contact from Mrs X in July 2023 and said it had allocated the case to a social worker on 11 September. However, the Council said Mr Y had been admitted to hospital before an assessment could be completed and that his care had then passed to the hospital social work team.
40. The Care and Support Statutory Guidance (the Statutory Guidance) that accompanies the Care Act places on emphasis on the importance of effectively assessing a person’s needs. The Statutory Guidance does not provide a specific timescale within which an assessment must take place. However, the Statutory Guidance makes clear that it should be completed in a ‘timely’ fashion. This refers to the individual and their circumstances. In some cases, there may be risks associated with failing to complete an assessment promptly.
41. The Care Act also places a duty on councils to complete a carer’s assessment when an individual provides care for another adult, and it appears that carer may require support.
42. Mrs X first approached the duty team for support in July 2023. She reported that Mrs Y was struggling to cope with Mr Y’s increased level of need. Mrs X also felt Mr Y would benefit from additional equipment at home.
43. The Council’s records show the duty team arranged some initial support. This included an OT assessment and the provision of some equipment for Mr Y. The duty team also contacted Mr Y’s care provider to see whether his care package could be increased temporarily. The care provider was able to offer additional day visits, but the records suggest Mrs X and Mrs Y did not think this would be helpful and were seeking extra support at night. However, the care provider could not provide night care.
44. On 25 July, the duty team submitted an urgent referral for the case to be allocated to a social worker. The referral noted “there are concerns over [Mr Y’s] safety over the next 24 hours as his wife is on the verge of carer breakdown and requires support urgently.”
45. The Council did not allocate the case to a social worker until 11 September. However, Mr Y was admitted to hospital before the social worker could complete an assessment. This meant his case passed to the hospital social work team. This team completed a Care Act assessment on 25 September, while Mr Y was an inpatient.
46. The case records show Mrs X remained in contact with the Council throughout August. She continued to report that Mrs Y was struggling to cope and needed a break from her caring responsibilities. This was partly due to her own health problems and partly because Mr Y’s needs were increasing.
47. Despite this, it took over five weeks to allocate the case after the duty team submitted the urgent referral. The delayed allocation meant the Council was unable to complete a Care Act Assessment for Mr Y before he had to be admitted to hospital. Similarly, the Council did not offer Mrs Y a carer’s assessment during this period. This was contrary to the requirements of the Care Act and represents fault by the Council.
48. This represented a missed opportunity to thoroughly assess Mr Y’s care needs and explore options for support in the community. This in turn placed additional pressure on Mrs X and her family and caused them significant frustration and distress.

Hospital discharge

49. Mrs X complains that the Council and Trust discharged Mr Y from hospital without putting appropriate palliative care services in place for him.
50. In its response to Mrs X’s complaint, the Trust said Mr Y’s condition was stable at the point of discharge. It said an assessment found Mr Y suitable for a short-term bed (D2A2) to allow for further assessment of his care needs. The Trust said Mr Y did not meet the criteria for a D2A3 placement as he did not have complex nursing needs and was not at imminent risk of dying.
51. The clinical records show Mr Y had significant long-term health conditions, including dementia and heart failure. The Trust took chest X-rays as part of its clinical investigations when Mr Y was admitted to hospital in September 2023. These revealed lesions on Mr Y’s lungs that were consistent with a diagnosis of lung cancer. However, the clinical team felt Mr Y was too frail to undergo further invasive investigations. Mrs X agreed with this approach.
52. Despite Mr Y’s frailty, Mr Y’s condition remained relatively stable. The clinical notes show he engaged well with physiotherapy and exercise sessions on the ward. Staff also noted that Mr Y was generally eating and drinking well, with assistance.
53. By 19 September, the clinical team were satisfied Mr Y was medically fit for discharge and that his ongoing constipation could be treated in the community. An assessment on 21 September concluded that Mr Y had “no complex nursing needs”.
54. The Council assessed Mr Y in hospital on 25 September. The assessment found Mr Y had extensive social care needs due to his dementia. He required assistance with most activities of daily living. This included continence care, medication and nutrition. The assessment concluded that a short-term residential placement would allow for further assessment of Mr Y’s long-term care needs. Mr Y’s family identified a suitable care home placement, and the hospital discharged him to it on 9 October.
55. Mr Y was clearly frail and had significant health conditions. However, the clinical team concluded he did not have complex nursing needs. This was ultimately a matter of clinical judgement for the professionals involved in Mr Y’s care. The clinical records appear to support this conclusion and I found no evidence to suggest clinicians considered Mr Y to be at imminent risk of death.
56. At the point of discharge, the main health need for which Mr Y required active treatment was his constipation. The clinical team prescribed medication for this.
57. The care records show Mr Y’s primary need at the point of discharge was social care support. This was to be provided in a short-term residential placement that would allow Mr Y to receive 24-hour care. The evidence suggests Mr Y would not therefore have been eligible for fast track CHC funding or end of life care services at that time. However, the plan was to review Mr Y in the community.
58. It is understandable Mrs X was concerned about Mr Y’s wellbeing given the seriousness of his underlying health conditions. Nevertheless, I am satisfied the Trust and Council handled Mr Y’s discharge appropriately and I found no fault here.
59. I have commented separately below regarding Mr Y’s care in the community.

Delayed allocation and CHC assessment

60. Mrs X complains the Council delayed in allocating Mr Y’s case to a social worker and that this meant it did not properly assess his needs. Mrs X says the Council and Trust failed to complete a timely CHC checklist for Mr Y, despite his rapidly deteriorating condition.
61. In the Trust’s response to Mrs X’s complaint, it said the clinicians treating Mr Y recognised he was unwell and had a diagnosis of possible cancer. Nevertheless, they did not consider him to have complex nursing needs or to be at imminent risk of dying. The Trust said Mr Y’s health conditions would not in themselves have been sufficient to make him eligible for fast track CHC funding. However, the Trust said Mr Y’s eligibility could have been reviewed in the community.
62. The Council said it allocated Mr Y’s case to a social worker on 1 December. The Council said the social worker asked Mr Y’s GP to make a referral for fast track CHC funding on 6 December and this was agreed on 8 December.
63. Section 118 of the CHC Framework says that “[s]creening for NHS Continuing Healthcare should be at the right time and location for the individual and when the individual’s needs are clearer.” Section 119 explains that “[i]n the vast majority of cases, individuals should be screened for NHS Continuing Healthcare in a community setting.”
64. On 6 October, a social worker visited Mr Y on the ward to complete a mental capacity assessment. During this visit, the social worker spoke to Mrs X. The social worker recorded that she “[a]dvised we will transfer over details to the locality team who can complete a long term need assessment where they will consider CHC due to [Mr Y’s] level of need.” The social worker also recorded that Mrs X “explained that GP had advised that he feels [Mr Y] would be eligible for full health funding.”
65. Mr Y was discharged to the care home on 9 October. The Council’s case notes record that he “[w]ill require a review in the community.”
66. As I have explained above, I am satisfied the decision to discharge Mr Y to the care home for further assessment was appropriate. At that stage, clinicians did not consider Mr Y’s condition to be rapidly deteriorating. Similarly, they did not consider him to be imminently approaching the end of his life. This meant he would not have been eligible for fast track CHC funding.
67. The process for standard CHC funding, as set out in the CHC Framework, requires a suitably trained professional to complete a screening checklist. This can be done by a health or social care professional.
68. The care records show Mrs X repeatedly raised the issue of CHC funding with the Council. In early November, Mrs X made further contact with the Council to request an update. The case records show she continued to request progress updates throughout the month. Further, Mrs X made clear that Mr Y’s condition was deteriorating.
69. Despite this, the Council did not allocate Mr Y’s case to a social worker until 1 December. This was over seven weeks after his discharge from hospital. It was then not until 6 December that the social worker could visit Mr Y, by which point he had to be readmitted to hospital.
70. As I have explained above, the Care Act places an emphasis on the importance of completing a timely assessment. In each case, the Council should consider the circumstances of the individual and any associated risk. There was a significant delay by the Council in allocating Mr Y’s case to a social worker. This was contrary to the requirements of the Care Act and represents fault by the Council.
71. This represented a missed opportunity to review Mr Y’s care needs and explore his eligibility for CHC funding (either standard or fast track) at an earlier stage. It should be noted, however, that the Council does not bear sole responsibility for the failure to complete a CHC checklist. This could have been done by any suitably trained professional (such as a GP or care home nurse). Further, I am ultimately unable to say, even on balance of probabilities, whether Mr Y would have been found eligible for CHC funding had he been assessed sooner.
72. I am satisfied the delay did not have a significant impact on Mr Y’s day-to-day care as he was already receiving 24-hour support in the care home.
73. Nevertheless, I recognise the delay caused Mrs X significant uncertainty and distress.

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Agreed actions

74. Within one month of my final decision statement, the Council will:

• write to Mrs X to apologise for the distress and uncertainty caused to her by its failure to properly assess Mr Y’s care needs in the community; and
• pay Mrs X £500 in recognition of this distress and uncertainty.

75. Within three months of my final decision statement, the Council will write to the Ombudsmen to:

• explain what action it will take to ensure cases are allocated promptly to allow for the timely assessment of a person’s care needs in keeping with the requirements of the Care Act 2014. This should include a clear process for dealing with urgent referrals.

76. The Council will provide us with evidence it has complied with the above actions.

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Final decision

77. I found fault by the Council concerning its failure to assess Mr Y’s needs in the community. I am satisfied the actions the Council has agreed to complete represent a reasonable and proportionate remedy for the injustice caused to Mrs X by this fault.
78. I found no fault by the Trust with regards to how it managed Mr Y’s discharge from hospital.

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Investigator's decision on behalf of the Ombudsman