The Ombudsman's final decision
Summary: Mrs X complained on behalf of her sister, Mrs Y, about the way the Council carried out financial assessments for Mrs Y’s care and support charges. The Council upheld Mrs X’s first complaint, about delays and lack of information, and I have not made further findings on it. The Council was not at fault for the way in which it included Mrs Y’s funeral plan in her financial assessments.
The complaint
Mrs X complained on behalf of her sister, Mrs Y, about the way the Council carried out financial assessments for Mrs Y’s care and support charges.
Mrs X said there were delays and the Council did not properly take account of a funeral plan payment.
Mrs X said this resulted in Mrs Y making extra payments to her care home when she should no longer have been self-funding. She said Mrs Y was left out of pocket by over £4,000.
What I have investigated I decided to investigate back to Mrs X’s original complaint in 2020. The new complaint follows on from that one, and the first complaint provides helpful background and context.
The Ombudsman’s role and powers
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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended) 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)
How I considered this complaint
As part of the investigation I have considered the following: The complaint and the documents provided by the complainant.
Documents provided by the Council and its comments in response to my enquiries.
Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
What I found
Legislation and Guidance Charging for permanent residential care The Care Act 2014 provides a single legal framework for charging for care and support under sections 14 and 17. It enables a council to decide whether to charge a person when it is arranging to meet a person’s care and support needs.
The charging rules for residential care are set out in the Care and Support (Charging and Assessment of Resources) Regulations 2014 and councils should have regard to the Care and Support Statutory Guidance.
When the Council arranges a care home placement, it must follow the regulations when undertaking a financial assessment to decide how much a person has to pay towards the cost of their residential care.
The financial limit, known as the ‘upper capital limit’, exists for the purposes of the financial assessment. The upper capital limit is currently £23,250. This sets out at what point a person is entitled to access council support to meet their eligible needs. People who have over the upper capital limit are expected to pay the full cost of their residential care home fees.
Once a person’s capital has reduced to less than the upper capital limit, they only have to pay an assessed contribution towards their fees.
Where a person’s resources are below the lower capital limit, which is currently £14,250, they will not need to contribute to the cost of their care and support from their capital.
What happened I have summarised below some of the key events leading to Mrs X’s complaint. This is not intended to be a detailed account of what took place.
Mrs Y was hospitalised in October 2018 following a medical incident. On leaving hospital, she went into a care home. This was at first a short-term measure but turned into a long-term placement when Mrs Y’s health did not recover.
Depending on her finances, Mrs Y has at times had to self-fund the cost of her care in the care home. At other times the Council has contributed to the costs.
The Council employs a third-party company to manage its financial assessments. I shall call this third-party ‘the contractor’.
Mrs Y sold her home in November 2019. The contractor asked Mrs X for details so it could decide whether Mrs Y needed to self-fund the costs of her care.
The contractor completed an updated financial assessment for Mrs Y in March 2020. It calculated she became self-funding in November 2019.
Mrs X contacted the contractor in May. She said she sent details of the sale of Mrs Y’s house in December, and she asked why it took the contractor so long to act on the information. The contractor apologised for the delay. It wanted to ensure Mrs Y capital did not fall below the threshold before it stopped making payments to the care home.
In June, Mrs X told the Council there were issues with Mrs Y’s financial assessments. She said the Council did not tell her that when Mrs Y became self-funding the top-up fee would stop. She said they awaited a bill from the care home which would take Mrs Y below the capital threshold. The Council said it would ask the care home for a copy of the invoice and then start a financial assessment for Mrs Y.
The Council asked the contractor to confirm details of Mrs Y’s funding status. The contractor said Mrs Y had self-funded since November 2019.
The Council told Mrs X the provisional start date for Council contributions to Mrs Y’s care and support charges was 2 June 2020, but it could change when her financial assessment was complete.
The contractor asked Mrs X to send more bank statements in July so it could complete Mrs Y’s financial assessment. It also asked for a receipt for the funeral plan Mrs Y took out.
After receiving details about the funeral plan, the contractor included the cost of the plan (£4,181) in Mrs Y’s financial assessment.
Mrs X complained to the Council on 15 July. She said: she sent details of Mrs Y’s house sale in December 2019 but did not receive her review until March 2020, and this did not include up-to-date information.
The care home then said Mrs Y was responsible for an extra £202 a week plus a top up fee of £300 which had been waived while the Council was contributing. She said the Council had not told her.
Mrs X telephoned the Council in August. She said she had to pay the care home for Mrs Y’s fees in June but should not have had to because this was when the Council started contributing. The Council said it would refund Mrs Y once the care home signed the contract.
The Council responded to Mrs X’s complaint on 20 August: It apologised for the delay revising Mrs Y financial assessment. It recognised this caused backdated payments to the care home.
It also apologised for not explaining top-up fees were included in the full cost when Mrs Y became self-funding. It said the finance team did not tell the Council Mrs Y was self-funding, or it would have sent this information.
It recognised the service it provided did not meet expected standards and apologised for any inconvenience. It said it would take action to ensure service improvements.
Mrs X made a second complaint on 17 May 2021. She said the Council had not included a funeral plan in Mrs Y’s financial assessment, leaving £19,400 in her bank account.
The Council replied on 2 June. It said: The contractor confirmed the funeral plan was included in Mrs Y’s financial assessment before the £23,250 threshold was reached.
The contractor also said Mrs Y has a tariff on her income between £14,250 and £23,250 which is £36 a week, or £1,872 a year, so her capital will incrementally decrease. It said the figures Mrs X calculated did not include the monthly pension income Mrs Y received or the money in another bank account.
Mrs X contacted the contractor in June. She had reviewed the funding calculations from the previous year and could not understand how it calculated Mrs Y’s capital to be £23,000 when she only calculated £19,000.
The contractor said it had deducted the funeral plan payment. Mrs X said this payment was not due until the end of June.
The contractor clarified that although it deducted the funeral plan payment before Mrs Y spent it, this worked in her favour. It meant her capital fell below the threshold sooner and she was not self-funding for as long.
Mrs X continued to dispute the contractor’s calculations in July. She said the funeral plan payment took Mrs Y’s capital from £27,000 down to £23,000, but she only had £19,000 in her bank accounts. Mrs X said there was no explanation for the fall in Mrs Y’s balance because she had not been able to spend any money due to the COVID-19 pandemic.
The contractor provided a breakdown of its calculations for Mrs Y’s May 2020 financial assessment. The final total of Mrs Y’s capital was £23,674.52. That included a deduction of £4,181 for the funeral plan. It calculated Mrs Y’s capital would have fallen below the threshold on 8 June 2020 and she was therefore eligible for Council funding from that date.
The Council sent its final complaint response on 10 September 2021. It confirmed the contractor did take account of the funeral plan before Mrs Y reached the £23,250 threshold and there is no change in the date Mrs Y stopped being self-funding. It said the contractor gave Mrs X a breakdown of their calculations over the telephone in August. It said it had revisited the assessment several times and further investigation will not lead to a different result.
Mrs X brought her complaint to the Ombudsman on 11 January 2022.
My investigation Mrs X told me Mrs Y received a large bill from the care home when she became self-funding. Previously, while the Council was contributing, the care home’s fees were £500 a week. However, when Mrs Y became self-funding the cost went up to £700 a week. She said the Council did not tell her about this.
Mrs X also said she told the Council about Mrs Y’s funeral plan in 2020 but, because Mrs Y was shielding during the COVID-19 pandemic, it took time to complete the plan. When the Council calculated Mrs Y’s assessment, she had not paid the cost of the plan. When Mrs Y paid for the plan in 2021 it took her capital down to £19,000. However, the Council’s assessment said her capital was about £23,000. Mrs X considers Mrs Y has been left out of pocket because of the way the Council calculated her finances.
The Council told me it has developed the quality of its financial advice and support since Mrs X’s first complaint. The Council now starts the financial assessment process rather than the contractor and adult social care workers are responsible for the initial advice and support given to families. This is complemented by finance factsheets.
The Council said it gave staff training to support the implementation of this approach and appointed ‘finance champions’ for each of its teams.
The Council also said its financial assessment took account of Mrs Y’s funeral plan before she reached the threshold. This meant she was self-funding for a shorter period. The only detriment was an overpayment of a months’ fees to the care home, which Mrs Y got back.
Analysis The Council apologised for its delays and poor service when it responded to Mrs X’s first complaint in 2020. It explained the contractor did not pass on the fact Mrs Y was self-funding.
The delays resulted in Mrs Y making an overpayment to the care home. However, this was refunded so did not cause significant injustice.
The Council recognised it needed to make improvements, and it made changes to its financial assessment process. That is welcome.
I have included the events from 2020 for context only. The Council upheld Mrs X’s first complaint and I do not consider it is proportionate to make further findings about it.
Turning to Mrs X’s second complaint, I can appreciate she was confused about how the contractor calculated Mrs Y’s financial assessments. I therefore do not dismiss her complaint. However, I have not seen evidence of fault.
The contractor included the funeral plan in Mrs Y’s May 2020 financial assessment. The result was Mrs Y became eligible for Council support from June 2020.
The contractor’s financial assessments are a paper exercise only, based on the available bank statements and records. It does not physically deduct money from people or reduce their account balance. Any errors would impact whether and when Mrs Y was self-funding or entitled to Council support.
As the contractor pointed out, if it included the funeral plan early, or twice, that would benefit Mrs Y from a financial assessment viewpoint because she would be eligible for financial support from the Council sooner.
I have not seen evidence the Council’s financial assessments caused any shortfall in Mrs Y’s finances.
Final decision
I have completed my investigation. The Council upheld Mrs X’s first complaint, about delays and lack of information, and I have not made further findings on it. The Council was not at fault for the way in which it included Mrs Y’s funeral plan in her financial assessments.
Investigator's decision on behalf of the Ombudsman