Summary: We do not consider Bedford Borough Council and East London NHS Foundation appropriately supported Mr Q’s sensory, mental health, social care, and communication needs. This most likely impacted his wellbeing. The Council also did not offer his mother, Mrs P, a carer’s assessment after June 2020, which caused her uncertainty. The Council and Trust should take action to remedy Mr Q and Mrs P’s injustice.

The complaint

1. Mrs P complains about the care and support that Bedford Borough Council (the Council) and East London NHS Foundation Trust’s (the Trust) Intensive Support Team (IST), and Community Mental Health Team (CMHT) provided to her son, Mr Q, during 2020.
2. Mrs P complaints about:
1. The lack of services to support her son’s complex needs, including psychological therapy, occupational therapy, cognitive behavioural therapy (CBT) and social activities.
2. The IST’s and CMHT’s lack of interaction with the Council or herself in her son’s care.
3. The IST and CMHT did not understand her son’s conditions, including his autism, learning difficulties, social anxiety and obsessive-compulsive disorder (OCD).
4. The IST and CMHT did not complete care plans for her son. He should have been supported under the Care Programme Approach (CPA).
5. The Trust discharging her son to an unsuitable rehabilitation facility in June 2020, rather than send him home.
6. The Council’s lack of support to her as her son’s carer.
3. Mrs P says her son’s mental health deteriorated during 2020. She says she had to pay for private therapy due to the lack of support. Mrs P says the Council did not provide any respite to her in 2020.
4. Mrs P would like the Council and Trust to put appropriate support and therapy in place for her son. She would like staff to better understand how to support people like her son. She also would like the Council and Trust to reimburse the costs of private therapy.

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The Ombudsmen’s role and powers

5. 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 18ZA)
6. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen 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).
7. 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.
8. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may 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.
9. The Ombudsmen cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant organisation has to make. Therefore, my investigation has focused on the way that the body made its decision.
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. I considered the information Mrs P and the organisations sent to me, including their responses to my enquiries. I also considered the relevant national guidance and legislation.
12. Mrs P, Mr Q and the organisation had an opportunity to comment on two draft decisions. I considered any comments received before making a final decision.

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What I found

Key facts

13. Mr Q is autistic and has complex mental health issues.
14. Between January and June 2020, the IST and a Social Worker supported Mr Q under the CPA. The IST provides a “community-based service for people with a learning disability and who had additional mental health needs or present with challenging behaviour”. Two Councils (including the Council in this case) and a local Clinical Commissioning Group (CCG) commission the Trust to provide that service.
15. The Social Worker was responsible for ensuring Mr Q received support to improve his independence and access the community. She also tried to carry out a carer’s assessment of Mrs P between January and April 2020.
16. Mr Q had a mental health crisis in May 2020, which led to a voluntary admission to Hospital (part of the Trust). The Hospital moved Mr Q to Townsend Court (also part of the Trust). Townsend Court then discharged Mr Q to a residential home which supports people with autism (the Residential Home). Around that time, Mrs P made a referral to an Anxiety Disorder Residential Unit at another Trust (not subject to this investigation).
17. In June 2020, the IST transferred Mr Q’s care to the CMHT, as they were better placed to support his mental health. The Social Worker stopped supporting Mr Q.
18. Between June and December 2020, the CMHT supported Mr Q. Care Coordinators (CC1 and then CC2) supported him during that time. The CMHT referred Mr Q for support from different organisations to support his OCD. Toward the end of 2020, Mrs P called 111 and took Mr Q to the Hub (run by the Trust) due to Mr Q’s deteriorating mental health. The Hub provides 24-hour urgent mental health assessments.

The lack of services from the Trust

Occupational therapy

19. I have reviewed the IST and SW’s records.
20. In February 2020, the OT completed their sensory integration report. It said Mr Q’s “sensory preferences were potentially impacting his reduced engagement in activities, particularly in the community”. They recognised he did not like touch from others, or unpredictably loud and busy environments. Those can trigger his anxiety. Exposure to those sensory triggers can lead to high levels of anger, disengagement and avoiding going out. Mr Q’s calm impression may mask his high level of agitation. He would avoid most interactions and activities, especially outside the house unless he is with someone he trusts.
21. The OT said people should give Mr Q time to process information so he can retain control. He needed to feel confident in people supporting him. The OT recommended many ways for people to support Mr Q’s sensory needs. That included having a structured routine, giving Mr Q time to process information, and avoiding change (including staff). Also, the OT said Mr Q: “requires support to organise and plan activities within his week, and then initiate them. [Mr Q] would benefit from a weekly routine that is gradually built up of meaningful activities both at home and in the community.”
22. I have not seen any evidence the IST or CMHT reviewed Mr Q after receiving the OT report to consider how it could support his sensory needs. In April 2020, the IST said the “report was not being utilised and there could be an improvement in [Mr Q’s] wellbeing if there were attempts to try some suggestions, for example, asking [Mr Q] to take deep breaths.” That was one smaller suggestion from the OT report. I consider the OT’s recommendations should have triggered a review by the Trust to decide how to support his newly identified sensory needs. I have not seen evidence following February 2020 the Trust reviewed its approach to supporting Mr Q to consider his sensory needs. That was fault, which most likely adversely impacted Mr Q’s wellbeing throughout 2020.
23. The SW appropriately identified that a personal assistant would be a good way to support Mr Q’s sensory needs. The personal assistant could initially develop a rapport with Mr Q, and work towards supporting him at home and in the community. I have considered the actions of the SW later in this statement.

Cognitive behavioural therapy

24. I have reviewed the Trust’s records.
25. Between April 2019 and February 2020, Mr Q had fortnightly private CBT to support his anxiety.
26. In January 2020, the private Psychologist wrote to the IST. She said Mr Q needed more support to be more active to help manage his anxiety. He had periods where he struggled to manage his mental health. She added fortnightly sessions were not sufficient to significantly improve his anxiety. He should have a mental health support worker to carry out anxiety management strategies. Also, joint working with an Occupational Therapist (OT) to include his sensory issues would be essential.
27. In May 2020, Mrs P requested CBT to support her son’s anxiety. The IST agreed to consider her request.
28. I have not seen any evidence the IST or CMHT considered the private Psychologist’s letter about CBT for Mr Q. That was a missed opportunity. It also agreed to consider Mrs P’s request for CBT in May 2020 but I cannot see that it did. It was most likely forgotten during Mr Q’s mental health crisis in May 2020. That was another missed opportunity.
29. Those missed opportunities were fault. I do not consider the Trust needed to agree to the private Psychologist’s recommendations for CBT. However, Mr Q and Mrs P are left not knowing what the outcome of any review of CBT would have been during 2020.

The CMHT’s support

30. I have considered the CMHT’s records.
31. In late July 2020 CC1 told Mrs P that an OCD Specialist (at a different NHS Trust – not subject to this investigation) could support her son’s psychological needs related to his OCD. After speaking with the OCD Specialist, Mrs P was keen for the CMHT to send a referral to that service. The CMHT made that referral.
32. The OCD Specialist later told CC1 it could not accept Mr Q because he needed to have had at least two courses of CBT. He had not had that with the NHS, so CC1 asked if the CMHT Psychologist could offer Mr Q some sessions so he could be eligible for support from the OCD Specialist. CC1 later met with the Psychologists. There was confusion about whether the IST or the OCD Specialist was best placed to support Mr Q. They agreed to speak to the IST again to better understand what service should be supporting Mr Q. The IST said it would not support Mr Q owing to his significant mental health needs. So the CMHT placed Mr Q on a waiting list for a psychological assessment, so it could assess his psychological needs.
33. In mid-September, the CMHT discussed Mr Q at a meeting. CC2 told the Psychologist that Mr Q had received private CBT. The Psychologist said evidence to confirm that would support the OCD Specialist referral. CC2 made the referral to the OCD Specialist again later that month.
34. On 7 October, the OCD Specialist told CC2 its referral was incomplete. It needed a formal letter from Mr Q’s Consultant. It could then meet with the CMHT and decide if its service would assess Mr Q or not. The same day CC2 spoke to the Psychologist. The Psychologist told CC2 he would assess Mr Q in three weeks because Mr Q was not be eligible for support from the OCD Specialist. The CMHT needed to explore Mr Q’s psychological needs before considering support from the OCD Specialist.
35. On 20 October, CC2 called OCD Specialist 2 (a private organisation). It was open to support Mr Q, but he needed a robust care plan.
36. On 28 October, the Psychologist met with Mrs P. Mr Q did not attend the assessment due to his poor mental health at that time. The Psychologist explained why the CMHT needed to support Mr Q before referring Mr Q to any specialist services. Mrs P disagreed with that plan, and said her son needed specialist support. As Mrs P refused the CMHT’s psychological support, it closed its service to Mr Q.
37. Firstly, I consider the CMHT struggled to decide how to best support Mr Q. There was misunderstanding between staff (the Psychologist and the CCs) how to best support Mr Q.
38. I do not consider the CMHT understood how to refer Mr Q to OCD Specialist. Twice it sent incomplete referrals. Both times, it was clear that Mr Q would not be eligible for its support. I consider the priority should have been completing a robust assessment of Mr Q’s mental health needs. It took until October 2020 to attempt that. Amongst the confusion, the CMHT considered sending Mr Q back to the IST despite having come from that service a few months earlier. The IST quickly told the CMHT that would not happen. I consider after June the Trust’s indecision about how best to support Mr Q was fault.
39. By the time the Psychologist tried to assess Mr Q, Mrs P refused the CMHT’s offer. Mrs P only wanted support from a specialist service because she had lost faith in the Trust. I can understand how the Trust’s fault led Mrs P to lose faith with its support. However, I cannot say that had the Trust not acted with fault, she would have accepted the Trust’s psychological support. That was because Mrs P was always keen for specialist to support her son. Also, her engagement with services varied. But it does leave Mr Q with a sense of uncertainty if his support would have been better if not for the Trust’s fault.

The lack of services from the Council

40. Where councils have determined that a person has any eligible needs, they must meet those needs. When the eligibility determination has been made, councils must provide the person to whom the determination relates (the adult or carer) with a copy of their decision.
41. I have considered the SW and CMHT’s case records.
42. The Council’s 2019 care plan stated:
• A local Housing Association (the HA) would help Mr Q to employ a personal assistant (PA) for two/three hours per week. That PA would support Mr Q to access the community. Mr Q could interview PAs and choose someone he could work with at his own pace.
• Mr Q should attend weekly sessions from the Council’s Bedford Independent Living Team (BILT) sessions to practice meal preparation and money management (purchasing ingredients). This was to improve his independent living skills.
43. During the February 2020 CPA meeting, the SW agreed to review the BILT service and see if Mr Q would re-engage with it. Also, she agreed to keep working with the HA to help employ a personal assistant for Mr Q. The HA told the SW Mrs P had previously asked it to stop searching for a personal assistant. That was because he was not well enough to engage.
44. Not long after, the SW spoke to Mrs P. The SW noted Mrs P declined a visit from BILT to see Mr Q as it would distress him. The SW suggested a local charity that Mr Q could engage with to provide similar support. Mrs P agreed to reconsider it.
45. On 15 June, the SW asked the HA to continue sourcing a personal assistant. Mrs P had found someone keen to support her son.
46. In late July, CC1 agreed to arrange the 10 hours funding for a personal assistant for Mr Q.
47. On 7 August, the SW told the HA the IST had transferred Mr Q to the CMHT, and shared details of CC1, who was supporting Mr Q.
48. In mid-September, the CMHT agreed funding for the personal assistant. It told Mrs P it would “at least put this in place to try and support [Mr Q] whilst he is waiting”.
49. Firstly, I will consider Mr Q accessing the community.
50. The Council did not provide Mr Q with any support to access the community during 2020. Between February and June 2020, the SW could not successfully employ a personal assistant for Mr Q to help him access the community.
51. The Council told me that until June 2020 the SW was mindful of Mr Q’s worsening mental health when trying to support him. Between March and May, the SW prioritised supporting Mr Q’s mental health needs over his social care needs. Also, the SW said she still tried to engage Mr Q to access the community.
52. The Councils’ records show the SW worked with the HA in February and June 2020 to help Mr Q access the community. There was a gap of four months where she did not chase the HA or actively work with Mrs P and Mr Q to get that support in place. However, I understand Mr Q was suffering a mental health crisis between March and June. There is evidence that between March and May 2020, Mrs P said Mr Q was finding it impossible to do things as he was in a crisis.
53. I do not consider the SW acted with fault. The SW has provided a clear explanation why they (with the IST) prioritised supporting Mr Q’s mental health over helping him access the community. I consider even if the SW had put the right support in place, I cannot say, even on the balance of probabilities, if Mr Q would have been well enough to access the community from February to June 2020.
54. In June 2020, Mrs P told the SW she had found someone to support her son to access the community. While the SW correctly shared that information with CC1, the CMHT had to agree new funding for a personal assistant. The CMHT’s records show it was clearly unfamiliar with that type of support which caused delays.
55. By September 2020, the CMHT agreed funding for the personal assistant. However, I have not seen any evidence it tried to arrange that support. That was fault.
56. I now move on to Mr Q wanting to improve his independence.
57. By February 2020, Mr Q had stopped engaging with the BILT service. After then, the SW told me Mr Q disengaged from that service, despite Mrs P and Mr Q agreeing to reconsider the BILT in February. I can see the SW also suggested a local charity to help support Mr W to improve his independence. I am satisfied that before June 2020, the SW made appropriate attempts to put support in place for Mr Q to improve his independence. That was not fault.
58. However, after June 2020, I have not seen any evidence the CMHT made any attempts to support Mr Q to improve his independence. That was fault.
59. Section 75 of the NHS Act 2006 allows NHS organisations and councils to arrange to delegate their functions to one another. These arrangements are known as Section 75 Agreements and under them, NHS organisations can take on the provision of social work services which are normally the responsibility of councils.  Subsection 5 of section 75 says the NHS and councils remain liable for the exercise of their own functions. In this case, the Council has a section 75 agreement with the Trust for their CMHT to support service user’s social care needs.
60. Overall, after June 2020 Mr Q did not receive any support to access the community or to improve his independence. Those were still eligible needs. After June 2020, Mr Q’s mental health had generally improved. He would have been in a better space to consider support for his social care needs. However, that did not happen, which was fault. That fault would have an impact on Mr Q’s wellbeing. While the CMHT should have done more to support Mr Q’s social care needs, the Council remain responsible for that fault and the personal injustice Mr Q suffered.

Communication with Mrs P and support to Mr Q under the CPA

61. Mrs P says the Trust and the Council should have worked closer together. Also, the Trust should have supported her son under the CPA and develop a care plan.
62. The CPA is the process by which mental health services assess a patient’s needs, plan how to meet them and ensure they are met. Under Refocusing the Care Programme Approach (Department of Health, 2008), people under CPA should have a comprehensive assessment of their health and social care needs. They should have a care coordinator; have a care plan to show how their needs will be met and have the care plan reviewed by a multi-disciplinary team (MDT). When a patient is in hospital, their care coordinator is the key person responsible for arranging the care and support they will need on discharge.
63. The IST developed a report (called WRAP) to support Mr Q and Mrs P to avoid him going into crisis.
64. On 3 February 2020, the IST held a CPA meeting. Mr Q did not attend as he was suffering a mental health crisis. Mrs P said her son needed more support for his mental health.
65. In April, the IST and SW held a meeting without Mrs P and Mr Q. The Psychologist and Nurse recently visited Mr Q – he was low, anxious and depressed. They had concerns he was only taking his medication to suit Mrs P. The Psychologist said if Mrs P used the WRAP report more for his sensory needs, it could improve her son’s wellbeing, using techniques such as deep breaths.
66. In May, Mrs P told the IST and SW her son was having a mental health crisis. The SW told Mrs P they needed to complete a CPA care plan with the IST. During a home visit (on 15 May), Mr Q said he was doing better, so the IST would not change his medication. Mrs P said he was only doing well because she brought him a pair of trainers to agree to the home visit. He would get worse.
67. On 27 May, the IST and SW visited Mr Q at home. They noted Mr Q was anxious and angry. He said he was not well on 15 May. Mr Q and Mrs P agreed to an informal admission to assess his mental health.
68. A Locum Consultant Psychiatrist for the CMHT assessed Mr Q over the phone on 3 July 2020. The Locum noted a care plan in Mr Q’s medical records.
69. Mr Q did not attend a CPA review on 7 September, but Mrs P did.
70. In response to Mrs P’s complaint, in September 2020, the Trust said Mr Q’s care plans holistically considered historical and current needs, which it kept under review. Also, it agreed to check that Mr Q had been included in preparing his care plan.
71. In response to Mrs P’s complaint, in May 2021, the Trust said it allocated a care coordinator within a week of the previous one leaving. Also, it involved Mrs P in CPA meetings.
72. I have considered the Trust and Council’s records from 2020 when it started managing Mr Q under the CPA.
73. The IST was responsible for supporting Mr Q’s care under the CPA from January to June. During that period, Mr Q’s care coordinator was the SW. I have seen evidence of CPA reviews with and without Mr Q in February and March. Those CPA reviews contained a robust assessment of Mr Q’s needs. Also, there is clear evidence of regular communication between the SW and the IST between January and June. That was good practice.
74. In March and May, the SW noted that she hoped to develop a care plan with Mr Q as part of the CPA process. However, the SW and IST never created a care plan for Mr Q before it transferred his care to the CMHT. The SW said she struggled to complete the care plan for Mr Q because he did not engage with her or the IST. That is not an acceptable reason for not completing Mr Q’s care plan over six months. The Trust and Council should have found a way to work together with Mr Q over those six months.
75. From June to December, the CMHT were responsible for managing Mr Q under the CPA.
76. On 3 July, the CMHT noted it had developed a care plan for Mr Q. That was not formalised in a separate document. Rather, it was listed within the CMHT’s records as bullet points. That was fault. The CMHT should have developed a care plan for Mr Q bringing together his physical health, mental health and social care needs. That document should then have been shared with Mr Q and Mrs P.
77. Considering Mr Q’s complex mental health needs (alongside his autism), it was a crucial document to ensure the IST, SW and then CMHT could understand and manage Mr Q’s needs as effectively as possible. That was fault by the Trust and Council.
78. I cannot say that the lack of a CPA care plan directly caused Mr Q’s mental health crises. However, the lack of a care plan most likely increased the risk that his mental health could deteriorate. That leaves Mr Q and Mrs P uncertain if he would have received better support if the CPA care plan was in place.
79. The Council has provided evidence that the Trust carried out an assessment of Mr Q’s social care, physical and mental health needs in June 2022. The Council told me the Trust has not finalsied the support plan. It is good the Trust has now carried out a holistic assessment of Mr Q’s needs. However, this does not take away from the injustice that Mr Q suffered during 2020. Therefore, the Council and Trust should take further action to remedy the personal injustice Mr Q suffered.

Mr Q’s autism and reasonable adjustments

80. Autism is a developmental condition which affects the way a person communicates with others and perceives and makes sense of the world. People with autism have difficulty with social interaction, social communication and rigid and repetitive ways of thinking and behaving. They may also have other difficulties such as sensory sensitivity and anxiety.
81. The Equality Act 2010 places a duty on councils and NHS trusts to make reasonable adjustments for certain people. The duty aims to make sure that a disabled person can use a service as closely as is reasonably possible to the standard usually offered to people without disability. When the duty arises, a council must take steps to remove or prevent obstacles to accessing its service. If the adjustments are reasonable, it must make them. The Ombudsmen cannot decide that a Council has unlawfully discriminated against someone as a disabled person. Only the Courts can do that.
82. I have considered the Council and Trust records during 2020.
83. My investigation has considered if those organisations understood Mr Q’s needs related to his autism and made reasonable adjustments to support him.
84. I have already found fault with the Trust and Council’s care planning under the CPA. The CPA care planning process was crucial to understand Mr Q’s needs and support related to his autism also.
85. Mr Q’s autism meant he struggled to attend meetings with lots of and/or new people. This was clear from the February 2020 OT report. As Mr Q was being supported under the CPA, many professionals were involved in his care.
86. On 7 May, the IST developed a communication plan to positively support Mr Q and Mrs P. It included:
• Having two staff witness communication with Mr Q and Mrs P, owing to the different experiences of Mr Q between the IST and Mrs P.
• Always ask to speak to Mr Q to ensure his voice was not lost.
• Directly quote from Mr Q and Mrs P in his written records.
• Do not assume Mr Q does not have capacity to make decisions about his care and support.
• Offer measured responses to Mrs P and do not always challenge the accuracy of her complaints.
• Share complaints between the IST and the SW to increase awareness and have a joined-up approach.
87. The IST said its communication plan was to positively support Mr Q and Mrs P. However, I consider it mainly highlighted how to manage contact from Mrs P.
88. When Mr Q suffered a mental health crisis in late May the SW noted: “[Mr Q] would not respond well to too many people talking to him and telling him what to do. We discussed how these conversations can be relayed in a different manner, where [Mr Q] is in charge and says what he wishes to. [Mrs P] said this would be better.” The SW later agreed for three people to visit Mr Q, with one person staying downstairs. That visit was productive, and Mr Q engaged with staff. I consider the SW appropriately considered Mr Q’s autism and applied reasonable adjustments to effectively communicate with him. However, I have not seen evidence the Council or Trust consistently used that approach. That was fault. The Council and the Trust did not consider their duties under the Equality Act to support Mr Q’s autism.
89. After Mr Q moved to the CMHT, CC2 noted Mrs P was: “…not promising [Mr Q] will attend as he has problems with rooms that have many people he does not know. She was informed by CC [CC2] that this is typical of a individual [sic] who is autistic. However, he should try as this is the appointment that we need him to attend…”. CC2 later said: "[Mrs P] was informed that due to the diagnosis that [Mr Q] has as a CMHT there is not a lot that can be done as we are not trained to work with patients with Autism."
90. I understand the CMHT were better placed to meet Mr Q’s significant mental health needs after June 2020. But CC2’s comments clearly show the CMHT was not able to effectively support Mr Q’s autism alongside his mental health. That was fault. The CMHT would have had access to the February OT report, which detailed how staff can help support Mr Q’s needs related to his autism.
91. Throughout 2020, Mrs P repeatedly told the Council and Trust they were not supporting his communication needs. I accept that would have been frustrating for Mr Q. While I cannot say Mr Q would have always engaged with the Council and Trust if not for the fault, it was a missed opportunity. That leaves Mr Q uncertain if he would have received better support if they made reasonable adjustments.
92. I understand throughout 2020 the Trust supported Mrs P’s referral to a specialist autistic facility at another Trust. While Mr Q waited for that funding, the Council and Trust had a duty to support Mr Q’s needs related to his autism. As I have already found, I am not persuaded they did that well enough.
93. The Trust told me it has provided formal autism training to the IST and CMHT. Since Mrs P’s complaints, it created a plan to develop staff understanding of patients with autism using its service. It told me:
• It has drop-in sessions for clinicians to speak to an Adult Autism Specialist to discuss management and treatment of autistic service users.
• It has created a space in one of its buildings with enhanced facilities to support autistic service users.
• It has employed a Lead Practitioner to develop an autism pathway across the local Integrated Care System.
• It has employed a Strategic Lead to review the autism support it provides and to identify how it can improve that service.
94. I consider the Trust has made improvements to its service to build staff understanding around autism. However, I consider it needs to take further action to remedy the injustice to Mr Q and Mrs P.

The transfer to Townsend Court and discharge to the Residential Home

95. I have considered the Trust and Council’s records.
96. On 1 June, Mrs P called the IST and said her son was upset and anxious that he was going to Townsend Court that day. Townsend Court (part of the Trust) is an acute ward which supports people who experience a mental health episode.
97. The next day, the IST told the Council it wanted to move Mr Q to the Residential Home as “he has apparently been asking not to return to the family home”.
98. On 4 June, Townsend Court told the IST Mr Q wanted to move to supported accommodation, but Mrs P said her son wanted to come home. The IST agreed to hold a meeting with Townsend Court. The same day the Manager of the Residential Home said Mr Q would fit in well and could meet his needs.
99. The next day, Townsend Court reviewed Mr Q. Mr Q said he was very anxious and hoped to be discharged to supported accommodation. He wanted staff to be more patient with him. Townsend Court agreed to move him to supported accommodation. He said he was happy staff had listened to him and was happy with the plan.
100. On 8 June, Mr Q asked to leave Townsend Court due to “the chaos on the ward” making his anxiety worse. He said staff had snapped at him. A Consultant asked how they could make him more comfortable, and he said he “can’t thank us enough, you’re doing all you can”. Mr Q agreed to remain at Townsend Court.
101. The next day, the IST and Townsend Court said Mr Q could potentially move to the Residential Home. Mr Q said he wanted to return home. The SW and IST said he was not ready to move home yet. Mr Q then agreed to move to the Residential Home. Mrs P disagreed with the decision. The IST reviewed Mr Q that evening. He had settled well and played with other residents.
102. On 13 June, Mrs P told the IST her son called her 16 times saying he did not like the Residential Home. The IST noted Mr Q’s anxiety had reduced and he had settled very well. Mrs P visited the Residential Home at 11pm, packed her son’s belongings and took him home. The Residential Home told the IST that Mr Q had capacity to decide to leave. The IST was concerned that Mr Q told them he did not want to go home.
103. In response to Mrs P’s complaint, the Trust said it moved Mr Q to Townsend Court to reduce his anxiety, which had been so severe he could not eat or sleep. Mr Q said he wanted to stay longer at hospital due to his anxiety and OCD.
104. Firstly, I will consider the Trust’s decision to discharge Mr Q to Townsend Court from the Hospital. Townsend Court was part of the Trust, so the Trust had not discharged him at that point.
105. The Trust’s records state it moved Mr Q to Townsend Court for “...time to adjust before he can be discharged”. A Consultant explained to Mr Q that they needed to move him to a different ward, and Mr Q “agreed for that”. The Consultant also noted Mr Q “mentioned that he is still not ready for discharge because of his ongoing symptoms”. At that time, the Consultant was also satisfied Mr Q had capacity to make that decision. I do not consider the Trust acted with fault when it moved Mr Q from the Hospital to Townsend Court.
106. However, its communication with Mrs P at that time was poor. That was fault. There is no evidence the Trust kept Mrs P updated about moving her son. The Trust’s records showed Mrs P was first aware of the transfer after speaking to Mr Q. At that time, the IST recorded Mrs P was not happy the Hospital were keeping her updated. I appreciate the Hospital were not discharging her son at that time. However, the Hospital moved Mr Q to a different Trust setting over three miles away. I consider Trust staff should have updated Mrs P then.
107. I will now consider the decision to discharge Mr Q to the Residential Home.
108. On 9 June, the SW, IST and CMHT met with Mr Q. He initially said he would like to return home and support his mother but accepted he could not do that. The SW mentioned the Residential Home and noted: “[Mr Q] said he’d like to go there”. After Mrs P was invited to the meeting, the SW noted: “[Mr Q] was given the options whilst mum was on the phone and [Mr Q] said he’d like to stay on the ward and then go to [the Residential Home]. Mum then said she’d like for [Mr Q] to come home and [Mr Q] has said he wishes to come home [Mr Q] then said he’d like to go home”. The SW then gave Mr Q the two options again, and he chose to go to the Residential Home. The SW also told Mr Q he could leave if he wanted to, as he was not detained under section. The SW noted Mr Q thanked her and found the discussion very helpful.
109. I appreciate Mrs P disagreed with the decision to discharge Mr Q to the Residential Home. However, I consider the Trust appropriately involved both Mr Q and Mrs P in that decision and appropriately assessed his capacity to make it. Therefore, I do not consider the Trust, or the Council acted with fault in the way it decided to discharge Mr Q to the Residential Home.
110. Mrs P told me the Council and Trust did not consider Mr Q would only tell staff what they wanted to hear, which was a feature of his autism.
111. The SW said they were conscious of this, so she spoke privately to Mr Q and weighed up the positive and reasons for returning home. The SW also said that reintroducing an advocate for Mr Q may have been overwhelming and extended his time at Townsend Court while he got to know them. That would have caused Mr Q further distress while at Townsend Court.
112. The Trust said there was evidence Mr Q had settled well into the Residential Home and it was meeting his needs relating to autism.
113. I consider the Council and Trust appropriately Mr Q’s autism before moving him to the Residential Home.

The Council’s support to Mrs P as carer

114. Where an individual provides or intends to provide care for another adult and it appears 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. (Care and Support Statutory Guidance 2014)
115. An adult with possible care and support needs or a carer may choose to refuse to have an assessment. In these circumstances, councils do not have to carry out an assessment.
116. The Council told me Mrs P repeatedly asked to delay the carers assessment to support her son’s needs. The Council also said it offered Mr Q a respite placement after the Trust discharged him in June 2020.
117. I have considered the Council’s social care records.
118. During the February 2020 CPA meeting, the SW agreed to send dates for the carer’s assessment, and Mrs P agreed to confirm when she was free.
119. A month later, the SW chased a suitable date from Mrs P. Mrs P agreed to suggest a date soon but she was busy supporting Mr Q.
120. During a meeting with the IST, in April 2020, the SW said she would keep offering Mrs P a carer’s assessment.
121. Between April and June 2020, Mrs P was busy supporting her son. In early June, the SW noted she was “unable to complete reviews/carers assessments due to [Mrs P] not being available due to [Mr Q] being in crisis”. I am satisfied that on the balance of probabilities, Mrs P would most likely have refused a carer’s assessment between April and June.
122. When Mr Q returned home from the Residential Home, I consider it would have been appropriate to consider offering another carer’s assessment. While Mr Q felt better at home after the Residential Home, Mrs P most likely still had needs as a carer. That was a missed opportunity, which was fault.
123. After June, the SW stopped supporting Mr Q and Mrs P. I understand the SW worked for the Council’s Adult Learning Disability Team. But I consider the SW should have considered if Mrs P had any carer needs before closing its service to her. I consider that was another missed opportunity, which again was fault.
124. I cannot say what the outcome of a carer’s assessment would have been after June 2020. That leaves Mrs P uncertain about what support she could have received from the Council then. That is an injustice.
125. Mrs P engaged in a carer’s assessment in November 2021, so I will not recommend the Council to assess Mrs P’s carer’s needs. However, the Council should take further action to remedy the injustice to Mrs P.

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Agreed actions

126. Within four weeks of this decision, the Council and Trust should jointly:
• Apologise to Mr Q and pay £1,000 for the uncertainty caused by not developing a formal care plan to support his needs or meeting his communication needs (related to his autism) during 2020.
• Review the way it communicates with Mr Q and decide if that is in line with the recommendations of the February 2020 OT report.
127. Within four weeks of this decision, the Council should:
• Apologise to Mr Q and pay £400 for the adverse impact to his wellbeing by not supporting his social care needs after June 2020.
• Apologise to Mrs P and pay £200 for the uncertainty caused by not offering a carer’s assessment after June 2020.
• Apologise to Mrs P and pay £200 for the distress and time and trouble she suffered from the Council's faults.
128. Within four weeks of this decision, the Trust should:
• Apologise to Mr Q and pay £800 for adverse impact to his wellbeing by not reviewing its support for his sensory needs during 2020.
• Apologise to Mr Q and Mrs P and pay £300 for the uncertainty caused by not considering Mrs P’s and the private Psychologist’s request for CBT.
• Apologise to Mr Q and Mrs P and pay £300 for the uncertainty caused by its lack of direction in the CMHT’s care and support.
• Apologise to Mrs P for the distress caused by not communicating the decision to move her son to a new ward in June 2020.
• Apologise to Mrs P and pay £200 for the distress and time and trouble she suffered from the Trust’s faults.
129. Within eight weeks of this decision, the Trust should ensure the relevant staff in the CMHT are aware of their responsibilities to meet service user’s social care needs under its Section 75 agreement with the Council.

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Final decision

130. I found fault with the Council and Trust’s care and support to Mrs P and Mr Q.
131. I consider the Council and Trust have agreed to carry out reasonable and proportionate actions to remedy the personal injustice they suffered, and to potentially others.
132. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman