Summary: The Ombudsmen find no fault in the actions of a community health team. Staff considered relevant information before deciding to discharge Ms T from active care coordination, and it had a reasonable explanation for why it could not help with a benefit application ahead of time.

The complaint

1. Ms T complains about:
1. A decision to discharge her from active Care Coordination and care through the Care Programme Approach (CPA).
2. The way in which the CMHT managed her discharge from the team. Ms T said the team did not give her any warning and had previously assured her that it would not discharge her.
3. Unprofessional conduct by her previous Care Coordinator, Mr A. Ms T said he shouted at her and bullied her.
4. Inadequate record keeping by a member of staff, Mr B. Ms T said this related to his contact with the police about her.
5. A refusal to put her forward for a full assessment of her eligibility for Continuing Healthcare (CHC).
6. A failure to respond appropriately to her request for support before a change in welfare benefits, from Disability Living Allowance (DLA) to Personal Independence Payment (PIP).
2. Ms T said the lack of support has caused her great distress and made her mental illness worse. Further, she said it places an inappropriate burden on her 84-year old mother who is still her main carer.
3. Also, Ms T said the need to complain caused her avoidable time and trouble. Ms T said this had worsened the burden on her mother.
4. In bringing her complaint to the Ombudsmen Ms T said she would like:

• To stay under the CMHT with active Care Coordination under the CPA. Further, Ms T would like there to be no plans for discharge and for there to be a full risk assessment when the prospect of discharge next arises.
• The Ombudsmen to reprimand the CMHT for unprofessionalism.
• To be put forward for a full assessment of her eligibility for CHC.
• Support now to fully prepare for the transition from DLA to PIP.
• Action to prevent recurrences and to ensure the CMHT provides a person‑centred service.

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What I have investigated

5. I have investigated issues (a) and (f). I have explained at the end of this statement why I did not investigate issues (b) to (e).

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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 a single team has considered these complaints 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) 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.
8. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
9. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
10. 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

11. I read the correspondence Ms T sent to the Ombudsmen. I wrote to the organisations to explain what I intended to investigate and to ask for comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance.
12. I shared a confidential copy of my draft decision with Ms T and the organisations under investigation to explain my provisional findings. I invited their comments and considered those I received in response.

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What I found

Relevant guidance and policies

13. CPA is an approach used in secondary mental health care. It helps to assess, plan, review and coordinate treatment, care and support for people with complex mental health needs. The key guidance on this is: Refocusing the Care Programme Approach: Policy and Positive Practice Guidance (the CPA guidance).
14. There is no automatic right to treatment under CPA. Professionals have to use judgement to decide who it is right for. The CPA guidance guides professionals to consider a range of facts when deciding if they should use CPA. (Pages 13 and 14 of the CPA guidance)
15. Similarly, treatment under CPA does not automatically last forever. The CPA guidance notes that professionals should consider whether it is still suitable at every formal review. It notes: ‘As a service user’s needs change, or the need for co ordination support is minimised, moving towards self-directed support will be the natural progression and the need for intensive care co‑ordination support and new (CPA) will end’. (Page 15 of the CPA guidance)
16. If a service decides that someone no longer needs support under CPA it should complete a thorough risk assessment. It should also complete a suitable handover and have a clear plan in case of a relapse or negative change in the person’s mental well being. (Page 15 of the CPA guidance)
17. Pennine Care NHS Foundation Trust (the Trust) has its own policy on CPA. This mirrors the CPA guidance. Version 12, from November 2016, was in place during the events complained about. Section 6 advised staff that: CPA ‘is designed for people identified as suffering with a severe and enduring mental illness with complex mental health needs, posing a significant level of risk and requiring multi-disciplinary input and inter-agency involvement’. It also notes that: non-CPA care ‘is designed for people with a severe and enduring mental illness with on-going maintenance & monitoring needs; they would be identified as having a low to moderate risk of harm to themselves or others as a result of their mental illness and would expect to require limited interventions from secondary mental health services such as annual review, time-limited recovery based interventions or low level maintenance interventions e.g. deport administration’.
18. And, section 6 of the Trust policy also details that:

Service users not requiring CPA can expect:

• Support from professional(s)
• A full assessment of need for care and treatment, including risk assessment.
• An assessment of social care needs against Care Act eligibility criteria.
• Clear understanding of how care and treatment will be carried out, by whom, and when (can be in the form of a letter)
• On-going review as required
• At review, consideration of on-going need for support from the service.
• Potential need for advocacy support
• Self-directed care, with some support if necessary
• Carers identified and informed of rights of own assessment

19. As with the CPA guidance, the Trust’s policy notes that’s a person’s CPA status may change. Section 7.5 noted that professionals should consider a person’s CPA status at reviews. Section 7.6 noted that for ‘service users who are not on CPA, discharge from Secondary Care Mental Health Services will normally occur when: Treatment is complete and/or the service user is sufficiently well recovered to be managed in Primary Care…’ And, when someone is under CPA ‘discharge could occur if: Treatment and recovery is sufficiently progressed to otherwise warrant transfer to non CPA and the criteria for discharge above…
20. Section 7.6 also explains that: ‘All service users discharged from Pennine Care secondary care mental health services will be provided with a discharge plan outlining how to maintain their mental well-being and if required how to seek access to services in the future. The discharge plan should be agreed by and shared with all care providers and should contain information relating to early warning / relapse signs and identified risks. Any arrangements for obtaining support outside of specialist mental health services should also be clearly described.’

Background

21. Ms T has several mental health diagnoses. In the years leading to the middle of 2018 she was under the care of the Active Care Coordination Team which supported her under CPA.
22. Care Plans and Risk Assessments from late 2016 and 2017 focused on Ms T’s wish to move out of her mother’s house and into accommodation with 24‑hour support. Plans also noted the need to help Ms T with benefits applications.
23. Ms T’s Care Coordinator met her in late June 2018. During the meeting the Care Coordinator told Ms T there was a plan to discharge her from the Active Care Coordination Team. Ms T was upset by this news and asked for a meeting with a manager.
24. Ms T met staff in late July 2018. Staff did not change their view that Ms T did not meet the criteria for care under CPA. However, they recognised that Ms T still needed support with her housing needs. Following the meeting the Trust placed Ms T under the care of the Wellbeing and Recovery Team. Her care would not be under CPA.
25. A worker from the Wellbeing and Recovery Team visited Ms T toward the middle of September 2018. Plans continued to focus on helping Ms T move to new supported accommodation. The worker also noted they would help Ms T apply for benefits if they were still involved when that needed to be done. They noted that if they were no longer involved Ms T could approach the Citizens Advice Bureau for help.
26. In March 2020 the Wellbeing and Recovery Team completed a new plan for Ms T. It noted a date had been agreed for Ms T to move into an Extra Care placement. It also noted a plan to discharge Ms T three months after her tenancy began.

Complaints process

27. Bury Metropolitan Borough Council (the Council) registered a complaint from Ms T in May 2019. It listed several concerns including the decision to discharge her from the Community Mental Health Team and from CPA.
28. The Council replied in August 2019. It said it had been correct to discharge Ms T from CPA because she did not meet the criteria. The Council also found the Wellbeing and Recovery Team could provide suitable support for Ms T’s needs.
29. Ms T made a follow up complaint in September 2019. Again, Ms T noted several concerns. This included her continued dissatisfaction with the decision to discharge her, and a complaint about a failure to help support her to transition between different types of benefits.
30. The Council replied in October 2019. It’s view on the decision to discharge Ms T did not change. However, the Council accepted staff did not handle the process of discharging Ms T properly. It said there should have been better planning and communication about it, and not such an abrupt end to its service. In terms of helping Ms T change benefits, the Council said it would help her when this work took place.
31. Ms T remained unhappy and wrote back to the Council at the end of October 2019. The Council arranged a meeting which took place at the end of November 2019. The Council’s earlier conclusions did not change.

Analysis

a. Complaint about the decision to discharge Ms T from active Care Coordination and care through the CPA

32. There is no automatic right to be cared for under CPA. It is a decision that needs professional judgement based on the individual circumstances of each case. There is evidence that staff were keeping an appropriate understanding of Ms T’s needs and risks via care reviews, care plans and risk assessments. These documents show staff were providing consistent, basic support with practical issues. This evidence supports the Council’s conclusions that Ms T’s needs did not meet the criteria for CPA. Therefore, I have not found any evidence of fault in the process staff followed before making a professional judgement that Ms T no longer needed care under CPA.
33. During the complaints process the Council has already accepted it should have handled Ms T’s discharge better. The Council addressed the failings quickly by putting Ms T under the care of the Wellbeing and Recovery Team. The evidence shows this team remained involved in Ms T’s care. It supported her with her housing applications and later made referrals to Psychology and Psychiatry which did not lead to any continuing involvement. This provides further evidence to support the team’s decision to discharge Ms T from active care coordination.

f. Complaint a failure to respond appropriately to Ms T’s request for support before a change in welfare benefits, from DLA to PIP

34. In 2018 Ms T told staff she wanted an assessment of her needs for a benefit claim before they needed to be renewed. The worker told Ms T this was not a process the team followed. As noted above, Ms T’s plans included a plan to support her with benefits claims if they were still involved in her care when the need arose.
35. It was reasonable for professionals to consider the possibility that Ms T’s circumstances and needs could change before she needed to change benefits. Any support it could provide would need to based on an up-to-date understanding of Ms T’s needs. Therefore, I have not found any fault in the team’s actions here.

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Decision

36. I have closed this investigation on the basis that there is no evidence of fault.

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Parts of the complaint that I did not investigate

37. I did not investigate parts (b) to (e) of Ms T’s complaint to the Ombudsmen for the following reasons:
38. (b) During the local complaints process the CMHT acknowledged that it did not handle the original discharge process as it should have, and apologised. I do not consider an investigation is likely to achieve anything more for Ms T.
39. (c) An investigation would be able to consider Ms T’s account of events. Ms T notes her views would be supported by accounts from her mother, which we could also consider. However, we would need to balance this against accounts from Mr A who denies having acted in this way. It is unlikely there would be any further reliable sources of independent evidence to shed any further light on this disagreement. In these circumstances, from our independent perspective, it seems highly improbable that an investigation would be able to reach a robust, evidenced finding of fault, even on the balance of probabilities.
40. (d) Ms T raises concerns that it was shocking and disconcerting to learn, from records, of contact Mr B had with the police. This relates to contact in 2009, and Mr B no longer works for the Trust. It is highly unlikely an investigation would be able to reach a meaningful finding about this issue. In addition, based on the available information the impact of this event is not so significant to amount to an injustice.
41. (e) The CMHT has completed a CHC Checklist which was negative. It has offered to forward this to the relevant Clinical Commissioning Group for it to check, and to advise Ms T of the appeal process. The CMHT has also noted other professionals and teams Ms T could approach to ask for a new Checklist. In view of these actions there are no clear indications of fault to warrant an investigation of this issue.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman