Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they will meet these needs.

The complaint

1. The complainant, who I will call Mr X, is complaining about the care and support provided to him by Calderdale Metropolitan Borough Council (the Council), South West Yorkshire Partnership NHS Foundation Trust (the Trust) and NHS West Yorkshire Integrated Commissioning Board (the ICB).
2. Mr X has provided the Ombudsmen with a detailed summary of complaint. In the interests of brevity, I have not set this out in full in this section of this decision statement. However, I have commented on each of the issues raised in Mr X’s summary in the ‘analysis’ section of the statement.
3. In summary, Mr X makes the following complaints.

• Local health and social care services are not working effectively together to assess, and meet, his needs in a holistic way.
• There are inadequate services available in the local area for people with an Autism Spectrum (ASD) diagnosis. Mr X says this means he can only receive specialist support out of area.
• His support team is unreliable and has not given him the necessary support to access the assistance he requires.
• Health and social care professionals have communicated poorly with him, providing unclear or ambiguous information.
• The Council changed his care charge without properly involving him in this process.
• The Council failed to properly address his complaints and did not provide him with advocacy support to enable him to access the complaints process.

4. Mr X says these failings have caused him significant distress and anxiety and put him to unnecessary time and trouble.
5. Mr X would like the Council, Trust and ICB to take responsibility for the failings in his care. He would also like to see improvements in his care to ensure he can access the support he requires.

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What I have investigated

6. Mr X’s complaint is a complex one that spans events taking place over several years. My investigation has focused predominantly on the care provided to Mr X between and April 2017 and May 2020.
7. However, I am aware that many of these issues remain the subject of ongoing correspondence between Mr X and the organisations supporting him.
8. For this reason, and to provide context to the complaint, it has been necessary to refer to events occurring both before and after this period.

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The Ombudsmen’s role and powers

9. 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).
10. 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.
11. 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

12. In reaching making my final decision, I considered information provided by Mr X and discussed the complaint with him, his partner and his advocate. I also considered comments and documentation provided by the Council, Trust and ICB. This included relevant health and social care records. Furthermore, I sought independent clinical advice from a consultant psychiatrist.
13. I invited comments from all parties on my draft decision statement and carefully considered the responses I received.

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What I found

Relevant legislation and guidance

Autism – National strategy

14. 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.
15. Asperger’s Syndrome is a form of autism where the person usually has average or above average intelligence. People with Asperger’s Syndrome will not usually have a learning disability but may still experience challenges such as specific learning difficulties, anxiety or other conditions.
16. The Autism Act 2009 placed a duty on the government to publish a strategy for meeting the needs of adults in England with autistic spectrum conditions. Its aim was to improve the provision of relevant services to such adults by local authorities and NHS bodies.
17. The Department of Health (DoH) published the first autism strategy in 2010. This was entitled Fulfilling and Rewarding Lives (2010). The strategy set out that adults with autism should qualify for an assessment of need from social services. It highlighted the duty and importance of making reasonable adjustments to meet individual needs. The strategy also recommended appropriate training for staff working with people with an autism diagnosis.
18. In December 2010, the DoH issued statutory guidance for local authorities and NHS bodies to support the implementation of the strategy.
19. The government reviewed and updated the strategy in April 2014 with the publication of Think Autism (2014). This reiterated the importance of health and care professionals having a good understanding of autism so they could communicate effectively and adapt services accordingly.
20. In March 2015, the DoH published revised statutory guidance to accompany Think Autism. This was called Statutory guidance for Local Authorities and NHS organisations to support the implementation of the Adult Autism Strategy (2015).
21. This guidance reiterates the importance of ensuring that people with autism who may need community services are assessed by appropriately trained staff. The guidance emphasises that “[t]his is particularly important for some people with autism, including those with Asperger syndrome, who may face very significant challenges in their everyday lives”.

Autism – Local strategy

22. In 2016, the Council produced a local autism strategy in consultation with various agencies (including the Trust and ICB) and local people with autism. This is the Calderdale Adult Autism Strategy (2016). This reflects the Think Autism national strategy in terms of the importance of effective diagnosis and needs assessment for people with autism. It also makes clear the need to make reasonable adjustments for people with autism to allow them to access information and services.
23. In 2019, the Council began to develop a new all-age autism strategy. However, the council suspended this work due to the emerging pandemic.

Autism – Ask Listen Do

24. In 2018, NHS England launched a project entitled Ask Listen Do. This project aims to make it easier for children and adults with a learning disability, autism or both to raise comments and complaints.
25. The project has a series of key principles for public organisations working with people with learning disabilities and/or autism. These include:

• The organisation makes sure the person, their family or advocate know how to give feedback, raise a concern and make a complaint;
• The organisation and staff have the skills to listen and understand what it feels like for the person; and
• The organisation learns from the feedback, concern or complaint and changes things so the service can improve.

Care Act 2014

26. The Care Act 2014 (the Care Act) places a duty on local authorities to promote the wellbeing of people in their area.
27. The Care Act is accompanied by the Care and Support Statutory Guidance (the statutory guidance). This provides detailed guidance for local authorities on how to apply the Care Act in practice.
28. Sections 9 and 10 of the Care Act require local authorities to carry out an assessment of any adult who appears to need care and support. The assessment must consider the adult’s needs and how they impact on that person’s wellbeing and the outcomes they want to achieve. It must involve the individual and where appropriate their carer or any other person they might want to be involved.
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. There is no definition of what is considered ‘appropriate and reasonable’. However, local authorities should let the person know of the proposed timescale for conducting the assessment and keep them informed throughout the assessment process.
30. Where more than one agency is assessing a person, they should all work closely together to prevent that person having to undergo multiple assessments at different times, which can be distressing and confusing. Where a person has both health and care and support needs, local authorities and the NHS should work together effectively to deliver a high quality, coordinated assessment.
31. Where a local authority determines that a person has eligible needs, it must meet these needs.
32. Section 14 of the Care Act gives local authorities the power to charge for care and support, except in limited circumstances where they are required to provide it free of charge.
33. Section 17 of the Care Act sets out that, if a local authority decides to charge a person for care and support, it must complete a financial assessment to determine what that person can afford to contribute towards his or her care.
34. The statutory guidance emphasises the importance of the person’s participation in their own the assessment and care planning process. If a local authority finds a person has substantial difficulty engaging in these processes, it must identify someone appropriate to support and represent that person. The local authority must appoint an independent advocate if the person has no friends or family who are willing or able to provide that support.

Key facts

35. In 2013, Mr X received diagnoses of ASD and Attention Deficit Hyperactivity Disorder (ADHD) from a neurodevelopmental service in Sheffield. Mr X requires clear and consistent communication from the professionals involved in his care. He also needs support to coordinate his care and with administrative tasks.
36. Mr X has an allocated key worker. He is in receipt of Direct Payments from the Council which he uses to pay for various support services. These include a personal assistant and respite care. Mr X also pays for a specialist ASD counsellor in Bradford.
37. In 2015, Mr X was referred to the Trust’s ADHD service in Wakefield for further assessment and treatment. The service disagreed with the diagnosis of ADHD and concluded Mr X was instead suffering from generalised anxiety disorder, along with his ASD diagnosis.
38. The Trust allocated Mr X a care coordinator from the local Community Mental Health Team (CMHT). He also received support from the Trust’s Intensive Home-Based Treatment Team (IHBTT). This is a team that supports service users in crisis on a short-term basis.
39. In November 2016, Mr X’s case was allocated to a different care coordinator at the Trust when his initial care coordinator was off work on long-term sick leave.
40. Mr X contacted the Council in May 2017 to request a reassessment of his social care needs. However, Mr X’s social worker declined to complete a reassessment on the basis that his needs had not changed.
41. In February 2017, the Trust decided Mr X’s symptoms of low mood and anxiety were instead related to his ASD and ADHD diagnoses. It referred him to the neurodevelopmental service in Sheffield for further assessment and treatment.
42. The Trust discharged Mr X from the CMHT in June 2017. The Trust said it was not commissioned to provide care to service users with a primary diagnosis of ASD and without significant secondary mental health issues.
43. Later that month, the neurodevelopmental service in Sheffield advised Mr X that he would need a reassessment as it had been several years since his initial assessment.
44. Mr X remained in regular contact with the IHBTT and his social worker throughout this period regarding his ongoing care and support needs.
45. In April 2018, the Council completed a financial assessment for Mr X that determined he would need to contribute £28.04 per week towards his care.
46. In July 2018, Mr X attended the Trust’s Improving Access to Psychological Therapies (IAPT) service for a screening assessment. However, the IAPT service said it would be unable to support Mr X due to his primary ASD diagnosis.
47. The Council notified Mr X in November 2018 that his weekly care contribution would increase to £52.80 per week.
48. In January 2019, Mr X met with his social worker to review his care and support plan. The social worker shared a draft version of the revised plan with Mr X and the other agencies involved in his care later that month.
49. During that month, the consultant psychiatrist who had been working with Mr X left the neurodevelopmental service in Sheffield. The service confirmed it had no immediate plans to replace him. This meant the ADHD assessment did not proceed as planned.
50. In April 2019, Mr X’s social worker identified an alternative private ADHD service in Manchester that could work with Mr X. Mr X’s GP applied for funding for the service through the ICB’s Individual Funding Request (IFR) process. However, the IFR panel declined the funding request because the service in Manchester did not hold an NHS contract.
51. In November 2019, the ICB’s IFR panel approved funding for Mr X for an alternative neurodevelopmental service in Wilmslow.
52. Mr X met with representatives from the Council and ICB, along with other supporting agencies in December 2019 to discuss his health needs. The meeting agreed treatment for Mr X’s ADHD would be a priority.
53. At a further meeting in early January 2020, Mr X’s social worker advised him that she would be leaving her role. The Council allocated Mr X’s case to another social worker.
54. Mr X attended a follow-up meeting later that month with representatives of the health and social care agencies supporting him. The meeting heard the neurodevelopmental service in Wilmslow had prescribed medication to treat Mr X’s ADHD. Mr X was initially anxious about taking the medication. Nevertheless, he agreed to trial a two-week trial period in March with support from his care team.
55. However, the introduction of national lockdown restrictions due to the COVID-19 pandemic meant the trial stalled. Mr X was concerned that he did not have enough clinical and social care support in place for the trial to proceed safely.
56. In March 2020, Mr X, his NHS advocate, and his new social worker agreed an action plan to support him during the national lockdown. The Council also suspended Mr X’s care contributions temporarily as he was unable to receive direct support due to the restrictions.
57. In the following months, Mr X continued to contact services to report concerns about his care and support.
58. In February 2021, Mr X referred himself to the Trust’s Single Point of Access for further consideration of his mental health needs. However, a consultant psychiatrist who reviewed Mr X’s case noted that he had a comprehensive care plan in place to meet his needs. The consultant concluded there was no further role for secondary mental health services.

Analysis

Support planning

59. Mr X says he requires a holistic health and social care assessment and care plan and a jointly funded package of care to meet his needs. Mr X says his last full support plan was signed off in 2016 and that he remains without care to meet his mental health needs.
60. To properly consider this issue, it is important first to understand the local commissioning arrangements. Since April 2018, the ICB has commissioned the Trust to provide an ASD assessment and diagnosis service for adults. This includes two follow-up appointments for people who receive an ASD diagnosis.
61. The ICB does not commission any further ASD intervention services locally for adults with an ASD diagnosis, but without a learning disability, like Mr X. Furthermore, the ICB does not commission ADHD diagnosis or intervention services locally. Rather, adults seeking these services are required make applications via the ICB’s IFR process. The services are then provided out-of-area. This means there is a gap in locally commissioned services for people with Mr X’s diagnoses. The evidence I have seen suggests this makes it more difficult for Mr X to access appropriate support.
62. The case records show Mr X’s ASD and ADHD diagnoses have a significant impact on all areas of his everyday life. In his complaint correspondence, Mr X emphasises his need for a care plan that incorporates all his physical health, mental health and social care needs. Mr X needs clear direction as to how these needs will be met, and by whom.
63. The case records show Mr X has been seeking mental health support from the Trust since his discharge from the CMHT in 2017. However, the Trust maintains that it is not commissioned to provide services to people with Mr X’s needs. This has yet to be resolved..
64. Between 2015 and 2017, Mr X was under the care of the Trust’s local CMHT and had an allocated care coordinator. However, in April 2017, the care coordinator told Mr X that the CMHT could no longer support him as he had a primary diagnosis of ASD. She explained her plan was to support Mr X’s transition to the neurodevelopmental service in Sheffield for continuing support with his ASD and further assessment for ADHD.
65. The Trust wrote to Mr X to confirm this in June 2017. The Trust explained that “Calderdale Community Mental Health teams are currently not commissioned to work with service users who have a primary diagnosis of Autistic Spectrum Conditions”.
66. I have significant concerns about the Trust’s handling of Mr X’s discharge. The Royal College of Psychiatrists produces guidance entitled Standards for Community-Based Mental Health Services. This guidance underlines the importance of involving the service user in discharge planning. The guidance also says a discharge letter should be sent to the service user including “the plan for on-going care in the community/aftercare arrangements (and) crisis and contingency arrangements.”
67. In Mr X’s case, the clinical records suggest the Trust had already decided to discharge him by the time the care coordinator discussed this with him in April 2017. I found no evidence to suggest the Trust actively involved Mr X in the planning for his discharge. Despite the complexity of Mr X’s care needs, the Trust did not convene a multidisciplinary team meeting to discuss the proposed discharge, as would have been good practice. The discharge letter of June 2017 contained no details of aftercare arrangements or contingency plans. This was fault by the Trust.
68. In addition, I found no evidence to suggest the Trust made any reasonable adjustments to account for the communication difficulties Mr X experiences as a result of his ASD diagnosis. This is reflected in the clinical records, which show Mr X did not properly understand the decision to discharge him.
69. The guidance accompanying the Think Autism strategy emphasises the importance of ensuring that people with autism who may need community services are assessed by appropriately trained staff. The guidance says that “[t]his is particularly important for some people with autism, including those with Asperger syndrome, who may face very significant challenges in their everyday lives”.
70. Furthermore, Section 4.5 of the same guidance says that “[h]ealth and social care services need to recognise the impact that autism has on an individual’s life and consider this alongside any additional needs such as a learning disability or mental health condition ensuring there is a personalised approach with targeted support.”
71. The Trust failed to have proper regard for Mr X’s mental health needs in the specific context of his ASD diagnosis. The Trust was content to say that Mr X did not have an acute mental illness of the type that might typically require support from secondary mental health services. This does not reflect a personalised approach to Mr X’s care. Again, this was fault by the Trust.
72. In my view, this suggests a lack of understanding of autism among the Trust staff who dealt with Mr X. Indeed, I note from the Trust’s complaint response of May 2018 that staff within community mental health services are not specially trained in ASD (though some have completed basic autism awareness training).
73. The case records show Mr X was extremely distressed by the Trust’s decision to discharge him. Mr X does not have a learning disability and so was not suitable for learning disability services. However, he was unable to access mental health services for support.
74. The situation was made worse as the transfer of Mr X’s care to the neurodevelopmental service in Sheffield did not proceed smoothly. That service concluded Mr X would need a further assessment as its original ADHD diagnosis had been made in 2013 and subsequently disputed by the Trust’s ADHD clinic in Wakefield in 2015. When the consultant psychiatrist who had been working with Mr X in Sheffield left that service in 2019 and was not replaced, the assessment did not proceed.
75. In 2018, the Council began working with Mr X on a new care and support plan. This work continued until November 2019. The evidence suggests this was a long and involved process due to Mr X’s complex care needs. The process was further complicated due to Mr X’s heightened anxiety and his engagement in various complaints that also demanded his time and attention. Nevertheless, the case records show Council officers attempted to keep Mr X informed about their progress.
76. Mr X’s social worker, in consultation with Mr X and his support team, produced a thorough care and support plan. This clearly set out Mr X’s care needs against each of the care domains identified in the Care and Support Statutory Guidance and explained how these would be met in the community.
77. However, although the care plan recognised that Mr X experienced high levels of anxiety and distress, it included minimal mental health support to address this. This was due primarily to the Trust’s decision to discharge Mr X from secondary mental health services because of his primary ASD diagnosis.
78. As noted in paragraphs 56 and 57, there were limited services available locally to support Mr X with his ASD and ADHD diagnoses and associated anxiety. Mr X was instead required to seek support from services in Sheffield and Bradford. This meant he had to travel regularly and engage with several different agencies and professionals. Mr X’s diagnoses make this particularly challenging for him.
79. It is important to recognise that the Council did extensive work to produce a thorough care and support plan for Mr X. This included extensive correspondence with Mr X and his representatives regarding his care needs.
80. Nevertheless, the care plan did not contain any meaningful mental health support. This, along with the obstacles Mr X encountered securing appropriate provision for his ASD and ADHD diagnoses, meant the care plan was limited in its effectiveness. The evidence I have seen suggests the Council, Trust and ICB failed to work together to deliver a “high quality, coordinated assessment” as required by the statutory guidance.
81. The failure to coordinate care to meet Mr X’s health and social care needs caused him significant distress. The impact on Mr X is reflected in the fact that he regularly contacts out of hours, crisis, and emergency services for support. This is not an adequate substitute for robust mental health care and places pressure on services that are unable to provide meaningful support.
82. In summary, I recognise the complexity of Mr X’s needs and the work already undertaken to meet them. However, the evidence I have seen suggests Mr X still does not have a care plan in place that fully sets out his health and social care needs and how these will be met. The Council, Trust and ICB share responsibility for this fault.

Delivery of support

Commissioning

83. Mr X says his needs are not being met as the specialist support he requires is only available out of area. Furthermore, Mr X complains there is no care pathway in the area for adults with a diagnosis of Autism but not an accompanying learning disability.
84. I have commented in paragraphs 56 and 57 above about the local commissioning situation and will not produce those comments here. The Ombudsmen cannot decide what services an organisation should commission. Nevertheless, the records make clear there was a lack of dedicated mental health support available for Mr X.

Communication

85. Mr X complains that health and social care services are not working together effectively to meet his needs. Mr X says this means he is signposted between services without proper coordination.
86. The evidence suggests communication can be very challenging for both Mr X and the professionals supporting him. Mr X has a documented need for clear and unambiguous communication. I found many examples in the case records that show professionals made appropriate efforts to maintain clear communication with Mr X. Nevertheless, examples like those provided below show they were not always successful.
87. In October 2018, Mr X’s social worker attempted to refer him to the Council’s Adult Occupational Therapy (OT) and Speech and Language Therapy (SALT) service for input. The service would not accept the referral due to Mr X’s ASD diagnosis. The service signposted Mr X to the learning disability team instead. However, this service would also not accept a referral as Mr X does not have a learning disability. This was understandably distressing for Mr X, who was left without OT or SALT input.
88. A further example occurred in 2019 when Mr X was seeking funding for alternative ADHD support.
89. In January 2019, the consultant responsible for Mr X’s care at the Sheffield neurodevelopmental service, left the service. This meant Mr X needed to seek alternative support.
90. In May 2019, Mr X’s GP applied to the ICB’s IFR panel for funding for a private ADHD service in Manchester. This was to confirm his diagnosis and secure treatment. However, the IFR panel rejected the application because the service did not hold an NHS contract.
91. When Mr X’s NHS complaints advocate challenged the decision, she was advised by the ICB that Mr X already had a confirmed diagnosis of ADHD. This contradicted what Mr X had previously been told by the Sheffield neurodevelopmental service in 2017.
92. It was not until November 2019 that the ICB approved funding for Mr X to attend an alternative ADHD service in Wilmslow.
93. Similar confusion arose with regards to the possibility of a Care and Treatment Review (CTR). This is an NHS-led process intended to improve the care provided to people with learning disabilities or autism. Its main aim is to reduce inpatient hospital admissions for people with these diagnoses.
94. In November 2019, Mr X spoke with an officer at NHS England who advised him that he would benefit from a CTR. Mr X’s social worker subsequently arranged a meeting with the ICB to explain the CTR process to him. At this meeting, all present agreed a CTR would not be helpful for Mr X.
95. I understand the ICB ultimately did arrange a CTR in October 2020 at Mr X’s request. This suggests Mr X remained confused about the purpose of the CTR. The CTR proved limited in its effectiveness.
96. Mr X has contributed at times to these wider communication problems. This is because he regularly contacts numerous different agencies and professionals to secure the support he needs. This can make it very difficult for those professionals to provide clear and consistent information.
97. This was evidently a very challenging situation and I accept the agencies involved in Mr X’s care did not always successfully meet his need for clear communication. However, the case records suggest they generally did so. I find no fault on this point, therefore.
98. However, in my view, the lack of a comprehensive care plan involving clear input from all relevant health and social agencies has contributed to the communication issues in this case. As a result, there remains a lack of clarity around Mr X’s needs and how these will be met. I have already made a finding of fault on this point in the ‘support planning’ section of this decision statement.

Support team reliability

99. Mr X raises concerns about the reliability of his support team. He says staff involved in his care regularly commit to completing actions, but then either do not do so or fail to let him know they have completed the agreed action.
100. To consider this issue, it is important to first consider the support Mr X has in place. The complexity of Mr X’s care needs is such that a significant number of people and organisations have been involved with supporting him.
101. In late 2017, the Council allocated Mr X a social worker. Essentially, this officer acts as Mr X’s care coordinator. This involves (among other things) care planning, overseeing support, and arranging meetings and referrals.
102. Mr X also uses his Direct Payments to employ various personal assistants. Over the years, these personal assistants have fulfilled different roles in Mr X’s care. In some cases, they support Mr X with activities of daily living, such as accessing the community and shopping. Other assistants offer limited administrative support.
103. In addition, Mr X sometimes receives support from voluntary organisations, such as specialist autism charities or Care Act advocacy services. He also has a dedicated NHS complaints advocate.
104. The evidence I have seen suggests it has not always been possible to maintain continuity in Mr X’s support. This is often unavoidable, such as when the Council had to reallocate Mr X’s case in January 2020 when his social worker left the service. On another occasion, one of Mr X’s personal assistants had to withdraw her services as the demands of supporting him were affecting her own health.
105. Situations like those described above cause further problems for Mr X given his complex care and communication needs. I accept this means there have been occasions when professionals have agreed to carry out an action but have then been unable to do so. This is understandably frustrating for Mr X.
106. It is important to recognise that the people supporting Mr X have worked extensively to be responsive to his needs. Nevertheless, Mr X continues to experience difficulties obtaining the level of support he requires.
107. The most significant omission, in my view, is the lack of meaningful mental health support. I have commented on this above.
108. I also have concerns about the problems Mr X experiences when using his Direct Payments to secure support. The case records, including the care and support plan of 2019, show Mr X requires ongoing support to access his care. In addition to the more general care coordination role fulfilled by his social worker, Mr X needs:

• support with activities of daily living (such as shopping and preparing meals);
• dedicated administrative support to help Mr X with correspondence relating to his care (such as accessing benefits and the financial assessment process); and
• advocacy support to help him bring concerns and complaints about his social care to the Council.

109. Mr X continues to find it difficult to secure this support on a consistent basis using his Direct Payments. The evidence I have seen suggests Mr X finds this process very challenging as he is required to interact with several different agencies and support workers.
110. I note this was discussed at a meeting in December 2019. Mr X was present, along with his support team and representatives from the ICB and Council. Mr X said he needed support from someone who “would have an overview of his situation and act as a support worker, communicate on his behalf, help with complaints/advocacy, help identify his priorities.” Mr X’s social worker agreed to draft a job profile with a view to finding a provider to support him via his Direct Payments.
111. When this subject was discussed again at a meeting in January 2020, the Council had been unable to identify a suitable provider. The records suggest this work was subsequently disrupted by the emerging pandemic and national lockdown.
112. The Council has a duty under the Care Act 2014 to support Mr X to engage with the assessment and care planning process. This is supplemented by the Council’s responsibility under national and local autism strategies to provide a service that is accessible to someone with Mr X’s needs.
113. I acknowledge Mr X continues to use his Direct Payments to secure some support. However, he still does not have a dedicated provider that can help him effectively coordinate his care and support and provide administrative assistance.
114. This was fault by the Council and means Mr X continues to struggle to secure the support he requires.

Accessing assistance

115. Mr X says staff have not properly supported him to access assistance (such as with Personal Independence Payments and a Blue Badge application) and that he has been left to complete paperwork himself. Mr X feels the support team do not understand the communication difficulties associated with his autism.
116. In April 2018, Mr X had to reapply for his Blue Badge. Mr X discussed this with his social worker and support worker at a meeting on 19 April. The social worker noted that she would write a letter to support Mr X’s application. She provided Mr X with a letter shortly after the meeting.
117. In May, Mr X contacted his social worker again as he had been asked to provide medical evidence to support his application. She agreed to contact the Blue Badge team to see whether the medical evidence was necessary. It is unclear from the Council’s records whether she did so.
118. On 23 May, the social worker accompanied Mr X to his Blue Badge assessment. This was evidently a distressing appointment for Mr X. The assessor was unwilling to consider Mr X’s autism and would only record his physical health needs. The social worker agreed to contact the Blue Badge team with her concerns. She subsequently did so and, on 8 June, the team confirmed Mr X would be issued with a Blude Badge.
119. There are similar examples in the care notes that show Council staff were supporting Mr X to access benefits and assistance. While I recognise these processes can be distressing for Mr X, I found no fault by the Council on this point.
120. However, as I have explained above, I it remains my view that Mr X lacks the dedicated support he needs to engage effectively with his care.

Financial concerns

Care charging process

121. Mr X complains that the Council changed his care contributions with little notice and failed to support him with this process. He says he did not have an up-to-date care plan in place at the time and the assessment process did not take into account his disability related expenditure. Mr X says the Council failed to have regard for the requirements of the Care Act 2014 when completing the assessment.
122. It is important to note that the Local Government and Social Care Ombudsman (LGSCO) has already considered a complaint from Mr X about the way the Council calculated his contribution towards his care costs. LGSCO concluded, in November 2019, that the Council acted in accordance with the Care Act 2014 and accompanying statutory guidance in calculating Mr X’s contribution.
123. My consideration has instead focused on whether the Council made reasonable adjustments for Mr X in its communication with him during the assessment process.
124. Following a financial assessment in April 2018, Mr X had been contributing £28.04 per week towards his care.
125. In October 2018, the Council determined that Mr X’s care contribution would increase to £52.80 per week from 5 November. The Council informed Mr X of the increase on 1 November.
126. The Care Act 2014 gives local authorities the power to charge for services they provide or arrange. It is not in dispute that the Council was entitled to charge Mr X in this case.
127. The principle of the charging process, as set out in Section 8.2 of the statutory guidance, is that a person should not be charged more than they can afford. If a local authority decides to charge a person, it must carry out a financial assessment to determine what that person can afford to pay. The local authority also has a duty to provide information and advice at an early stage that is accessible to the person receiving it.
128. The statutory guidance gives local authorities the power, in certain circumstances, to treat a person as if a financial assessment had been carried out. To do so, the local authority must be satisfied the person can afford, and will continue to be able to afford, any charges. This is known as a ‘light-touch’ financial assessment.
129. The main circumstances in which a local authority may consider carrying out a light-touch financial assessment are set out in Section 8.23 of the statutory guidance. These include where a person has significant financial resources and does not wish to undergo a full financial assessment. They also include cases where a person is in receipt of benefits that demonstrate they would be unable to contribute towards their care. In my view, none of the circumstances set out in Section 8.23 of the statutory guidance would have applied in Mr X’s case.
130. This meant the Council was required to complete a full financial assessment to properly consider how much he could afford to contribute towards his care.
131. Mr X’s care and support plan from 2019 recognises the importance of careful planning for any proposed change in his care charge. While this care plan was not in place at the time of the increase in care charge, it is clear the team supporting Mr X were aware that he needed clear information and time to process it.
132. The Council’s records show the financial assessment team contacted Mr X’s social worker for information about his income in mid-October 2018. The records show the financial assessment team was aware there was a possibility Mr X’s care charge would increase due to a change in his benefits. However, I found no evidence to suggest the social worker, or the financial assessment team, discussed this with Mr X.
133. Indeed, the Council appears not to have made Mr X aware of the increased charge until 1 November, just four days before it was due to take effect. Mr X contacted the Council to request additional time to consider the charging information. In Mr X’s correspondence with the Council, he described himself as ‘overwhelmed’ and requested support to complete an affordability assessment.
134. Despite this, I found no evidence to suggest the Council arranged support to help Mr X complete the necessary charging paperwork. This meant Mr X was required to gather key financial information himself, without a clear idea of what was expected of him. This situation was made more difficult for Mr X because his care and support plan remained under review at that time.
135. The Council was entitled to increase Mr X’s care contributions based on its calculations. However, the case records show the Council failed to have proper regard for Mr X’s needs and did not make reasonable adjustments to allow him to participate fully in the care charging process. This was fault by the Council and caused Mr X significant distress and worry.
136. It is not possible to say whether Mr X’s care contribution would have been calculated differently even if the Council had properly supported him to access this process. It is important to note that the previous LGSCO investigation found the Council calculated Mr X’s care contribution correctly.
137. Nevertheless, I recognise this situation caused Mr X considerable distress. My correspondence with Mr X suggests the affordability of his care charges remains an area of concern for him. I have addressed this in my recommendations.

Direct Payments

138. Mr X says the Council has provided him with mixed messages around how his Direct Payments can be used.
139. The Council provides Mr X with Direct Payments. I understand the Council agreed this arrangement (rather than directly commissioned services) to allow Mr X greater choice and flexibility in selecting services to meet his complex needs. The case records suggest there are both benefits and drawbacks to this approach.
140. The key benefit is that Mr X can use his Direct Payments creatively in a way that would not necessarily be possible with a commissioned service. One example of this is that Mr X has been able to use his payments to rent a room in which he can practice his hobby. This helps Mr X to access the community.
141. However, the case records show Mr X often found it difficult to understand which services he could use his Direct Payments to pay for. There is evidence in the Council’s records to show that Mr X’s social worker regularly responded to his queries on this point.
142. This placed Council officers in a difficult position as they were unable to provide an exhaustive list of services for which Mr X could use his Direct Payments. This is because exceptional circumstances or unusual spending requests sometimes arise for which Council officers are required to seek authorisation from senior officers.
143. The care and support plan written by the social worker in 2019 recognised the importance of clarity on this issue. The plan included a guidance sheet to which Mr X could refer. I understand this included general guidance on the use of Direct Payments, along with a list of items and services Mr X could purchase using these funds.
144. In my view, the evidence shows the Council made every effort to provide Mr X with clear direction regarding his Direct Payments. While I accept Mr X sometimes found this process difficult to manage, I found no fault by the Council on this point.
145. Nevertheless, I consider it likely that improved administrative support would be helpful in reducing Mr X’s confusion in this area. This is addressed in the ‘recommendations’ section of this decision statement.

Complaint concerns

146. Mr X says the Council has failed to properly address his complaints, and complaints made on his behalf. He says there has been a lack of clarity around who will respond to his complaints and that his requests for confidentiality have been ignored. Mr X says this situation has been exacerbated by the lack of advocacy support in the area for social care complaints.
147. Local authority duties with regards to complaints are set out in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the regulations). The regulations place a duty on local authorities to deal with complaints efficiently, carry out proper investigations and inform complainants of the outcome of their complaint. The regulations also explain that complainants must receive assistance to enable them to understand the complaints procedure, or advice on where they can obtain such assistance.
148. Mr X has had long-standing concerns about his care needs and how these are being met. The case records contain prolific correspondence between Mr X and his representatives, and the professionals involved in his care.
149. The process of pursuing his concerns has evidently been very frustrating and distressing for Mr X. When he is unable to reach a dedicated point of contact (such as his social worker), Mr X often contacts other professionals to secure the support he needs. This can sometimes be professionals who are not directly involved in his care and support.
150. In addition, Mr X’s frustration has led him to make a significant number of complaints to the organisations involved with his care, as well as the Ombudsmen. This often leaves him in correspondence with several different agencies at a time regarding his complaints. This is particularly challenging for Mr X due to his complex communication needs. The case records suggest this can become overwhelming for Mr X. This in turn affects his ability to engage fully with his ongoing care and support.
151. Mr X and his representatives have submitted several formal complaints about his care in recent years. However, the evidence I have seen suggests the Council has not always treated them as such. Rather, its focus has been on resolving Mr X’s concerns informally. This is with a view to reducing Mr X’s focus on complaints and allowing him to engage with his care.
152. While I appreciate the Council is attempting to support Mr X to engage with his care, this approach has caused him considerable confusion. This is because he is left unsure as to whether, and how, his concerns will be addressed. This situation has been exacerbated as Mr X has no access to dedicated advocacy support for his social care complaints.
153. There is evidence to show that the Council has made some reasonable adjustments to enable Mr X to access the complaints process. These include its decision to allow Mr X to complain by telephone rather than in writing.
154. Nevertheless, I consider there is a lack of clarity with regards to how the Council investigates and responds to Mr X’s complaints. Furthermore, it is unclear what, if any, action the Council has taken to support Mr X in identifying an advocate to support him. This was fault by the Council. This continues to cause Mr X anxiety and distress.

Summary

155. For ease of reference, in this section I have summarised the fault I found, based on the evidence I have seen.
156. The Trust’s handling of Mr X’s discharge from secondary mental health services in 2017 was contrary to good clinical practice.
157. The Trust did not properly consider Mr X’s mental health needs in the context of his dual ASD and ADHD diagnoses.
158. The Council, Trust and ICB failed to produce a comprehensive joint care plan setting out Mr X’s health and social care needs and how these would be met.
159. The Council failed to ensure Mr X received the dedicated support he needs to engage effectively with his care.
160. The Council failed to ensure that Mr X was supported to participate fully in the financial assessment process.
161. The Council failed to provide appropriate clarity around how Mr X could raise complaints about his care and how these would be addressed. In addition, the Council failed to ensure Mr X had the necessary advocacy support to enable him to engage with the complaints process.

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Agreed actions

162. Within one month of my final decision statement, Council Trust and ICB will:

• apologise to Mr X for the impact on him of their shared failure to put appropriate care and support in place to meet his complex needs; and
• each pay Mr X £500 in recognition of the impact of this fault on him.

163. Within three months of my final decision statement:

• the Trust will carry out a further mental health assessment for Mr X. This assessment should be completed by a clinician with appropriate knowledge and experience of autism. The assessment should consider the impact of Mr X’s ASD and ADHD diagnoses on his wider mental health needs. The Trust will also ensure Mr X is properly supported to contribute to the assessment;
• the Council will work with Mr X to identify a suitable provider who can support him with his administrative and care coordination needs so that he is able to fully engage with his care and support; and
• the Council will work with Mr X and his support team to complete a further financial assessment. The Council should ensure Mr X is properly supported to engage with the assessment process.

164. Within three months of the above actions, the Council, Trust and ICB, in consultation with Mr X and his support team, will produce a comprehensive joint care and support plan. This should include:

• a detailed record of Mr X’s health and social care needs (including any assessed mental health needs) and how these needs will be met. This should also make clear how Mr X will be supported to access care and treatment for his ASD and ADHD diagnoses, as well as other community health services, including his GP;
• a clear record of the agencies and professionals involved in Mr X’s care and what support each will provide;
• a crisis and contingency plan explaining what support Mr X can access when in crisis or out of hours and how he can access this;
• clear guidance for Mr X on what items and services he can, and cannot, use his Direct Payments to procure. This should also provide Mr X with a simple and accessible process whereby he can raise queries about his Direct Payments; and
• a comprehensive communication plan setting out how Mr X can raise concerns about his care and how these will be addressed.

165. The Council, Trust and ICB will ensure there is a clear process in place for sharing relevant information about Mr X with key partner agencies (such as the NHS 111 service). This is to ensure that Mr X is provided with consistent advice and signposting.
166. The Council, Trust and ICB will also ensure that professionals involved in Mr X’s care and support are appropriately trained to support people with a dual ASD/ADHD diagnosis.
167. The Council, Trust and ICB will provide the Ombudsmen with evidence that they have completed this work.
168. It is important that the assessment and care planning process is fully collaborative and that Mr X is supported to engage with the process. I recognise this may mean that the agreed deadlines for some of the actions above will be challenging.
169. If the Council, Trust or ICB consider they will not be able to complete certain actions within the deadline, they will advise Mr X of this and explain why. They will also provide Mr X with a revised timescale for completion. In addition, they will copy this correspondence to the Ombudsmen.
170. Similarly, if Mr X requires additional time or support to engage in the assessment and care planning process, he will notify the Council, Trust and ICB of this.
171. The Ombudsmen will continue to monitor the progress of the Council, Trust and ICB against the agreed actions.

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Final decision

172. I found fault by the Council, Trust and ICB in terms of the care and support they provided to Mr X.
173. In my view, the actions these organisations have now agreed to complete represent a reasonable and proportionate remedy for the injustice Mr X has suffered because of this fault.
174. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman