Summary: Ms P complains that the Trust and Council failed to give her adequate support and care, and did not communicate well with her about what to expect from the care she did receive. The Council and Trust were not at fault regarding the support provided during the period complained of. I also found that both the Trust and Council made reasonable arrangements to communicate with Ms P about her care.

The complaint

1. Ms P complains that between August 2016 and November 2018, Lancashire Care NHS Foundation Trust (the Trust) and Lancashire County Council (the Council) failed provide her with adequate support and care. Specifically, although she had been assessed as having eligible needs, a suitable care plan to meet those needs was not put in place. She was told a review would take place but this did not happen. The communication plan to tell her what to expect regarding how and what she would be told about her care was inadequate.
2. Ms P says the lack of support and appropriate communication has had a detrimental effect on her mental and physical health. She also says having to repeatedly contact the Council and Trust to try to resolve her concerns has made the situation even more difficult and resulted in depression and suicidal thoughts.
3. Ms P would like the Trust and Council to provide the support she requires, and put in place a communication plan that lets her know what care and support she can expect.

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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 reaching this decision, I discussed the complaint with Ms P, and considered the written information she sent me. I made enquiries of the Trust and Council, and considered their comments and supporting evidence, including clinical records.
8. I also took account of relevant guidance and policies.
9. I sent Ms P, the Trust and Council a draft version of this decision and considered their comments on it.

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What I found

Relevant legislation and guidance

10. The Autism Act 2009 (the Act) required the government to publish an adult autism strategy and to issue associated statutory guidance by the end of 2010. The Act placed a duty on local authorities and NHS bodies to follow this guidance.
11. The Department of Health published the first autism strategy in March 2010: Fulfilling and Rewarding Lives. The strategy set out that adults with autism should qualify for an assessment of need from social services. In addition, it highlighted the duty and importance of making reasonable adjustments to meet individual needs. The strategy recommended training to make sure that staff understood this, and which would lead them to adapt their communication and service for the person’s needs.
12. In December 2010 the Department of Health issued statutory guidance for local authorities and NHS organisations to support the implementation of the strategy. Organisations needed to follow it unless there was good reason not to. The strategy was reviewed and updated in April 2014 with the publication of Think Autism. This reiterated the importance of health and care professionals having a good understanding of autism so they could communicate effectively and adapt services accordingly.

Care Act 2014

13. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of 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 be of the adult’s needs and how they impact on their 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.
14. Everyone whose needs are met by the Council must receive a personal budget as part of their care and support plan.
15. The Care Programme Approach (CPA) is the process by which mental health services assess a patient’s needs, plan how to meet them and ensure they are met. Under Refocusing the Care Programme Approach (Department of Health, 2008), people under CPA should have a comprehensive assessment of their health and social care needs. They should have a care coordinator; a care plan to show how their needs will be met and have the care plan reviewed by a multi‑disciplinary team (MDT) on an annual basis.

Background

16. Ms P has diagnoses of anxiety and Asperger’s syndrome. Asperger’s syndrome affects how a person communicates with others and perceives and makes sense of the world.
17. Ms P has received input from the Trust’s mental health team and the Council’s adult social care team for several years. However, she considers the Trust and Council have not provided the level of support she needs, and she has made several complaints about this over the years. She has regular contact with both organisations and communication plans are in place to manage her contact with them.
18. Ms P wants the Trust and Council to work together to produce a holistic plan for care and support, so that activities or strategies arranged by one organisation take the other into account. She says in providing care and support to her, the Trust and Council were operating separately of each other.

Previous investigations

19. The Local Government and Social Care Ombudsman (LGSCO) has previously investigated complaints from Ms P about the Council and Trust. The most recent investigation in 2016 found fault with the Council for not adhering to a communication plan, and with the Trust for failing to tell Ms P it decided not to seek funding for a type of specialist Asperger’s service.

What happened

20. In October 2016, Ms P requested reassessments from both the Council and the Trust’s Community Mental Health Team (CMHT). She explained she had recently been diagnosed with chronic fatigue syndrome (CFS) and felt that her needs had changed as a result. In November 2016, the Council arranged for a social worker from its learning disability and autism team to review Ms P’s current support plan with her. Ms P was then to meet the social worker for a reassessment, and agree a new support plan so that a care package could be put in place.
21. The reassessment identified eligible social care needs requiring 21 hours of care per week. A personal budget was made available for a care package. However, Ms P felt this amount of care was not sufficient. Communication continued between Ms P and the Council about this, and a support plan was finalised and put in place in July 2017. However, Ms P continued to consider the support offered was not adequate and in May 2018, she declined any further care. A budget remained available for Ms P. It was agreed that a social worker would review the care plan and Ms P was advised to contact the duty team if she had an urgent request for support in the meantime.
22. During this period, the Trust’s CMHT also reassessed Ms P with a view to providing psychological therapies and occupational therapy to support her in her daily activities and help with communication. The CMHT provides mental health care support from professionals in the community. This usually includes social workers, community psychiatric nurses, psychologists and psychiatrists.
23. In August 2017, the Trust undertook a Care Programme Approach (CPA) review. The CPA is used to plan a person’s mental health care and set out the support they will get. It is used when a person needs input from different agencies such as mental health teams and social workers, and involves service users and carers in assessment, care planning review and care coordination.
24. The review notes Ms P’s diagnosis of Asperger’s and anxiety. It is noted that Ms P was dissatisfied with the services being provided, including lack of support from her social worker. The Trust supported Ms P to attend an out of area assessment with a specialist autism service, which clarified Ms P’s autism diagnosis.
25. In December 2017, the Trust’s complex care and treatment team met with the occupational therapist and Ms P’s social worker to discuss care planning, care act assessment and proposed care pathway. A further CPA review took place in February 2018 at Ms P’s request.
26. In August 2018, a meeting involving practitioners from both the Trust and Council was held to discuss Ms P’s care and treatment. Ms P also attended. It is documented that the professionals involved explained they wanted to support Ms P by writing a collaborative care and communication plan. It is noted that Ms P asked for an increased care package over the 21 hours offered, and wanted practical day to day support to help her to get employment. It was noted a communication plan for weekly contact with both services would be drawn up, and that Ms P should engage with her care co-ordinator with a view to starting psychological therapy.
27. Ms P complained to the Trust and Council about a lack of support. In response, the Trust said that it felt it had offered all the services it could, and that these had been stopped because Ms P had failed to engage with them. The Trust said although psychological therapy was offered, Ms P was asked to first engage with her care coordinator for at least four appointments before the Trust would make a referral. The Trust said she had not done so and said she did not want to be contacted by CMHT. The Trust said therapy was still available to her if she would agree to be contacted by CMHT.
28. The Trust said in summary that it had provided a range of options to help support Ms P, but she did not feel these options met her needs and had not engaged with them. “The team feel that there is no active role for CMHT or any treatment pathway being followed. We believe we have offered you all the treatment options available to us.”

Needs assessment

29. When Ms P requested a reassessment of her needs following her CFS diagnosis, the Council placed her on a waiting list for reassessment as a high priority. Ms P was advised that there were a number of referrals waiting at that time and they could not give her a timescale for allocating a social worker.
30. Six weeks later, a social worker from the Council’s learning disability and autism team met Ms P to review her current social care assessment and gather information for the review. The social worker sent Ms P a copy of the current assessment in advance as a template/questions for the information she would need. In December 2016, while the support plan was being completed, the Council referred Ms P (with her agreement) to an interim support service.
31. There was then ongoing contact between Ms P and the social work team to try and resolve concerns Ms P had identified with the assessment. In April 2017, the Council sent a completed amended assessment to Ms P, and contacted her to arrange a meeting to discuss a support plan that could meet the needs identified.
32. Emails and phone calls continued between Ms P and the Council, and the social worker arranged a meeting to discuss the support plan in June 2017. It was identified that Ms P had unmet needs as she struggled to do household tasks and keep her home to a suitable standard; required support with shopping and preparing meals and snacks; personal care; help with developing and maintaining relationships; accessing the community and accessing employment. A communication plan was also set out in the needs assessment. There was an indicative budget for 21 hours of care. However it is documented that Ms P said only a live‑in carer specialising in autism, providing 24/7 care could meet her needs, and that she did not want to consider supported living.
33. The social worker said this would not be possible based on her assessed needs, but that she could apply for an additional 20 hours contingency, although this might not be approved as it would be significantly over budget. A referral was made for this request for additional hours to be considered by a panel. Ms P later said she could consider an alternative to 24/7 care as long as it was fully flexible in meeting her needs. The social worker explained that level of flexibility could be difficult to organise. The support plan was finalised and put in place in July 2017.

Analysis

34. The way the Council worked with Ms P to agree an assessment and make amendments to this, was in line with the Care Act which states the individual should be involved in their assessment. I recognise Ms P’s assessed needs were for 21 hours of care per week, and that Ms P said she required significantly more than that. However, the Council worked to manage Ms P’s expectations about the level of support that could be provided, and sought to work with her to make amendments to the assessment.
35. The Care Act guidance says “while there is no defined timescale for the completion of the care and support planning process, the plan should be completed in a timely fashion, proportionate to the needs to be met”. It is clear that it took some time (from October 2016 to July 2017) for the assessment process and support plan to be completed, but it is documented that this was because Ms P wanted amendments to the assessment and discussion of this took some time. It is also documented that there was regular contact between Ms P and the Council during this time, and that the Council sought her input. The information available shows that the Council made reasonable efforts to agree an assessment with Ms P.

Council’s Care and Support Plan

36. Ms P complains that the Council failed to produce a care and support plan that meets her needs. As noted above, the needs assessment identified a need for 21 hours care per week, and the support plan that was put in place was to meet those needs and a care package was arranged.
37. However Ms P remained dissatisfied with this. The Council agreed to do a reassessment in February 2018. In response to her concerns, in March 2018 the Council and Trust also offered Ms P a meeting to discuss the care plan, but she did not attend.
38. As noted above, in May 2018, Ms P declined any further care because she felt what she was being offered was not sufficient. She contacted the Council to say she had no support in place, and the Council agreed that a social worker would be allocated to review the support plan again. The Council also said a budget remained available for Ms P and advised her to contact the duty team if she had an urgent request for support in the meantime.
39. During the period complained of, the Council completed a support plan based on the needs identified in the assessment. I recognise that Ms P was without support for some time but that was after she declined the 21 hours’ support that was in place, as she felt it was not meeting her needs. It is documented that the Council advised her that a budget for care remained available to her during this time, and that further reassessment was offered with a different social worker to discuss how this might be taken forward. I understand Ms P has recently been allocated another new social worker, and that a new reassessment process has begun. As this is ongoing, I am not able to take a view on this at this stage.

Care and support offered by the Trust

40. In its response to Ms P’s complaint, the Trust said it had offered all the treatment options available but that Ms P had not engaged with them. In her appointment with the consultant psychiatrist, Ms P said she was struggling at home and feeling suicidal. To address this, the consultant referred her to the Trust’s acute therapy service (ATS). This is an intensive six-day support programme provided in the community, based on dialectal behaviour therapy principles.
41. In May 2018, Ms P declined to attend her ATS session. It is documented she explained this was because her mood and anxiety, as well as her CFS, meant it would be too much for her. It is documented that the Trust “discussed [with Ms P] that we were willing to problem solve how the service might be adapted in order to allow her to engage, eg attending every other day”. However, it is documented that Ms P declined this.
42. Following on from this, the Trust referred Ms P to an autism specialist, to plan how she could best access the therapy on offer. The specialist advised Ms P should attend a life skills group before accessing therapy, as this would help provide Ms P with the skills to deal with therapy, which can be challenging. Ms P was asked to first engage with her care coordinator prior to referral to the life skills group. I understand that she is in ongoing contact with the care coordinator and is on the waiting list for therapy.
43. The consultant also recommended support from a psychologist from autism services. The team discussed this with Ms P, but it is documented that she said she would not be able to engage with their requests to “develop daily activity”. However the Trust said it was willing to re-refer Ms P for this service.
44. The Trust’s response that it has made appropriate referrals and offers of therapy and support, is reasonable and based on the records provided. During the period complained of, there is evidence of numerous contacts between Ms P and the CMHT and occupational therapy team suggesting meetings to discuss her care, as well telephone calls to arrange appointments ahead of time. It is documented that Ms P was discharged from OT (where she had been referred for help with social isolation) because of lack of engagement, and that she had failed to attend three consecutive appointments. It is also recorded that she told CMHT she hadn’t responded to her care coordinator because the responses did not provide her with what she needed.
45. I understand it has since been agreed Ms P would meet her care co-ordinator regularly to agree and finalise her care plan and focus on some techniques to help her anxiety while waiting for therapy. I also understand Ms P has recently attended the ATS service.
46. Ms P provided the Ombudsmen with evidence of correspondence between herself and Trust and Council staff to demonstrate that she has engaged with services. I recognise that over the period complained of, she has had numerous email and telephone contacts with the Trust and Council. However, as noted above, there are records from both the Trust and Council show that Ms P has cancelled or not attended appointments or meetings planned to discuss her support, and so further appointments were not made.
47. Ms P complains the Council and Trust did not work together to produce a holistic care plan. She said actions were put in place without considering all of her needs together. The Care Act guidance (Care and Statutory Support Guidance 2014) says that where more than one agency is assessing a person, they should work closely together to prevent that person having to undergo a number of 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.
48. The information available shows the Trust and Council did work together to produce and review Ms P’s care plan. The Council’s needs assessment encompassed a health needs checklist included as part of the Council assessment. There is also evidence of ongoing contact and planning between the social care and mental health care teams. Both teams were present at Ms P’s CPA reviews and actions arising from these were agreed jointly. This is in line with the Department of Health CPA guidance referred to above.

Review

49. Ms P complained that her care plan was not reviewed as it should have been. During the period complained of, the records provided by the Trust show Ms P’s care plan was reviewed in August 2017, May 2018 and February 2018. The reviews involved her care coordinator, social worker and mental health practitioners. This is in line with the Department of Health CPA guidance referred to above, and I have found no fault in the Trust’s reviews of Ms P’s care plan.
50. With regard to the Council’s care planning, the records show that the Council has reviewed Ms P’s care and support plans annually. This is in line with the Care Act 2014.

Communication

51. Ms P explained that because of her diagnosis of autism, clear communication and knowing what to expect is vital. She said that the Trust and Council did not make reasonable adjustments for this.
52. Records of the Council’s contact with Ms P indicate the Council has provided her with information on what to expect, by working with her to arrange meetings and appointments at suitable times and venues, explaining who would be attending, and giving her information in advance about the types of things that would be discussed. Ms P’s support plan also documents that Ms P values support from her advocate and prefers to have information written down, and given in small chunks so she can take it on board.
53. I note that Ms P and her social worker discussed the communication plan, and agreed to arrange a call week by week. They would speak on a designated day and at the end of that call, arrange the call for the following week. They also agreed to weekly emails, but because of the social worker’s working pattern, they agreed that a second staff member would also be able to email Ms P. I understand that Ms P wanted the same person to contact her each time, but as noted above this was not always possible. The Council provided a reasonable solution to this by suggesting an additional staff member be involved in responding to Ms P when her own social worker was not available.
54. Regarding the Trust, as with the Council, it documented that Ms P prefers to receive information in advance, and there is evidence that practitioners took her autism diagnosis into account. The occupational therapist adjusted how plans and goals were set out, and the therapy service offered to make adaptations in line with her diagnosis, to enable her to attend.
55. The Trust said its referral to a specialist autism service would help support Ms P with her communication needs, including interpretation of people and situations and reciprocal interaction, and how those needs would be met. This was good practice by the Trust in supporting Ms P with communication.
56. In its response to Ms P’s complaint, the Trust said staff would make efforts to ensure communication was clear and precise, plan and agree appointments in advance, and will “endeavour to return calls promptly, however this may not be on the same day.” The Trust also said Ms P could call the duty practitioner or the out of hours crisis service if needed. The records show the Trust made reasonable efforts to communicate with Ms P and to make adjustments for her in line with her autism diagnosis.
57. Both the Council and the Trust have communication plans in place to manage contact with Ms P. The Council said it had intended to create a single communication plan in conjunction with the Trust, but Ms P did not give her consent for this, and therefore separate plans are in place.
58. The Council sent Ms P a finalised communication plan designed to “manage lines of communication between us and enable you to access our service when required”. The communication plan states that if Ms P needs urgent help, she should contact her GP or the mental health crisis services. It also set out other ways that Ms P can contact the Council. The communication plan also said that while waiting for a social worker to be allocated (which has since been done), Ms P could contact the Council’s customer access service. These arrangements are to be reviewed every six months with input from Ms P. Although Ms P is dissatisfied with this plan, it seems a reasonable approach to communicating with Ms P and clarifying what she can expect.

Summary

59. Ms P explained that she experienced a difficult time over the period complained of, and I understand she feels strongly about the level of support she should get from the Trust and Council. It is apparent that there is a gap between her assessed needs and the level of support Ms P feels she should receive and I recognise this can cause her distress.
60. However, based on the information provided, I found the Trust and Council have offered appropriate care and support, have explained why they are asking her to engage with services so she can be supported, and have communicated with her about this in a reasonable way.
61. I understand that things have moved on since Ms P made her complaint to us, and the Trust and Council have put a number of actions in place to help support Ms P with the matters she raised with us. I also understand that Ms P is engaging with these. However as these are ongoing and outside the scope of this complaint, I cannot take a view on these actions.

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Final decision

62. I do not consider there was fault in the way the Trust and Council provided care and support to Ms P during the period complained of. I also found the Trust and Council made reasonable arrangements to communicate with Ms P during this time.
63. I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman