Summary: We found fault by the Council with regards to the care and support it provided to Miss X, a woman with complex needs, in the community. We also found fault by the Council and Trust concerning the handling of Miss X’s discharge from hospital. This fault caused Miss X significant distress and frustration. The Council and Trust have agreed to apologise to Miss X and the Council will make a payment in recognition of the distress she suffered.

The complaint

1. The complainant, who I will call Miss X, is complaining about the care and treatment provided to her by Surrey County Council (the Council), Royal Surrey NHS Foundation Trust (the Trust) and NHS Surrey Downs Clinical Commissioning Group (the CCG). Miss X complains that:

• The Council delayed in submitting a Continuing Healthcare checklist for her.
• The Council completed an annual review in March 2019 but failed to provide her with an advocate to enable her to access the review process.
• The Council failed to provide her with an updated care and support plan despite her requesting this repeatedly.
• The Council failed to provide the CCG with relevant information during the CHC process.
• The CCG delayed in determining her eligibility for Continuing Healthcare funding.
• The Council and Trust delayed in discharging her from hospital in June 2019 and eventually discharged her without an appropriate care package.
• The Council completed a financial assessment without her input that was flawed as a result. Miss X says the Council continues to chase her for fees for which she is not liable as she is in receipt of Continuing Healthcare funding.
• The Council delayed in responding to her complaint and did not properly address the issues she raised.

2. Miss X says these failings by the Council, Trust and CCG have caused her severe distress and anxiety. She says this has been exacerbated as the Council continues to demand money from her that she does not owe.
3. Miss X would like the organisations she is complaining about to apologise and provide her with financial recompense in recognition of the distress, time and trouble caused to her by the failings in her care. Miss X would also like the Council to confirm she does not owe any money for her care.

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The Ombudsmen’s role and powers

4. 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).
5. 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.
6. 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

7. In making my final decision, I considered information provided by Miss X. I also considered comments and documentation from the Council, Trust and CCG, including copies of the clinical and social care records. Furthermore, I invited comments on my draft decision statement from Miss X and the organisations she is complaining about and considered their responses.

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What I found

Relevant guidance and legislation

Care Act 2014

8. The Care Act 2014 is the legislation that sets out local authorities’ powers and duties in respect of social care.
9. Sections 9 and 10 of the Care Act 2014 require local authorities to assess any adult who appears to need care and support. They must assess anyone, regardless of their finances or whether the council thinks they have eligible needs. The assessment must consider the adult’s needs, how these needs impact on the adult’s wellbeing and the outcomes the adult wants to achieve. It must involve the adult and, where appropriate, their carer or any other person they might want to be involved.
10. 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. The local authority should provide the adult with a proposed timescale for completion of the assessment. It should also keep the adult informed throughout the assessment process.
11. The Care Act 2014 is accompanied by a guidance document entitled Care and support statutory guidance (the statutory guidance). This provides guidance for local authorities on how to meet their statutory duties under the Care Act.

Hospital discharge

12. The Department of Health produces guidance entitled Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go guidance’). This is the core guidance around hospital discharge. It contains ten key steps for staff to follow during discharge planning, including:

• start planning for discharge or transfer before or on admission;
• identify whether the patient has simple or complex discharge and transfer planning needs and involve the patient and carer in your decision;
• involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.

Continuing Healthcare

13. Continuing Healthcare (CHC) is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (The CHC Framework) is the key guidance relating to CHC.
14. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. The threshold for meeting the CHC Checklist is set low.
15. If the completed CHC Checklist indicates the person may be eligible for CHC, the next step is a full multidisciplinary assessment. This assessment is completed using a decision support tool (DST). The DST is a record of the relevant evidence and decision-making.
16. The DST is used to make a recommendation on that person’s eligibility for CHC funding. The relevant CCG will then make a final decision which must uphold the recommendation of the DST in all but exceptional circumstances.
17. The CHC Framework explains that the assessment and eligibility decision-making process should be completed within 28 days of the CCG receiving a completed CHC checklist unless there are ‘valid and unavoidable’ reasons for it taking longer.
18. If a CCG takes longer than 28 days to decide that a person is eligible for CHC funding and a local authority or service user has been funding care whilst awaiting this decision, the CCG should refund the cost of this care from day 29 of the period following its receipt of a completed CHC checklist unless it can demonstrate the delay was due to circumstances beyond its control.

Key facts

19. Miss X has complex physical and mental health needs and a diagnosis of Autism. Her physical disabilities mean she is wheelchair dependent. Miss X requires support with most activities of daily living. Miss X had been in receipt of a package of care from the Council for several years.
20. In May 2018, Miss X informed her key worker that she would like to test her eligibility for CHC funding.
21. The key worker completed a CHC checklist for Miss X in July 2018.
22. In October 2018, Miss X was admitted to hospital for insertion of a jejunostomy tube. This is a tube inserted into the small intestine that allows food, fluids and medication to be administered directly.
23. In December 2018, Miss X’s key worker acknowledged he had omitted to submit the completed CHC checklist. The Council allocated Miss X a new key worker, who completed a fresh checklist in January 2019. The key worker submitted the checklist to the CCG in early February 2019.
24. In March and May 2019, the key worker met with Miss X to complete a reassessment of her social care needs.
25. Miss X was admitted to hospital again in May 2019 suffering from nausea and vomiting. The clinical team treating Miss X inserted a percutaneous endoscopic gastrostomy tube (PEG - a tube inserted directly into the stomach). This was to allow the release of built-up gas and acids in Miss X’s stomach.
26. During this admission, the Council completed a financial assessment for Miss X. This determined that she would need to contribute £110.50 per week towards her care (later reduced to £65.73).
27. Miss X remained in hospital until late June 2019, when she discharged herself.
28. The CCG held a meeting with Miss X in October 2019 to complete a DST.
29. The CCG awarded Miss X full CHC funding in December 2019. It backdated the funding to the date of the DST meeting in October 2019.

Analysis

First CHC process

30. Miss X complained that she first asked the Council to complete a CHC checklist in June 2018. However, she said it was not until February 2019 that the Council did this.
31. I understand Miss X first approached her key worker in late May 2018 with regards to the possibility of testing her eligibility for CHC funding.
32. Miss X met with the key worker in late July 2018 to complete a CHC checklist. She subsequently confirmed, in early August, that she was happy for the key worker to submit the completed checklist to the CCG.
33. Miss X chased the progress of the CHC application in December. However, the key worker admitted he had not sent the checklist to the CCG. The key worker said this had been an oversight caused in part by “lack of time due to other commitments”. The key worker’s failure to submit the completed checklist represents fault by the Council.
34. This led the Council to reallocate Miss X’s case to another key worker in January 2019. Around five months had passed since the first checklist had been completed. The new key worker completed a fresh checklist and submitted it to the CCG in early February.
35. I am unable to say with any certainty whether Miss X would have been eligible for CHC funding in 2018 even if the first key worker had submitted the checklist as planned.
36. During the period between the completion of the first checklist in July 2018 and the eventual end of the DST process in December 2019, Miss X was experiencing significant health problems. These necessitated several hospital admissions, as well as the insertion of both jejunostomy and PEG tubes. For this reason, it is not possible to directly compare Miss X’s care needs in July 2018 with her care needs in December 2019.
37. Nevertheless, the key worker’s failure to submit the checklist caused significant delay (around six months) in the CHC assessment process. This caused Miss X understandable frustration and distress.
38. I have addressed this in the ‘recommendations’ section of this decision statement.

Advocacy

39. Miss X complained that the Council completed an annual review in March 2019 but failed to provide her with an advocate to enable her to access the review process.
40. In March 2019, the Council reallocated Miss X’s case to another key worker. The new key worker approached Miss X to explain that she would be undertaking a review of her social care needs.
41. The key worker arranged to meet with Miss X later that month. In the meantime, she provided Miss X with a copy of her most recent social care assessment (from December 2017) for comment. Miss X returned this in advance of the meeting. Miss X made clear that she would require the support of an advocate.
42. Chapter 7 of the statutory guidance sets out local authorities’ responsibilities with regards to independent advocacy. Section 7.4 of the statutory guidance says “[l]ocal authorities must arrange an independent advocate to facilitate the involvement of a person in their assessment, in the preparation of their care and support plan and in the review of their care plan…if 2 conditions are met. That if an independent advocate were not provided then the person would have substantial difficulty in being fully involved in these processes and second, there is no appropriate individual available to support and represent the person’s wishes who is not paid or professionally engaged in providing care or treatment to the person or their carer.”
43. In its response to my enquiries, the Council accepted the issue of advocacy should have been explored as part of the initial planning for the review. However, the Council said none of Miss X’s previous assessments or reviews suggested she struggled to retain information put to her, weigh this information, or make her needs and wishes known.
44. I note the Council’s view on this and accept that Miss X has engaged in extensive correspondence regarding her care needs. Nevertheless, the Council had a responsibility to explore in advance of the meeting whether Miss X would have “substantial difficulty” engaging in the review process if she did not have advocate to support her. This is particularly relevant in Miss X’s case, given her Autism diagnosis and the communication difficulties this presents.
45. Miss X raised her need for support from an advocate again at the meeting in March. The Council has acknowledged, and I agree, that the key worker should have suspended the meeting at that stage so it could be rearranged with an advocate present. However, the key worker proceeded with the meeting
46. The key worker convened a further meeting in early May to discuss her draft assessment. This meeting also appears to have proceeded with no advocate present to support Miss X.
47. Following her discharge from hospital in late June, Miss X again requested support from an advocate. She continued to do so throughout July.
48. The Council eventually offered Miss X support from its contracted advocacy agency. However, Miss X was unwilling to use this service and instead funded advocacy support from an agency of her choosing for the next assessment meeting in September.
49. The Council had a duty to provide Miss X with an independent advocate once it became apparent she would have substantial difficulty engaging with the care planning process without this support. The evidence shows the Council failed to provide an advocate between March and July 2019. In my view, it was not sufficient simply to presume that Miss X did not require this support. This was fault.
50. The failure to provide an advocate made it harder for Miss X to participate in the care planning process. This caused her unnecessary distress and frustration. I have addressed this in the ‘recommendations’ section of this decision statement.
51. In late July, the Council offered Miss X support from its contracted advocacy service. I understand this service provided specialised Care Act advocacy and that advocates were trained to support people with Autism. This shows that, from August, the Council did make appropriate advocacy support available, albeit Miss X chose not to accept this support. This was in keeping with its duties under the Care Act and I found no fault on this point.

Hospital discharge

52. Miss X complained that the Council and Trust delayed in discharging her from hospital in June 2019 and eventually discharged her without an appropriate care package. Miss X says this meant there was no care in place when she returned home.
53. Miss X was admitted to hospital on 10 May 2019, suffering from nausea and vomiting. At that point, Miss X had a nasogastric tube that was used to drain gastrointestinal secretions. The clinical records show the purpose of the admission was to monitor the effectiveness of Miss X’s nasogastric tube and consider insertion of a venting PEG as an alternative.
54. The clinical team decided a PEG would be appropriate to vent gas and release secretions from Miss X’s intestines. The clinical team completed this procedure successfully on 15 May.
55. A clinician reviewed Miss X the following day and found she had significant constipation. The clinician recommended a gradual increase in Miss X’s feed via the jejunostomy tube, as well as treatment for her constipation.
56. However, Miss X reported feeling hot and clammy during the feeding process and was experiencing pain in her abdomen. The clinical team arranged an abdominal ultrasound. This did not identify any problems.
57. On 22 May, the dietetic team decided to try a different feed preparation as it hoped Miss X may be able to tolerate this better. In the meantime, the clinical team continued to treat Miss X’s constipation.
58. As Miss X continued to experience pain during feeding, the clinical team requested input from the clinician who had inserted the jejunostomy tube in October 2018 to check for abnormalities. This review identified no problems.
59. The clinical records suggest Miss X was becoming increasingly frustrated and upset about her continued admission. The records show Miss X felt she was dehydrated as she was thirsty with a dry mouth and was experiencing headaches. However, the clinical team felt there was no evidence of dehydration.
60. A multidisciplinary team meeting on 30 May heard that Miss X’s behaviour was becoming increasingly difficult to manage and that she was making complaints about the clinical and adult social care teams.
61. The clinical team recommenced Miss X on intravenous fluids on 3 June at her request.
62. On 4 June, a consultant gastroenterologist spoke to Miss X to explain that her condition was generally stable. The consultant explained that it would be necessary to increase Miss X’s feed level to maintain her nutrition and enable discharge. However, Miss X said she would be unable to tolerate an increase.
63. The Trust convened a further meeting with Miss X on 11 June to discuss her care. The consultant gastroenterologist explained to Miss X that investigations had found no cause for the pain she was experiencing during jejunal feeding. The clinical team emphasised that it would be necessary to increase Miss X’s feed to meet her nutritional needs and remove the need for intravenous fluids so she could be discharged home.
64. The notes show the clinical team felt input from mental health services would be helpful to explore whether there was a psychological component to the symptoms Miss X was experiencing. Miss X was reluctant to accept this. She left the ward after the meeting and had to be persuaded to return.
65. It is clear from the records that Miss X was keen to return home as soon as possible. However, the clinical team felt it would not be possible to discharge her safely until her jejunal feed was at a suitable level.
66. The records show clinical staff had further discussions with Miss X on 19 June, during which she was noted to be very upset and abusive. Miss X subsequently left the ward again. She initially refused to return to the ward but was eventually persuaded to do so.
67. At a ward round the following day, Miss X reiterated that she wanted to return home. The clinical team felt she had the capacity to make this decision and arranged a professionals meeting for 21 June to discuss Miss X’s discharge requirements. However, Miss X left the hospital again that evening and contacted the police to report she was being neglected. Police officers accompanied Miss X back to the ward again later that evening.
68. The professionals meeting proceeded as planned and agreed to aim for discharge on 26 June. This was to allow time for Miss X’s existing care package to recommence. The meeting also agreed to complete a risk assessment setting out potential risks relating to Miss X’s ongoing care in the community. The clinical notes suggest Miss X attended the latter part of the meeting and agreed to the discharge plan.
69. On 24 June, the care agency that had been providing Miss X’s domiciliary care package contacted the hospital social work team. The care agency explained that Miss X would need to sign a behaviour agreement before it would recommence the care package.
70. On 25 June, the clinical notes record that Miss X became verbally and physically abusive towards staff. Staff noted Miss X had thrown items and was “scratching, punching, kicking and biting” staff when they tried to help her. Miss X disputes this account of events and said the actions of staff amounted to restraint and abuse. In any case, Miss X subsequently discharged herself and returned home.
71. The clinical records show this was a difficult admission. There was a significant dispute between Miss X and the clinical team as to the extent of her needs. The evidence suggests the clinical team carried out extensive investigations, but these identified no underlying physical conditions that would explain the pain Miss X reported when feeding. The clinical team also wanted to explore whether there may be psychological basis for her symptoms. However, Miss X refused input from mental health services.
72. The clinical team continued to explain that, if Miss X increased her jejunal feed to the recommended level, this would prevent her feeling dehydrated and ensure she was receiving appropriate nutrition. Miss X continued to insist she was unable to tolerate a higher level of feed and continued to report nausea and vomiting.
73. It is clear this impasse led to a deterioration in Miss X’s relationship with the clinical team. This caused her to become increasingly agitated as the admission continued.
74. In her representations to the Ombudsmen, Miss X explained that, when she discharged herself on 25 June, she understood the care package would restart the following day (on 26 June). The case records suggest the professionals supporting Miss X shared this understanding.
75. The case records show the in-reach GP agreed to visit Miss X on 24 June to share a copy of the risk assessment with her and discuss this. In fact, the in-reach GP did not visit Miss X until the morning of 25 June. The in-reach GP said she explained the risk management plan to Miss X and shared a paper copy of this with her. However, she said Miss X told her she would not sign the plan.
76. Miss X disputes this. She says the GP did not share a copy of the risk assessment with her at this meeting. Rather, she says the GP sent her the risk assessment that evening, by which point she had already left the hospital. Miss X says she could not have refused to sign the risk assessment if she had not seen it.
77. I found no note of this visit in the clinical records. In the absence of a contemporaneous record of the discussion, I am unable to establish with any certainty whether the GP shared a copy of the risk assessment with Miss X at that time. This remains a matter of dispute, therefore.
78. Miss X’s care records show that her Autism diagnosis presents her with communication difficulties. There is ample evidence that she prefers to receive information in writing as this allows her time to consider it properly.
79. In my view, much of the confusion around Miss X’s discharge might have been avoided if the professionals supporting her had provided her with a written copy of the risk assessment on 24 June as planned. This would have given her time to consider it in advance of any discussion. However, this did not happen. This represents fault by the Trust and Council. This caused Miss X avoidable frustration and distress.
80. However, I am unable to say whether the delay in recommencing the care package would have been avoided even if Miss X had been given an opportunity to properly consider the risk assessment on 24 June as originally planned.
81. This is because the care agency contacted the hospital social worker on the afternoon of 25 June to request some amendments to the risk assessment and said Miss X would need to agree to the amended assessment before the care package could recommence.
82. Miss X’s decision to discharge herself from hospital that afternoon meant the professionals supporting her did not have an opportunity to share an amended copy of the risk assessment with her for agreement.
83. This led the care agency to write to the hospital social work team on 26 June to report that it was unwilling to restart the care package that day. The care agency manager wrote “[o]ne condition we stipulated, for [the care agency] to continue supporting [Miss X] back in her own home, was that she signs the new risk assessment. Unfortunately, due to her refusing to sign this, and in light of the latest incident, we are not willing to support her at home at this time.”
84. I consider it likely, on balance of probabilities, that the confusion and delay would have been avoided if Miss X had remained in hospital until 26 June as planned. This would have given the multidisciplinary team an opportunity to finalise the discharge arrangements, including the reinstatement of the care package.
85. In summary, my view is that it was Miss X’s decision to discharge herself from hospital before the planned date, rather than the actions of the Trust or Council, that led to the care package delay.

Financial assessment

86. Miss X complained that the Council completed a financial assessment when she was still in hospital and was unable to fully contribute to the process. She says the Council’s assessment was flawed as a result. Miss X says the Council continues to chase her for fees for which she is not liable as she is in receipt of CHC funding.
87. When Miss X’s key worker was completing her social care needs assessment between March and May 2019, she established that a fresh financial assessment would be required. The key worker logged a request for an assessment with the financial assessment team on 3 May 2019.
88. A member of the financial assessment team phoned Miss X on 16 May. By this point, she had been admitted to hospital. The note of this conversation records that Miss X “is reluctant to complete a financial assessment as she stated that her circumstances have not changes since she was assessed in 2013”. Miss X also advised the Council officer that she was in the process of seeking CHC funding.
89. On 22 May, the financial assessment team officer sent Miss X a financial assessment form to complete. She noted that “[Miss X] is still in hospital so she will get her father to help her complete the assessment.” It is unclear where this information came from, as it is not referred to in the note of the above telephone conversation.
90. Miss X sent the financial assessment team an email on 23 May. This explained that “[t]here is no way I have the capacity or physical ability to do [the financial assessment] paperwork by 29th.” Miss X raised the same concerns with a hospital social worker the following day.
91. The financial assessment team contacted Miss X’s father on 5 June. However, he told the officer that Miss X could manage her own finances and that the team should contact her once she had left hospital.
92. Miss X discussed the matter with the financial assessment team again on 13 June. She queried whether an assessment was necessary given her care needs had not yet been established. Nevertheless, the officer noted that “[Miss X] said that we have her benefit information and we could complete the financial assessment from that. I advised it would be better if it could be completed together, with the Advisor to ensure the figures are correct. [Miss X] stated she does not want to do the financial assessment and is happy for it to be completed using the benefits.”
93. The financial assessment team completed the assessment on 17 June. This found Miss X should contribute £110.50 per week towards her care.
94. The Council subsequently completed a fresh financial assessment with Miss X in September following her discharge. This took account of a number of outgoings related to Miss X’s disability and reduced the assessed care contribution to £65.73 per week.
95. The Care Act 2014 sets out that, where a local authority arranges care and support to meet an adult’s needs, it has discretion to charge. If a local authority decides to charge, it must follow the Care and Support (Charging and Assessment of Resources) Regulations. These regulations set out that the local authority must carry out a financial assessment to assess the adult’s ability to contribute towards the cost of his or her care.
96. Miss X was in receipt of a package of domiciliary care. The Council funded this until Miss X’s discharge from hospital in June 2019, at which point joint funding was agreed between the Council and CCG on a temporary basis pending the outcome of the CHC process.
97. On this basis, I am satisfied the Council was entitled to charge Miss X for her care for the period between June (when the Council completed its assessment) and October (when the backdated CHC funding commenced). This necessarily involved completing a financial assessment.
98. However, I have significant concerns about the way the Council handled the assessment process.
99. In its response to my enquiries, the Council said it would have accepted Miss X’s position that she could not complete the financial assessment forms while she was in hospital. However, the Council said Miss X subsequently changed her mind and was willing to be assessed on her benefit entitlement alone. Miss X denies that she gave the Council consent to proceed with an assessment on this basis.
100. The records do not support the Council’s position on this point. On 23 and 24 May, Miss X made clear to both a member of the financial assessment team and a hospital social worker that she felt unable to fully participate in the financial assessment process while she remained an inpatient. Despite this, members of the financial assessment team continued to contact Miss X and her father to request her input into the financial assessment process. In my view, the Council failed to have proper regard for Miss X’s wishes and specific circumstances – namely her ongoing treatment in hospital. This is fault.
101. I am satisfied the Council’s decision to proceed with the financial assessment while Miss X was still in hospital did not put her at a financial disadvantage. This is because the subsequent assessment, which reduced her care contribution, was backdated to the start of the charging period in June 2019.
102. Nevertheless, this process caused Miss X additional distress at what was already a difficult time.
103. I have addressed this in the ‘recommendations’ section of this decision statement.

Care planning and CHC process delays

104. Miss X complained that the Council failed to carry out a reassessment of her social care needs following her discharge from hospital and did not provide her with an updated care and support plan when she requested this. Miss X says the Council failed to provide the CCG with relevant information to inform the CHC assessment process and that this led to a delay in determining her eligibility.
105. In early 2019, Miss X was in receipt of a package care from the Council. This consisted of 1.5 hours of domiciliary care visits twice per daily. In addition, Miss X had one allocated shopping call (20 minutes) per week and 10 hours of personal assistant support per week.
106. The Council submitted a completed CHC checklist to the CCG on 6 February 2019.
107. The CCG wrote to the Council later that day. It noted that Miss X had previously been detained under the Mental Health Act 1983 and queried whether she may be eligible for free aftercare services (known as Section 117 aftercare) as a result. I found no evidence to suggest the Council responded to the CCG at that stage.
108. The CCG told me an officer chased this with the Council on 26 February and received a response from Miss X’s key worker on 28 February. This explained Miss X was not eligible for Section 117 aftercare. The CCG said on officer then requested a copy of Miss X’s file. Again, the Council does not appear to have responded to this request initially.
109. It should be noted that I was unable to locate copies of the above correspondence between the Council and CCG in the Council’s records. However, the Council’s records show an officer did make enquiries with a local Mental Health Trust regarding Miss X’s eligibility for Section 117 aftercare. Furthermore, in its response to my enquiries, the CCG quoted from one of the emails it received from Miss X’s key worker. I consider it likely, therefore, that events occurred as described by the CCG.
110. In March, following a brief hospital admission, Miss X requested an additional lunchtime care call. The Council agreed to this on a temporary basis and Miss X’s new key worker advised her she could fund the additional call through her Direct Payments.
111. As Miss X’s most recent social care assessment had been completed in December 2017, Miss X’s key worker arranged a meeting for 27 March, with a view to completing a fresh social care assessment. The key worker shared a copy of the existing assessment with Miss X in advance of the meeting. Miss X returned this with her comments. At this meeting, the key worker arranged a follow-up meeting for 3 May.
112. On 1 April, the new key worker told the CCG she would try to obtain a copy of the file. The CCG told me it did not receive this. Again, I found no evidence of the key worker’s email within the Council’s records.
113. I understand the meeting of 3 May went ahead as planned, though I found no note of this in the Council’s records.
114. In any case, on 13 May, the key worker shared a copy of the revised social care assessment with Miss X. By this point, Miss X had been admitted to hospital. I have commented in detail on this admission elsewhere in this decision statement.
115. The CCG arranged an assessment meeting for 20 May. However, as Miss X was in hospital and under consideration for a venting PEG insertion, a CCG clinician visited her on 17 May to discuss whether she wanted to proceed. Miss X emphasised that her situation had not changed significantly and that she wanted to proceed with the assessment.
116. The meeting went ahead on 20 May as planned and the assessor completed a provisional DST. However, the CCG was concerned that Miss X was still undergoing acute hospital treatment and that her condition had not stabilised. As a result, the Council and CCG agreed a temporary joint funding arrangement to facilitate Miss X’s discharge from hospital. The CCG agreed to convene a further assessment meeting four weeks after Miss X’s discharge, by which point her condition would have stabilised.
117. A hospital social worker visited Miss X on 24 May 2019. She noted Miss X felt her current package of care was inadequate. However, the case records show the hospital social work team did not agree and felt her current support package was meeting her needs and did not need to be changed.
118. The evidence suggests Miss X’s key worker had not yet shared an updated care and support plan with her further to the social care assessment she completed earlier that month. This is understandable in my view, given that Miss X was still undergoing acute hospital treatment and there was no consensus regarding the level of care she would require in the community. I find no fault by the Council on this point.
119. The CCG arranged a further meeting for 29 July. Miss X subsequently cancelled this meeting. The evidence shows Miss X was concerned that she did not have an up-to-date care and support plan and that her key worker did not have a full understanding of her needs.
120. The CCG extended the joint funding arrangement to 9 September to allow the Council time to resolve the ongoing problems with Miss X’s care plans.
121. In the meantime, due to Miss X’s deteriorating relationship with her key worker, the Council decided to reallocate her case. The new key worker completed a social care assessment visit on 16 September. After some discussion, Miss X signed off the new assessment on 15 October.
122. The CCG rescheduled the DST meeting for 24 October. This proceeded as planned. Following the meeting, the CCG requested some additional information from the Trust and Miss X’s GP. There appears to have been a delay of around a month before the GP provided the requested records.
123. On 5 December, the CCG verified the DST recommendations and agreed Miss X was eligible for CHC funding. It backdated this decision to the date of the DST meeting on 24 October.
124. The evidence shows the CCG received a completed checklist for Miss X in February 2019. It did not make a decision on her eligibility for CHC funding until December 2019. It is clear there was significant delay in the CHC process for Miss X, therefore.
125. In her correspondence with the Ombudsmen, Miss X says she believes the delay was attributable to the Council’s failure to complete necessary assessments and share information promptly with the CCG.
126. In my view, there is some evidence to support this aspect of Miss X’s complaint.
127. The evidence I have seen suggests that, between February and April 2019, the CCG was making efforts to obtain information from the Council regarding Miss X’s CHC application. However, it received no substantive response from the Council. This appears to have been attributable in part to the reallocation of Miss X’s case from one key worker to another during this period. This caused a delay of around two months.
128. There was another period of significant delay between July and October 2019. This came after Miss X cancelled the DST meeting scheduled for 29 July. In her submissions to the Ombudsmen, Miss X says she felt unable to proceed with the CHC assessment process during this period as she had no confidence that her key worker had a proper understanding of her needs.
129. In its response to my enquiries, the Council disputes that they worker did not understand Miss X’s needs. Rather, the Council says there was a fundamental disagreement between Miss X and her key worker as to the extent to which her needs were influenced by her mental (rather than physical) health. The Council said this led to a deterioration in the relationship between Miss X and her key worker. The Council said this meant Miss X was reluctant to meet with the key worker to complete a review.
130. At the point of her discharge in June 2019, Miss X clearly felt her care package was not adequate to meet her needs. Furthermore, her care needs had potentially changed following her surgery the previous month.
131. In my view, these circumstances should have prompted the key worker to complete a reassessment, or at least a comprehensive review, of Miss X’s needs following her discharge from hospital. This would have allowed the key worker to explore Miss X’s concerns about her existing care package.
132. In fact, this did not happen until October, almost four months later. By that point the case had been allocated to another key worker.
133. I accept that Miss X deteriorating relationship with her key worker made this process harder. The situation was also exacerbated by the ongoing lack of advocacy support. Nevertheless, I consider this to be an unreasonable delay, for which the Council bears most responsibility. This is fault.
134. In its response to my enquiries, the Council said the CHC process could have gone ahead in the absence of a recent social care assessment and care and support plan. Similarly, the Council said the disagreement between Miss X and her key worker would not have prevented the DST meeting going ahead. The Council said the purpose of the DST process is to allow the multidisciplinary team to gain a shared understanding of the person’s needs.
135. I note the Council’s views on this point. However, in my view, this fails to take into account the communication difficulties arising from Miss X’s Autism diagnosis. The Council’s records show Miss X regularly made clear that she requires clear and unambiguous information to be provided to her in writing to allow her time to consider it fully. I consider it unlikely, on balance of probabilities, that a DST meeting in July (in the absence of an updated assessment and care plan) would have been productive.
136. For this reason, I consider the Council’s delay in completing an up-to-date assessment and care plan did contribute to the delays in the CHC process.
137. The Council has now informed me that it has decided to waive Miss X’s outstanding care charges of £1,183.14. In my view, this is appropriate given the Council contributed to the delays in the CHC process.
138. However, the case records show this delay caused Miss X great frustration and distress.
139. I have addressed this in the ‘recommendations’ section of this decision statement.

Complaint handling

140. Miss X complained that the Council delayed in responding to her complaint and did not properly address the issues she raised.
141. The Council’s records show Miss X first complained to the Council by telephone on 1 July 2019. This led to an exchange of correspondence as Miss X was not satisfied that the Council’s complaint summary accurately reflected her concerns.
142. On 6 August, Miss X complained directly to the Council’s Director of Adult Social Care. She received an acknowledgement on 8 August. This explained that her complaint would be addressed via the ongoing complaints process.
143. The Council responded to the complaint on 30 August. However, Miss X was dissatisfied with the response and wrote two further emails of complaint in early September.
144. The Council provided a further, final, response on 4 October 2019.
145. I acknowledge it took some time to agree a summary of complaint that Miss X felt was an accurate reflection of her concerns. However, given the complexity of her complaint and the fact that the care she was complaining about was effectively ongoing, I do not consider this delay so significant as to amount to fault by the Council.
146. The Council provided a response within two months of receiving Miss X’s complaint. It then provided a further response within a month of her setting out her dissatisfaction with the first response. In my view, there is no evidence to suggest undue delay by the Council, albeit I appreciate Miss X was dissatisfied with the responses.
147. It was open to Miss X to take her complaint to the Ombudsmen in accordance with the Local Authority Social Services and national Health Service Complaints (England) Regulations 2009. She did so in January 2020.
148. In summary, I find no fault by the Council with regards to its handling of Miss X’s complaint.

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Agreed actions

149. Within one month of my final decision statement, the Council will write to Miss X to apologise for the fault I have identified above and the impact this had on her. Namely:

• The Council’s failure to submit the completed CHC checklist to the CCG in August 2018 as agreed.
• The Council’s failure to provide Miss X with appropriate advocacy support when she requested this between March and July 2019.
• The Council’s decision to proceed with a financial assessment when Miss X was still in hospital and unable to participate fully in this process.
• The Council’s delay in completing a fresh assessment (or review) of Miss X’s care needs and an up-to-date care plan following her discharge from hospital in June 2019.

150. The Council will also pay Miss X £500 in recognition of the distress caused to her by this fault, as well as the additional time and trouble she was put to pursuing her concerns.
151. Within one month of my final decision, the Council and Trust will write to Miss X to apologise for:

• Their shared failure to provide Miss X with clear written information (a risk assessment and behaviour plan) in advance of her planned discharge on 26 June to allow her time to properly consider this information.

152. Within three months of my final decision statement, the Council will write to the Ombudsmen to explain what action it will take to:

• Ensure the Council has a robust CHC procedure is in place. This should provide clear guidance for staff on submitting timely information (including CHC checklists) to local Clinical Commissioning Groups as part of the CHC process. The Council should explain how it will record and monitor CHC cases to prevent unnecessary delays.
• Ensure the Council has a robust procedure in place for completing timely social care assessments, reviews and care plans in accordance with the requirements of the Care Act. The Council should explain how it will monitor and audit cases on an ongoing basis.
• Ensure the Council has a clear process in place for providing advocacy services in accordance with the requirements of the Care Act. The Council should also explain how it will ensure staff are aware of the duty to provide an advocate for someone who would otherwise have ‘substantial difficulty’ participating in the assessment or review process.
• Ensure the Council has a dispute resolution procedure in place. This should provide both staff and service users with a means to escalate cases in which there is a dispute around the level of support required.
• Ensure the Council has a clear process in place for completing financial assessments in accordance with the Care and Support (Charging and Assessment of Resources) Regulations 2014. This should provide guidance for staff on the importance of a ‘person-focused’ approach that recognises the circumstances of the individual and provides support to enable service users to participate fully in the assessment process.
• Ensure staff are appropriately trained to support service users with an Autism diagnosis.

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Final decision

153. I found fault with the care and support provided to Miss X in the community by the Council. This fault resulted in delays in the CHC assessment process and caused Miss X significant distress.
154. I also found fault by the Council and Trust with regards to the handling of Miss X’s discharge from hospital in June 2019.
155. In my view, the actions the Council and Trust have agreed to undertake represent a reasonable and proportionate remedy for the injustice caused to Miss X by this fault.
156. I found no fault by the CCG with regards to its handling of the CHC assessment process.
157. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman