Decision date: 28/11/19
Mr C is and was non-verbal, on the autistic spectrum and suffered from epilepsy and a brain injury. He lived at his home and was cared for by Personal Assistants (PAs) who need specialist training as he communicated through them using a letter board. He received care and support through the CCG and from Direct Payments funded by the Council in a split package.
Mr C’s mother, Mrs C, had provided all other aspects of care for him since the Independent Living Fund (ILF) was closed by the government in June 2015. At this point, Mr C contacted the Council with concerns over his worsening anxiety. He had requested an increase in his care package to fund another PA in order for his mother to act as a facilitator instead of actually providing personal care.
The Council agreed to reassess his needs and got in touch with the CCG to review how the funding for Mr C’s care plan should be split between them. A support plan created by his social worker in September 2015 documented the unfunded care provided by Mrs C and expressed the necessity for an increase in the support package to sufficiently meet Mr C’s needs. The CCG then assessed Mr C’s specifically healthcare needs in October as sufficient to warrant a jointly funded care package.
Nothing happened to get this underway, until March 2016 when a new care manager was assigned to review the plan. However, it wasn’t until December the same year that the CCG was contacted about considering 24 hour care for Mr C. The CCG felt they had been provided with insufficient evidence to support the need for a PA every night and offered only 1 flexible night a week. The care manager suggested that the PAs record what care they provided at night to show the necessary input.
The LGO said as follows:
- The support plan [September 2015] documents that Mr C explained he had “a direct payment that is used to employ PAs to support me throughout the day. There is currently not enough money in my budget to employ PAs to support me 7 days a week. My Mum supports me when the PAs are not working.” At this stage, Mr C employed PAs for six hours, six days a week, and a PA for five and a half hours on the remaining day. He also employed a PA to provide a sleeping night for four nights per week.
- The social worker completing the plan noted that Mr C required constant supervision during the day because of seizures and falls linked to his epilepsy. He noted that Mr C would be unable to press a button or trigger an alarm if he were alone. The social worker also documented that Mr C’s anxiety had increased, and this was a particular risk at night. He went on to say: “Due to Mr C’s health conditions he requires 24 hour support to ensure that he is safe and well cared for and all of his health needs are met… Currently the support package in place needs increasing to meet his needs. Without a care package in place Mr C’s health and wellbeing would be significantly impacted upon.”
A new care manager was assigned in May 2017 and yet another in September 2017. Meanwhile, Mr C’s mother became ill and unable to provide care for him and the Council temporarily increased Mr C’s budget through ‘Service Amendments’. Further amendments were issued in June, August and October of 2017 and January, March and July of 2018.
The Council completed a questionnaire which again stressed that Mr C’s support package had to be increased to meet his care needs. The CCG completed an annual DST review but declared there was still “insufficient information to carry out a social and health JPOC split”. Mr C complained to the Council about the suffering he had experienced as a result of the series of delays in reassessing his needs. The Council apologised and claimed that the process would be completed promptly, adding that it had acted on the delays by issuing temporary Direct Payment increases.
In July 2018 Mr C’s funding was increased as the joint support plan was authorised. He says he now receives the care and support that he needs.
What was found
The evidence suggests that Mr C’s care plan was left unreviewed for nearly 3 years and this is clearly not in line with the 12 month guidance in the Care Act 2014. These delays were attributed in part to the poor communication and cooperation between the Council and the CCG. Mr C was asked over and over to relay the same information to social workers and CHC assessors, and to provide evidence to the CCG and the Council about the level of care he required, despite 4 separate social workers stating that he needed more support.
The LGO said this:
- It is understandable that Mr C felt frustrated by these repeated requests, and that he found them intrusive and troublesome. He also told us receiving conflicting information from the Council and CCG was confusing, and caused him anxiety about how much his care might change or reduce. Mr C said he felt his and his PAs’ views on his needs were being ignored.
- The CSSG states that “information sharing should be rapid and seek to minimise bureaucracy… Particular consideration should be given to ensuring that health and care planning processes are aligned, coherent and streamlined to avoid confusing the person with two different systems.” It goes on to say that local authorities should “seek to work with health colleagues to combine health and care plans wherever possible… In combining plans… is it vital to avoid duplicating processes.”
The Council and CCG were both at fault in this case for failing to ensure that review processes were “aligned, coherent and streamlined”. There was more than once occasion when each body carried out similar reassessments of Mr C within 2 months of the other. There was no evidence provided as to why these could not have been conducted jointly. The Ombudsman felt that this was particularly concerning due to Mr C’s poor communication and that he was struggling with the reassessment process as early as 2015.
The LGO thought it was likely that Mr C would have received the increase in his care package sooner if he had been reassessed more quickly. This joint fault by the CCG and the Council therefore caused Mr C an injustice. Mrs C also suffered an injustice as she was left to provide unfunded care to her son.
The Council and CCG have agreed that within four weeks, they will send a written apology to Mr C.
Within 8 weeks, they will jointly:
- Pay Mr C £1500 in recognition of the care he would likely have received and for the distress suffered by the delay in reassessment.
- Pay Mrs C £300 for the injustice caused by effectively leaving her responsible for Mr C’s care at certain points.
- Undertake a review of their agreement to improve assessment and care planning processes for service users whose care is jointly funded.
Points for the public, CCGs, families, service users, advocates and councils
For many years it was not accepted by Primary Care Trusts when a person failed to qualify for Continuing National Health Service health care services that they ought still to be considered from the perspective of what specific inputs were such as to be the sort that the NHS ought to pay for, because they were not realistically to be expected to be provided and funded by way of social services (which are of course chargeable).
This CCG and council seem to have had a theoretical compact for joint funding but in reality, the local authority could never make the CCG come to a conclusion and take on the contracting or funding responsibility that a joint package entails. That is a failure of leadership at a senior management level and no doubt to do with the attitude in some parts of the health service that it will just humour local authority counterparts instead of recognising the impact on the individual patient or family.
What we cannot understand is why the LGO investigator did not award restitution of a much larger sum. If the shortfall of input was even only 8 hours a week over 3 years, the cost of that input would have been £12,000. Perhaps the mother did not wish to claim for the cost of the additional input, but there is a great deal of legal and ombudsman precedent in favour of that having been the right way to frame the redress for injustice.
Very few councils and CCGs that we know of even attempt combined forms of assessment. Very few councils even manage to combine different types of assessment all under the auspices of social services, let alone the assessments of another organisation, so that even combining children’s, carers’ and service user’s assessment within one process simply does not happen. We think that that is because the resource allocation algorithms don’t work across a combined number of clients or funders.
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The full Local Government Ombudsman report on the actions of Sheffield City Council can be found here: