‘NHS Community Nursing would be able to provide daily administration of subcutaneous insulin injections, reading of blood glucose levels and providing response to concerns raised by family members and care provider staff regarding skin integrity’ (G/348). ‘[The] NHS Community Dietician service … provide telephone contact within 5 working days of receipt of a fully completed written referral to check there are no immediate concerns following discharge and will provide a Dietician home visit within 2 weeks. Once AM is set up and has a stable regime, Dietician follow up AM face to face every 6 months with telephone calls in between. AM's weight and Body Mass Index would be monitored every 6 months most likely by taking a mid-arm circumferential measurement as his safety would not be able to be maintained in a standard weigh chair. // The service provides a Clinical Nurse Specialist who is able to train family members and care provider staff on how to look after the gastrostomy tube, stoma site and administer feeds. The Nurse is able to change the balloon gastrostomy tube when it is due for changing and the Dietician will ensure that spare consumables are available at home’ (G/348). ‘Any deterioration in his condition would require referral to the GP for assessment and to initiate treatment or therapy management options’ (G/344). A care agency called CM had visited AM to assess him. It reported that they would be able to care for him with a team of six carers who had the required competencies. Furthermore, their insurance would not prevent them from being able to work with trained and competent family members. •. The remainder of the personal care at home would need to be provided by family carers. They had agreed a family care rota to provide the additional care which AM needs that the NHS cannot fund. The original rota is at G/473. At the time it was written, it was likely that AG would require knee surgery and be out of action for several weeks. The rota is carefully thought out and comprises three weekly alternatives: a rota for when AG is fit to provide day and night care; a rota for when AG is fit to provide day care but not night care; a rota for when AG is unfit to provide any care. In the event, AG underwent a right total knee replacement on19 August 2019 . In my view, by the time the hearing resumed in November 2019, the general concerns which the Third Respondent raised at the hearing in April 2019 — that AG’s own health might prevent her from being a carer or from performing some of the care tasks required of her — were not supported by the evidence (see the OT assessment and the letter from her Consultant Orthopaedic Surgeon, at G/496). •. The competencies which paid and unpaid carers will require were assessed and set out by IR on behalf of ECCG at para. 5 of his statement of31 January 2019 (G/344G/345). They include matters such as manual handling, positioning requirements, correct use of equipment to ensure AM’s safety, personal care, PEG and water system operation, respiratory management, communication strategies, social activities and stimulation, and the identification of when to alert clinical services as required. All of the proposed family carers were willing to undergo necessary training and accepted the need to meet the required competencies. The CCG told me that it would support them in accessing the appropriate training. Evidence of completion would be required prior to discharge. Many of the required competencies are considered valid for one year only and therefore refresher training will be necessary (G/345). •. I have no concerns about the suitability of the proposed family carers. AG has been providing care to her husband at X Nursing Home over many years. AM’s sister works as a paid carer for a care agency, and she already spends 2-3 days at X Nursing Home caring for her only brother. AG’s and AM’s daughter HH was previously coPresident of her university student union, and impressed me by her willingness to make considerable personal sacrifices to look after her father. MH2 runs a tutoring company and, as a diabetic himself for 20 years, has a particularly good understanding of that area. HAM is a qualified optician. All of the children can assist AG with translation and interpretation. As to the required competencies, they are able to understand and implement some quite technical requirements. •. Given their commitment and skills, and the careful way in which they have devised a home care package, I do not share TR’s reservations about the sustainability of a home care package. Nor do I believe that they have under-estimated the level of care and expertise required to continually care for someone with AM’s needs (I/49I/50). They have been providing a great deal of care for many years already, are highly intelligent and have a very good understanding of what is required. They consider that it is their duty, and an honour, to care for AM within the family home. Their devotion and commitment to him, and their willingness to give up their time and comfort, and in one case their job, to care for him is admirable. •. The local authority’s Adaptations Team considered that it was reasonably straightforward to adapt the family home to suit AM’s needs (see the statement and plans at I/9-I/12). The necessary work could be completed within around six weeks of approval by the relevant housing department, and the preliminary view was that the proposed adaptations would probably be approved. TR, the independent nursing expert, also considered that the proposed adaptations would be appropriate and provide adequate accommodation. However, the accommodation would be ‘cramped’ and carers could be hampered in their delivery of care. She raised a concern that AM’s dignity could be compromised during transfers to the bathroom, but I think it likely that overall being cared for in his own home, with his wife or a family member present, will be a more dignified experience for him. Looking at this package, it can be seen that the family have worked thoughtfully and assiduously to construct a viable alternative to X Nursing Home. Equally, ECCG and the relevant local authority have put in a lot of hard work to assist the family with their endeavour. That is particularly commendable given their limited resources and the fact that they believe that remaining at X Nursing Home is in AM’s best interests. There is much that can be said in favour of AG’s application. AM wishes to live at home with his wife and family, and therefore my starting point is to try to enable him to live the life he wishes if it is feasible: the underlying purpose of the Act is that it is an enabling Act. He is fortunate in having a devoted wife and family. The family home can be adapted to suit his needs. The CCG have constructed a care package which, taken with the family care rota, meets his day-to-day care requirements. Furthermore, although the package is not equivalent to what is provided at, or readily-available, on-site at X Nursing Home, it is nevertheless a significant package of care. ECCG has recently ‘reprocured’ its adult community, nursing, dietician and therapy services, which resulted in a new NHS provider taking over the delivery of the contract (G/349). Given AM’s vulnerability and need for support, I have borne in mind that there is always a risk that some services may not remain available to AM, and also that the current configuration of local services may change, for better or worse. I agree with much of TR’s balance sheet (I/33-I/35) but not with all of her assessment of the burdens of home care. The family carers are competent, devoted and willing to undergo training; it is inevitable that assuming a care role comes at a cost; on the evidence I believe that the pool of carers is sufficient; I do not agree without more evidence that the fact that AM has not been home since 2009 is likely to be a significant problem; the family home can be adapted and ‘made fit for purpose’ quite easily; the family carers are sufficiently experienced and committed that I find it is more likely than not that they can sustain their care roles; a suitable domiciliary care provider appears to have been identified; and I believe that regular visits to AM by MH can be managed by the court if necessary. The burden that I agree with is that, ‘AM will not have immediate access to the Primary Care Services i.e. GP, Community nurses and therapists.’