London Borough of Hammersmith & Fulham (18 019 465)

Category : Adult care services > Assessment and care plan

Decision : Upheld

Decision date : 25 Feb 2020

The Ombudsman's final decision:

Summary: Ms C complained about the time it took for the Council to complete her needs assessment and the amount of support the Council has said she needs. The Ombudsman has decided to uphold Ms C’s complaint. The Council has agreed to pay a financial remedy to Ms C for the delay in providing her with support and the distress this has caused her. It will also review the pathway through which it carries out assessments for clients with a sight impairment, and the staff it has in place to implement it.

The complaint

  1. The complainant, whom I shall call Ms C, complains there has been an unreasonable delay by the Council in carrying out her needs assessment to determine what care support she should receive. Once the Council carried out the assessment, there was a further unreasonable delay in putting the care package in place. Furthermore, the amount of support allocated by the Council is not enough to meet her needs.
  2. Ms C also complains the Council has failed to explain to her:
    • What the outcome has been of her assessment(s),
    • Why she has not received support in certain areas (in which she identified a need) and
    • What she can use her personal budget for (failed to provide her with a support plan).

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The Ombudsman’s role and powers

  1. 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)
  2. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
  3. If we are satisfied with a council’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)

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How I considered this complaint

  1. I considered the information I received from Ms C and the Council. I also carried out a telephone interview with a manager from the Council. I shared a copy of my draft decision statement with Ms C and the Council and considered any comments I received, before I made my final decision.

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What I found

What should have happened

  1. The Care Act requires that needs assessments should be carried out over an “appropriate and reasonable timeframe”. The Department of Health, Care and Support Statutory Guidance that (6.29): “An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs and a consideration of any fluctuation in those needs. Councils should inform the individual of an indicative timescale over which their assessment will be conducted and keep the person informed throughout the assessment process”.
  2. The Care Act also stresses the critical importance of preventative services intervening early in this process to maximise independence and reduce the need for longer term support. It states that:
    • (6.25): “The first contact with the Council, which triggers the requirement to assess, may lead to a pause in the assessment process to allow such interventions [a period of reablement and providing equipment or minor household adaptions] to take place and for any benefit to the adult to be determined”.
    • (6.26) The Care Act provides councils with the powers to meet urgent needs where they have not completed an assessment.
  3. The Association of Directors of Adult Social Services (ADASS) have published a position statement on this specific area. It sets out guidance to councils on timescales for sensory assessments and provision of vision rehabilitation. It states: “It is important that all involved in the assessment and delivery of vision rehabilitation understand how people are supported by their local council, and are aware of the Adult UK eye health and sight loss pathway in their local council. Assessments and support must be promptly available, as delays in receiving vision rehabilitation can have significant human consequences and financial implications for health and social care. The RNIB recommends that assessments are carried out within 28 days, and that support begins within 12 weeks of a person’s initial contact with the local authority.”
  4. The Adult UK Eye Health and Sight Loss Pathway referred to above, says that:
    • A Specialist Visual Impairment assessment of social care need, should be followed by a
    • Visual Impairment Rehabilitation Programme, followed by a
    • Community Care Assessment
  5. The Care and Support (Eligibility Criteria) Regulations 2014 set out the eligibility threshold for adults with care and support needs. Where the Council decides a person has eligible needs, it must meet these needs. The Council must provide a care and support plan which outlines:
    • The needs identified in the assessment and to what extent they are eligible needs
    • How the needs will be met
    • A personal budget
  6. The personal budget is the money the council has worked out it will cost to arrange the necessary care and support for that person to meet the eligible needs. The detail of how the person will use their personal budget will be in the care and support plan. The personal budget must always be an amount enough to meet the person’s eligible care and support needs.
  7. The Council has told me that in 2018/19, it did not have an assessment process / pathway for people with sensory impairment. However, it has now started to develop one.

What happened

  1. Ms C’s GP sent a letter to the Council on 15 March 2018, asking for an assessment of her needs. The letter said that Ms C felt very isolated and unsupported.
  2. An Intake & Assessment worker tried to contact Ms C on 5 April 2018 to progress the referral and left a voice message asking her to call back. The worker contacted Ms C again on 23 April 2018 and agreed to carry out a care needs assessment the following day. The Face Screening Assessment form says Ms C:
    • Would like an assessment for any community-based support that will help her with daily living, as she felt very unsupported.
    • Advised she feels she cannot safely access the community, especially new places/buildings. Ms C says she cannot distinguish shapes, has ‘night blindness’ (‘her vision is especially bad at night or dimly lit environments’) and she cannot see people or obstructions until they are on top of her. Ms C said she has tripped up many times and has had multiple injuries as a result.
    • Said she has no friends or support and tries to visit her parents once a week. She feels very isolated.
    • Is working from home, selling handmade products such as hats, wigs, on a website.
    • She has difficulty with cooking, always knocking over and spilling things. She has also burnt herself on the cooker.
    • Ms C wanted support with:
        1. Accessing the community safely: a personal assistant to help her to accompany her to new places and help her to socialise in the community
        2. Support with housework.
        3. Support with shopping and meal preparation.
        4. Managing personal care independently without issue
    • The assessment concluded that Ms C should:
        1. Be referred to the Sensory Loss Team (SLT) for a Sensory Loss Assessment to assess the need for reablement and equipment support, to promote independence and well-being.
        2. Have a “Overall care needs assessment needed to assess level of need”.
  3. The assessor had identified the correct steps to take Ms C’s assessment further. The records state the assessor told Ms C on 1 May 2018, that she would refer her to the SLT for rehabilitation and equipment support.
  4. However, there was a subsequent delay before the SLT accepted Ms C’s referral. According to the records, the SLT manager asked for extra information and cancelled the referral on 15 May 2018. The social worker sent more information the following day. However, there is no evidence the SLT manager considered this, or that the social worker assured herself the SLT had now accepted the case.
  5. Ms C chased the Council on 13 June 2018, because she had not received any further updated. The Council’s record states that it would contact the SLT to get an update. However, there is no evidence this happened. As such, Ms C had to chase the Council again on 9 July to ask for an update. The Council subsequently established that her case was not open with the SLT.
  6. The Council told me that its adult social care services were part of a council-wide transformation programme at the time. The changes in personnel and processes would have been a major contributory factor in the breakdown in communication between the two teams, and the inevitable delay that followed. In future, it will ensure that cases remain open to a responsible officer until transfer is confirmed, before terminating their involvement.
  7. On 17 July 2018, the Council referred Ms C for a mobility assessment. Her case was allocated on 30 July and the Council tried to contact Ms C on 7 August, to arrange an appointment. The Council eventually spoke to Ms C on 23 August and booked an appointment for 30 August. This meant, it had taken three months to get a Sensory Impairment Assessment, which is an unacceptable delay (fault).
  8. In addition to what is mentioned underneath paragraph 15, the Sensory Impairment Assessment established that Ms C:
    • Wanted to be able to continue with her business as much as possible. However, she was struggling with buying materials for her business. She cannot distinguish colours and wanted to access new areas in London to search for new materials
    • Cleaning at home was a challenge for her, because she could not see dirt.
    • Wanted support with accessing the community to enable her to socialise and join social groups.
  9. The assessment identified that Ms C would benefit from support with accessing the community. However, there is no evidence in the records that shows the Council subsequently did anything to progress Ms C’s case. This was fault. Furthermore, the Council did not update Ms C about the outcome of the assessment and what would happen next. This was fault.
  10. Rather than organising mobility training, reablement support and/or providing equipment to help Ms C with reducing her needs, the Council decided to carry out another assessment in November 2018 by the Information & Assessment Team. Even though the assessment took place, the assessors failed to record this. This was fault. I am therefore unable to conclude this assessment was carried out properly.
  11. The assessment identified the following actions:
    • Social worker to contact local community resources to explore what support they could provide to Ms C.
    • Social worker to consider care package for Ms C.
    • Social worker to continue to liaise with the sensory team going forward.
  12. However, even though it was clear that Ms C could benefit from mobility training and/or reablement support, the assessment did not result in a referral for this. This is fault. Furthermore, there is no evidence the social worker looked into voluntary community organisation that could support Ms C. This is fault. The Council only ordered a light for Ms C.
  13. Following the assessment, the social worker concluded that a support package of eight hours a month would be enough to support Ms C. Ms C was very unhappy with this amount. However, I did not see evidence the social worker discussed with Ms C:
    • Why she had concluded that some of the needs Ms C had mentioned, would not be eligible, and any suggestions what Ms C could do to get other help with those.
    • Explain how she concluded that eight hours a month would be enough to meet her eligible needs. This is fault.
  14. Even though she was unhappy with the amount of support the Council was willing to provide, Ms C made it clear that she wanted to receive the support, while escalating her complaint further. However, despite several attempts to chase the Council.
  15. Nothing much happened until a Members Enquiry on 20 August 2019. This resulted in a joint assessment visit to Ms C on 23 August 2019 by a Senior Practitioner from the Information and Advice Team and the Eye Clinic liaison officer from the Sensory Impairment Team.
  16. The assessment concluded that Ms C should receive 8 hours per month. However, the Council again failed to update Ms C about the result of the assessment, share a copy of the needs assessment and support plan with Ms C.
  17. The assessment also concluded the Council should refer Ms C to the Rehabilitation Officer Visual Impairment (ROV) for mobility practice to access the community, and to the Reablement Team to maximise her independence. However, the Council told her that this could take some time because “she is the only ROVI working for the Borough”
  18. On 4 October 2019, the Council booked an appointment with Ms C for a mobility assessment. At the visit on 16 October, Ms C said she finds it difficult to cross and negotiate busy roads and public transport. Ms C said she struggled with the road from the bus to her college and the assessor agreed to arrange training to support Ms C with this route. According to the records, mobility training took place on 13 & 28 November and 6 December 2019 around: mobilising outdoors, access public transport and using stairs and escalators. The ROVI commented that Ms C was confident using her cane, was using the correct techniques and was happy with the training.
  19. Ms C is yet to receive reablement support in areas such as kitchen use etc.
  20. At the interview, the manager told me:
    • If the face assessment at the start identifies there are urgent needs that need to be met, and not meeting them will put the client at risk, support will be put in place to ensure the needs are met while the assessment process continues.
    • The role of the ROVI is carried out by a senior Sensory Worker who does all the mobility training. Waiting times for mobility training depends on whether a case gets referred from outside or not, and on risk. It is currently between 2 weeks and 4 months. Average waiting time around 6-8 weeks.
    • The case highlighted the need to develop a clear pathway for those with a sight impairment. The Council has begun work in this regard.
    • The Sensory, OT and reablement team have all been under one management team structure since November 2018. This enables quick referrals. He will look at job responsibilities to identify areas where more support is needed and adjust roles accordingly.


  1. The Care Act Guidance, and best practice guidance such as the ADASS guidance mentioned in paragraph 9, states that an assessment process needs to be completed within a reasonable timeframe. The ADASSS statement says that the assessment should be completed, and support should be in place, within three months. This did not happen, which is fault. The delays in this case were mainly due to:
    • The lack of a clear pathway that showed how an assessment for a person with a sight impairment should be progressed.
    • The Council’s failure to carry out / through referrals that were identified as action points in some of the assessments.
  2. As a result, Ms C received assessment after assessment (four in total), and it took until November 2019 (20 months) before she received her first mobility training sessions. She is yet to receive reablement support in the areas of kitchen use, personal care, domestic tasks and shopping.
  3. During the course of the investigation, the Council recognised its failure to have a pathway in place. As such, it has started work on developing one. The aim of the pathway should be to meet the requirements and guidance included in the Care Act and the ADASS guidance. In addition, any pathway should include time targets and a system through which to periodical review if these are being met.
  4. Furthermore, there was a failure by the Council to communicate with Ms C. It failed to:
    • Inform Ms C about the outcome of assessments and what would happen next.
    • Share a copy of her need assessments (and corresponding support plans) with her
    • Update her about any delays
  5. There was also a lack of an effective system in place to provide supervision and oversight. This allowed Ms C’s case to regularly drift without any real progress being made and/or the social workers not carrying out the actions that had been identified in various assessments (see paragraph 17, 18, 22, 23, 25, and 28). This is fault.
  6. Furthermore, the Council concluded in November 2018 that Ms C should receive a support package of 8 hours a month. However, it failed to take this forward without this being picked up by management. It took a member’s enquiry in August 2019 to progress this. Following another needs assessment in August 2019, there have been further delays in setting up a Direct Payment for Ms C.
  7. The Council told me there is currently only one staff member who carries out the role of the ROVI. As a result, the average waiting time to receive mobility support from the ROVI is 6 to 8 weeks. The Council has told me that it puts a support package in place if a client still has support needs after having received mobility support. As such, a delay of 6 to 8 weeks for mobility training to start, will result in the Council not being able to put a support package in place (if needed) within the recommended 3 months. The Council has told me that it will review this with a view of reducing the average waiting time.
  8. I did not find fault with the Council’s approach that: as long as there are no needs identified during an initial assessment that puts a person at imminent risk, there is no need to provide a support package while a person goes through the Council’s needs assessment process.

The amount of support hours Ms C should receive

  1. Ms C told me she is unhappy about the amount of support hours the Council has said she should receive. The Council has concluded she needs 8 hours a week. However, Ms C says she needs 4½ hours a week, in addition to any support she may need to access College. The disagreement centre around the following
  2. Support to access the Community / Socialising (2 hours a week wanted)
    • The assessment states that:
        1. “Ms C struggles to access the community as she has no depth perception and is continually bumping or falling over obstacles. She finds it difficult to go to new areas/environments. Ms C would need human support to access other environments.”
        2. Ms C stopped in April 2019 with her art/crafts business, making hats and wigs. However, she would still like a PA to occasionally support her to go shopping and look for materials.
        3. Ms C feels isolated. She does not have any friends or contact with family and does not have anyone to talk to. The Council has discussed several options to meet this need, including:
          1. Joining a local Blind Ramblers club to meet new people and access the wider community on a regular basis.
          2. Ms C is interested in sailing or joining a dance class.
          3. Information has been provided about Retina UK Peer Support Groups Meetings for the blind. 
          4. Ms C could access Bowles at her local park. 
        4. Ms C will undertake mobility practice with the ROVI, to become more confident when accessing the wider community and using public transport, by practicing certain routes.
    • Ms C says she needs two hours of support per week:
        1. Due to her hearing and visual impairment, she has difficulty noticing (on-coming) traffic. This makes her feel anxious because she is "unable to make judgements safely if there is a lot of background noise”.
        2. The mobility training will only be for a small number of local routes, which do not include central London. However, she will continue to have difficulties accessing new routes and unfamiliar buildings. She will continue to have a need to access new buildings, travel new routes into busy London, and travel at night, to enable her to take part in classes, social activities, recreational activities and attend art galleries/musea etc. She did this for many years before her sight loss and it is something she enjoys immensely when she is accompanied. She does not want to be restricted from doing this just because she is disabled.
        3. Without some level of appropriate ongoing support, she will continue to be at risk when doing this and reluctant to go into the community due to the anxiety and distress this will cause her.
        4. For instance, the location and the evening time of the weekly dance class she wants to attend, makes it difficult for her to access on her own. She needs one and a half hours of support for this per week.
    • The Council says that:
        1. Ms C is able to access the community by herself, but needs more confidence mobilizing. This will be provided through mobility training.
        2. The eight hours per months can be used to help her access the wider community to explore subjects of interest and participate in social activities.
        3. The Council would usually advise clients to attend classes during the day, especially for those with night blindness. As yet, Ms C has not actually identified or booked a class. Furthermore, Ms C could consider using her direct payments or use the mobility component of her PIP to access the community or use her taxi card to attend the classes.
    • My assessment: Ms C has identified that, while she can make some journeys, she will need support from a personal assistant with other journeys. However, the Council says Ms C has since received mobility training that showed she is confident mobilising outside using her cane. It says that, if she has to go outside at night and/or access routes or buildings she is unfamiliar with, she has a taxi card and sufficient funds to get support from a PA through her direct payments and her PIP mobility benefits. While the Council has considered Ms C’s needs in this area, I would have expected more clarity in the records (following discussions with Ms C) about: the places / activities Ms C wants to visit, how often she would want to do these activities per week/month, if these routes / activities require PA support, how many hours of PA support would be required for each etc, to be to conclude that the support currently in place is sufficient.
  3. Ms C’s ability to use the kitchen
    • The assessment states that:
        1. Ms C said she sometimes burns herself when using the cooker. It was agreed to make a referral to the Reablement Team for Cooking, to review her technique/routine.
        2. Ms C will receive a purchasing stool to rest on and a spiked chopping bord to enable her to cut and chop food more easily.
        3. Ms C will get support with planning her meals and cooking meals in batches, which she can then store in the fridge.
    • My assessment: The Council believes that reablement and equipment support in this area will ensure Ms C will be able to be independent in this area. However, so far, the Council has failed to provide this reablement support.
  4. Shopping (30 minutes a week):
    • The assessment states that:
        1. Ms C can only manage to carry one shopping bag. 
        2. Ms C would like to continue to go shopping once every 3-4 days to buy light weight and fresh items.
        3. Ms C will benefit from a period of reablement, to develop a core shopping list, assist her with reading food labels and recognising food items. The carer can encourage Ms C to download the KNFB reader. Alternatively, Ms C can take a photo of the food item and speech can then be used to help read the label. 
        4. Ms C can purchase heavier items on-line, but says she needs support to help her with unloading her shopping once it arrives. She wants 30 min a week to support her with: unloading the online shop, checking use by dates and assistance in planning shops/ meals for the week.
    • My assessment: The Council believes that reablement and phone apps will ensure Ms C will be able to be mostly independent in this area. However, so far, the Council has failed to provide this reablement support. The Council has accepted that she needs 30 minutes support a week with putting the online shop away meal planning.
  5. Maintaining a clean and safe home environment (one hour a week):
    • The assessment states that:
        1. Ms C can lack motivation, and fatigue makes it difficult for her to carry out some tasks. Ms C feels that having a clean home will have a positive impact on her motivation and mental wellbeing.
        2. Ms C can manage light cleaning tasks. However, she says she can’t hoover effectively or clean the kitchen floor, due to poor lighting and eyesight. The Council will order a new replacement light for the main room. The Sensory Team will also liaise with Housing to see whether any adjustments can be made to the existing lighting in the kitchen.
        3. Ms C will benefit from some regular assistance with cleaning her floors. This will also help to keep them free of any possible hazards that could cause her to trip or fall.
        4. Some work can be undertaken during the reablement process to look at how the hoover is being used. If this shows that Ms C needs longer term support, she can use one hour of the 8 hours per month for housework tasks.
        5. There is also scope for Ms C to use her daily living component of PIP to help fund any additional practical care that she might require in the longer term.
    • Ms C says she is struggling to meet this outcome. The needs assessment identifies that she cannot clean and maintain her home independently, because she is sight impaired and therefore unable to check where needs cleaning effectively. The assessment also clearly states that an unclean home has a negative impact on her mental wellbeing and puts her at risk of trips and falls. As such, this is an eligible need that the Council needs to meet. It will be a long-term cost-effective preventative approach for the Council to provide one hour per week to meet this need. As it is an eligible need, the Council should not ask her to pay for it.
    • My assessment:
        1. The Council has said that Ms C could use one hour a month (15 minutes a week) if she is still unable to meet this need following reablement support. However, the Council has so far failed to provide this. The Council has not yet explained, or identified in the support plan, how 15 minutes per week would meet this need.
        2. According to the assessment / records, the Council has agreed this is an eligible need. As this is an eligible need, the Council has a duty to meet it and should not ask Ms C to pay for it herself.
  6. Personal care (one hour per week)
    • The assessment says that:
        1. Ms C does not have any major difficulties carrying out her personal care and she prefers to do this herself.
        2. She can get (un)dressed independently and the Sensory Team will provide a colour aid to help her co-ordinate her clothes more effectively.
        3. Ms C will receive a period of reablement and input from the Sensory Team, who may be able to identify other aids and equipment that might prove beneficial to use in the bathroom.
    • Ms C says that she has problems ironing clothes, because she cannot see creases and is at risk burning herself. She also has problems identifying clean matching clothes and ensuring she is presentable when leaving the house. She does not believe she should wear creased clothing when attending college and in the community, simply because of her disability. She therefore wants one hour a week of support with this. The Care Act stresses “the importance to an adult's personal dignity of wearing clean, presentable and appropriate clothes”.
    • My assessment:
        1. The Council’s view is that, following reablement and equipment support, Ms C will be independent in this area. However, the Council has so far failed to provide this.
        2. I have not yet seen evidence the Council has considered Ms C’s view above.
  7. Access further education:
    • The needs assessment says:
        1. Ms C would like to return to college / university to undertake a course. It has been identified that Ms C would need assistance to attend this. In the first instance, Education will determine what support can be offered to students.
        2. Ms C has a Taxi Card and freedom pass. Ms C may need additional hours to meet this need. This can be further explored with the college and once a course date is confirmed.
    • My assessment: There was no fault with the Council’s view reached in August 2019. If Ms C believes the Council failed to carry out the above or failed to provide the support she needed once she identified a course, she can make a complaint about this to the Council.
  8. The assessment in August 2019 resulted in an Indicative Budget of £156 per week. This is significantly more than the two and a half hours a week the Council has allocated so far.

Agreed action

  1. The above faults have resulted in significant injustice to Ms C. There was a delay in Ms C receiving the mobility and reablement support she needed, which resulted in a delay in her becoming more independent. There was also a delay in Ms C receiving a support package, which resulted in Ms C not being able to access the community (and socialise) as much as she would have wanted, a reduction in her overall quality of life, distress and frustration, which have all impacted on her wellbeing.
  2. I recommended that the Council should:

Within four weeks of my decision:

    • Provide an apology to Ms C for the faults identified above and the impact these have had on her. It should also pay her £500 for the distress she experienced.
    • Pay Ms C an amount of £2,000 for the unreasonable delay in providing Ms C with a care support package, between March 2018 and August 2019.
    • Pay Ms C an amount of £950 for the unreasonable delay in providing Ms C with mobility support and reablement support.
    • Review its decision about the direct payment support for accessing the community and socialising. The Council should explore, in more depth, what activities Ms C wants to do in the community, when these take place during the day, how often they take place (a week/month), how long each session is, where they take place, if she would (therefore) (initially) need PA support and how much this would amount in terms of hours (per week/month), to come to a better view if her current support (Direct Payments plus PiP mobility) could be sufficient to meet this need. Alternatively, the Council could initially allocate more hours (than the five hours a month it has currently allocated) and review how she used this after three months.
    • Review its decision to only allocate one hour a month for ensuring Ms C’s house is clean and free from trip/fall hazards, and subsequently explain to Ms C how it has calculated this. The Council should not ask Ms C to pay for this support herself.
    • Review its decision not to allocate no support for personal care, in light of Ms C’s statement (paragraph 47 point 2 above)
    • Carry out the reablement support in the areas identified in the needs assessment and care plan
    • Once Ms C’s care support has started, the Council should review it after 6 to 12 weeks.
    • Remind staff of the importance of ensuring it updates clients about the outcome of their assessment and share a copy of the assessment and support plan within a reasonable timeframe.

Within eight weeks of my decision:

    • Carry out a review of its Sight Loss Team to ensure it has the resources in place to meet the ADASS guidance of completing assessments, and putting support in place, within three months. This should include a review of its ROVI capacity to determine if this should be increased to meet its obligations.
    • Finalise and approve the assessment pathway for clients with a vision impairment, to ensure it meets the ADASS guidance of completing assessments, and putting support in place, within three months.
    • Review the way in which it supervises and monitors individual cases within the Sight Loss Team, to ensure cases are not allowed to drift.
  1. The Council has told me it has accepted my recommendations.

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Investigator's decision on behalf of the Ombudsman

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