Summary: The Ombudsmen have upheld Mrs G’s complaint about the way her carer’s assessments were carried out. We have not found fault with the way the Trust, Council and CCG arranged Mr H’s accommodation under s117 of the Mental Health Act or how the Trust communicated with Mrs G and Mr H about this.

The complaint

1. The complainants, whom I shall call Mrs G and Mr H, complain about the actions of Bolton Metropolitan Borough Council (the Council), Greater Manchester Mental Health NHS Foundation Trust (the Trust) and Bolton Clinical Commissioning Group (the CCG) regarding delays in arranging suitable supported accommodation for Mr H under section 117 of the Mental Health Act 1983, following his detention in hospital between January to June 2017 under section 3 of the Mental Health Act 1983.
2. Specifically, they complain that
• only two referrals were made to housing providers within three months;
• the family’s expectations were not properly managed about how long the process could take; and
• Mrs G’s views were not taken into account when assessing Mr H’s accommodation needs, which meant time was wasted preparing him for independent living and further delayed the arrangement of supported accommodation.
3. Mrs G also complains that her carer’s assessments were inadequate and failed to sufficiently support her.
4. As a result, they say Mr H’s discharge was significantly delayed due to the time taken to secure suitable accommodation for him. This meant Mr H’s liberty was restricted as he was detained longer than necessary. Mrs G says the stress has impacted negatively on her own health and affected family relationships.
5. Mrs G and Mr H are seeking an apology, service improvements and a financial remedy.

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The Ombudsmen’s role and powers

6. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
7. 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).
8. 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.
9. 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

10. I have considered information provided by Mrs G, the Trust and the Council. I have also spoken with Mrs G on the telephone. I sent a copy of my draft decision to all parties and considered the comments they made.

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What I found

11. Under the Mental Health Act 1983, when someone has a mental disorder and is putting their safety or someone else’s at risk, they can be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’. Section 3 of the Mental Health Act is for providing treatment. People discharged from section 3 will not have to pay for any aftercare they will need. This is known as section 117 aftercare.
12. Section 117 of the Mental Health Act imposes a duty on NHS clinical commissioning groups (CCGs) and council social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients detained under specific sections of the Mental Health Act (e.g. section 3).
13. Section 117 aftercare services must:
• meet a need arising from or related to the mental disorder for which the person was detained; and
• have the purpose of reducing the risk of the person’s mental condition worsening and the person returning to hospital for treatment for the mental disorder.
14. The “Mental Health Act 1983: Code of Practice” (the Code) is statutory guidance. It says that section 117 aftercare can include supported accommodation and continues as long as the person needs these services.
15. The Code states that ‘the planning of after-care needs to start as soon as the patient is admitted to hospital. CCGs and local authorities should take reasonable steps to identify appropriate after-care services for patients in good time for their eventual discharge from hospital.’
16. “Care and support statutory guidance” (CSSG) is guidance on the Care Act 2014. It says that where an individual provides or intends to provide care for another adult and it appears the carer may have any needs for support, local authorities must carry out a carer’s assessment. Carers’ assessments must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself. This includes the practical and emotional support the carer provides to the adult. Where the local authority is carrying out a carer’s assessment, it must include in its assessment a consideration of the carer’s potential future needs for support.
17. The CSSG says the carer’s assessment must also consider the outcomes that the carer wants to achieve in their daily life, their activities beyond their caring responsibilities, and the impact of caring upon those activities. This includes considering the impact of caring responsibilities on a carer’s desire and ability to work and to partake in education, training or recreational activities, such as having time to themselves. This impact should be considered in both a short-term immediate sense but also the impact of caring responsibilities over a longer term, cumulative sense.
18. Further, carers with fluctuating needs may have needs which are not apparent at the time of the assessment, but may have arisen in the past and are likely to arise again in the future. Therefore, local authorities must consider an individual’s need over an appropriate period of time to ensure that all of their needs have been accounted for when the eligibility is being determined.

What happened

19. Mr H is a young adult with a diagnosis of Asperger’s Syndrome. In January 2017, following a suspected psychotic episode, Mr H was admitted to hospital under section 2 of the Mental Health Act 1983. In early February 2017, following a mental health assessment, Mr H was further detained under section 3 of the Mental Health Act 1983.
20. Planning began for Mr H to be discharged by the end of February 2017 with the view to him initially returning to his flat. The Trust considered he would need to complete at least three nights home leave before discharge and further assessments would need to be completed to confirm whether this option was suitable. The possibility of a rehabilitation placement was also being considered at that time. Mr H frequently expressed his wish to return home where he had previously been living on his own, however Mrs G, Mr H’s mother, had raised concerns about his ability to live independently.
21. In mid-February 2017, Mr H returned to his flat for a trial two day leave from hospital, with a planned visit from an Occupational Therapist to assist with discharge planning. However, Mr H felt unable to cope and asked to return to the hospital ward the next day.
22. Shortly after, it was agreed that Mr H would require 24 hour supported accommodation following his discharge and this would be funded under section 117 of the Mental Health Act 1983. Mrs G expressed a strong preference for Mr H to be located in an area close to her. Mrs G’s first carer’s assessment was also completed at this time.
23. Throughout late February and March 2017, Mr H’s care co-ordinator contacted five different supported accommodation providers about assessing Mr H. For a variety of reasons that I shall explore later, these were all unsuccessful.
24. In March 2017, Mrs G submitted a formal complaint to the Trust about delays sourcing supported accommodation for Mr H and lack of support for herself as a carer. The Trust replied on 27 April 2017, outlining the steps that had been taken to find suitable accommodation for Mr H and its view that Mrs G had been offered support.
25. Mr H’s accommodation was considered by the Joint Allocation Panel in March and April 2017. The matter was also discussed at monthly meetings for the Health and Social Care Resources group. Mrs G was present at four ward rounds where accommodation options were discussed.
26. In April 2017, Mr H’s care co-ordinator asked a supported accommodation provider (the Provider) who had previously declined Mr H to re-consider assessing him. This was on the understanding that a new site was opening in an area which Mr H could transfer to at a later date, to be closer to Mrs G. In the meantime, the Provider and the Council agreed to jointly fund taxi journeys to enable Mr H to regularly visit Mrs G and the family pet dog.
27. In April 2017, following Ms G’s dissatisfaction with the first carer’s assessment, a second carer’s assessment was completed for Mrs G.
28. On 17 May 2017, Mr H was discharged from section 3, although he remained in hospital while his supported accommodation was arranged.
29. In early June 2017, Mr H visited the Provider. Section 117 aftercare funding was in place by this time, however the flat still needed carpeting and white goods therefore Mr H could not move in until the outstanding work was completed.
30. Mr H was discharged to the Provider on 22 June 2017.
31. In December 2017, Mrs G’s third carer’s assessment took place.

Analysis

Arrangement of accommodation under s117 Mental Health Act

32. Mrs G complains that only two referrals were made to accommodation providers within three months. Having reviewed the documents, it shows that five providers were contacted over a period of around seven weeks between late February 2017 and mid-April 2017, when the Provider agreed to re-assess Mr H. Six other local providers were also considered but no referrals were made as there were no suitable local provisions available.
33. Unfortunately, the majority of these referrals were unsuccessful. The main reasons for providers declining to offer a placement to Mr H, both pre and post assessment, was because they felt unable to meet Mr H’s complex needs. Two potential specialist placements would have taken 6-8 months to set up and one referral was discontinued due to concerns over that provider. There was also a limit to the number of providers who could be approached within a limited geographical area as it was important to place Mr H within travelling distance of Mrs G’s home.
34. Once options started to appear exhausted, the care co-ordinator contacted the Provider again and asked them to reconsider assessing Mr H. It took a number of weeks for the Provider to complete their assessment, however the records show that the Trust’s staff chased up the Provider several times during this period.
35. It took from 13 April 2017, when the Provider formally agreed to reassess Mr H, until 22 June 2017 for him to be discharged. The Trust has explained that it and the CCG took steps outside the normal process to expedite matters and ensure Mr H’s section 117 funding was in place. Even if parts of the process could have occurred faster during this period, ultimately Mr H could not move into the accommodation until the decorating work and furnishing was completed, a matter outside of the control of the organisations complained about.
36. It is understandable that Mr H and Mrs G were frustrated by the time taken to secure appropriate accommodation. However, I have found no fault in the actions of the Trust, who had made substantial efforts to find a placement for Mr H.
37. Further I have found no fault in the actions of the Council or the CCG. The s117 funding was arranged and in place prior to Mr H’s flat with the Provider being ready for his discharge.

Communication

38. Having reviewed the records, I have not found fault with the way the Trust communicated with Mrs G.
39. Mrs G complains that the Trust did not properly manage her and Mr H’s expectations about how long it would take to find him a placement and did not properly explain the process to her, for example she had thought he would be given a choice about where he wanted to live.
40. It is understandable that Mrs G found the situation frustrating, however the Trust could not have predicted how many providers would decline Mr H because they could not meet his complex needs or that referrals to one provider would be suspended due to other circumstances. The records show that the Trust updated Mrs G about new referrals and options as they arose.
41. While a person would usually have a choice about where they wanted to live for accommodation arranged under s117 of the Mental Health Act, in these circumstances there were extremely limited options for Mr H due to the number of providers who declined to offer Mr H a placement and the requirement to be within travelling distance of Mrs G’s home. Again, while this was disappointing for Mrs G, this was outside of the Trust’s control and it could not have known in advance that choices for Mr H would become so limited.

Unnecessary preparation for independent living and ignoring Mrs G’s views

42. The Trust’s records demonstrate that Mrs G’s concerns about Mr H’s ability to live independently had been noted, discussed and considered when discharge options were being discussed. However, Mrs G’s views also needed to be balanced with Mr H’s wishes, who was strongly indicating his wish to return to his flat at the time. There were a number of requirements that needed to be fulfilled before he would have been discharged home, including at least three successful home leaves and an assessment from an Occupational Therapist.
43. At the time of the unsuccessful home leave in mid-February 2017, the Trust has confirmed that no final decision had been made about Mr H’s discharge location. As well as returning to independent living, other options still being considered at the time included a locked rehabilitation unit, a specialist autism placement and 24 hour supported accommodation. I have found no fault in the decision to test whether returning to Mr H’s flat was a viable option, in line with his wishes.
44. Further, I have seen nothing to suggest that exploring independent living caused any delay to Mr H’s discharge. As noted above, other options were still being considered and, once Mr H’s leave was unsuccessful, referrals to supported living providers were made promptly.

Carer’s assessments

45. Neither the Trust nor the Council have retained a copy of Mrs G’s first carer’s assessment, which was completed in February 2017. Mrs G has confirmed that she also no longer has a copy. As a result, I have been unable to take a view on this assessment.
46. The failure to maintain proper records is fault by both the Trust and the Council. Mrs G will undoubtedly be disappointed that the Ombudsmen is unable to review this assessment. However, had this assessment been found to be flawed, the Ombudsmen would have asked the Council to re-assess Mrs G. I note that a further assessment was already carried out in April 2017, owing to Mrs G’s dissatisfaction with the first assessment. Therefore, I have found no outstanding injustice to Mrs G.
47. Mrs G’s second carer’s assessment, completed in April 2017, resulted in Mrs G receiving a one-off payment of £150, being offered support via liaison with Mr H’s mental health team and being signposted to local carer support options.
48. Mrs G’s third carer’s assessment, completed in December 2017, noted that work was required to help increase Mr H’s independence from Mrs G, such as support to complete his own laundry and food shopping. Further, leave arrangements were to be reviewed as Mr H was visiting Mrs G every weekend.
49. A further assessment in June 2018 noted similar outcomes to the December 2017 assessment and also awarded Mrs G a one-off payment of £300.
50. During the course of this investigation, the Council told me that the outcomes of the assessments were different because Mrs G was relatively new to the Mental Health Team at the time of the April 2017 assessment and Mr H was an inpatient, meaning that most of Mr H’s practical needs were being met by the inpatient unit and this was reflected in the assessment. They said that, by later assessments, the assessor was more aware of the impact of Mrs G’s caring responsibilities and noted that while Mr H lived in supported accommodation, he spent a lot of time at Mrs G’s house.
51. As noted above, the “Care and support statutory guidance” (CSSG) outlines that ‘carers’ assessments must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself… Where the local authority is carrying out a carer’s assessment, it must include in its assessment a consideration of the carer’s potential future needs for support…This impact should be considered in both a short-term immediate sense but also the impact of caring responsibilities over a longer term, cumulative sense.’ The CSSG also states that carers’ needs which may have arisen in the past and are likely to arise in the future need to be considered.
52. While the April 2017 considered Mrs G’s need for her own time and noted that this was important for Mrs G’s health, no steps were put in place which would have directly addressed this issue. The outcomes provided Mrs G with options for emotional support, but no apparent practical support which would help decrease Mr H’s dependence on his mother.
53. The outcome of this assessment, and the Council’s subsequent explanation, only focused on the immediate circumstances. Mr H’s hospital admission was clearly intended to be short term, with discharge being discussed for as early as the end of February 2017 originally. The assessment should have taken a holistic approach and also considered what Mrs G’s caring commitments would be after Mr H’s discharge. Failure to consider Mrs G’s future needs is fault and not in line with the CSSG.
54. The later assessments consider this issue more fully and the outcomes outline practical steps to support Mr H in becoming more independent with domestic chores and also a suggestion to review the weekend leave arrangements. However, the Council has not provided any evidence to demonstrate that these outcomes were followed through and put in place. This is supported by the fact that the same outcome is suggested again in the June 2018 assessment, over 6 months later. This too is fault by the Council.
55. These failings mean Mrs G has potentially lost the opportunity to have some respite from her caring responsibilities. However, I cannot say, even on the balance of probabilities, that Mrs G has missed out on a definitive amount of respite as this would have depended on a number of unknown factors, including how Mr H may have responded to any work designed to increase his independence.

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Recommendations

56. The Council is responsible for all actions carried out under the Care Act 2014, even where another organisation, such as the Trust, has carried them out on the Council’s behalf. The Council is also responsible for ensuring carers receive the support as set out in their support plans.
57. I recommend that the Council, within one month of my final decision,
• Apologises to Mrs G for failings relating to her carer’s assessments
• Ensure that any support not already provided is put in place.
58. I further recommend that, within three months of my final decision, the Council reviews its processes to ensure it (and all organisations acting on its behalf):
• maintains records properly;
• carries out carers’ assessments in accordance with the Care Act 2014/CSSG; and
59. The Council should write to Ombudsmen to provide evidence it has completed the recommendations.

Investigator’s final decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman