Summary: Ms Y complained the accommodation the Council and ICB arranged for her brother, Mr X, as part of his Section 117 aftercare was unsuitable for his needs. We found fault with the Council and ICB in terms of a delay in acting on concerns Ms Y raised about the placement. We also found fault with lack of mental health care and support provided to Mr X by the Trust during the same period. The Council, ICB and Trust have agreed to provide an appropriate remedy for the injustice caused.

The complaint

1. Ms Y complains on behalf of her brother, Mr X, that his supported living accommodation, provided by London Borough of Brent (the Council) and NHS North West London Integrated Care Board (the ICB) as part of his Section 117 aftercare, was unsuitable. Ms Y complains there was a lack of care and mental health support provided to Mr X, that the placement was dirty and unhygienic, and he was not given adequate support with basic needs including preparing meals. Ms Y said she raised her concerns with the organisations between December 2019 and May 2022, but no action was taken about the accommodation.
2. Ms Y also complains there was a lack of support from Chilterns CMHT, managed by Oxford Health NHS Foundation Trust (the Trust), during this period. She complains the CMHT could have raised concerns and advised that Mr X should be moved, but this did not happen.
3. Ms Y says that living in these conditions was detrimental to her brother’s health, and led to him being admitted to hospital. She also said the situation was distressing and stressful for her.
4. As an outcome of her complaint to the Ombudsmen, Ms Y seeks an acknowledgement that the placement was not suitable for Mr X and that action could have been taken earlier to find an alternative. Ms Y also seeks an apology and service improvements, so that other people do not experience similar issues.

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The Ombudsmen’s role and powers

5. 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).
6. 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.
7. 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

8. I spoke to Ms Y about her complaint and read the information she sent to the Ombudsmen. I considered information from the Trust, Council and ICB. I also considered the relevant legislation and guidance.
9. Ms Y, the Council, the Trust and the ICB had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Integrated Care Boards

10. On 1 July 2022, NHS Clinical Commissioning Groups were replaced by integrated care boards (ICBs). For clarity, I will refer to the ICB throughout this draft decision statement, including when writing about the period before 1 July 2022.

Section 117 aftercare

11. Anyone who may have a need for community care services is entitled to a social care assessment when they are discharged from hospital to establish what services they might need. Section 117 of the Mental Health Act imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under specific sections of the Mental Health Act (e.g. Section 3). Aftercare services provided in relation to the person’s mental disorder under S117 cannot be charged for. This is known as section 117 aftercare.
12. Councils and ICBs have a joint responsibility to provide or arrange Section 117 aftercare for eligible service users.
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 of Practice) is statutory guidance. This means that councils and ICBs must follow it, unless there are good reasons not to.

The Care Programme Approach

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; have a care plan to show how their needs will be met and have the care plan reviewed by a multi-disciplinary team (MDT).
16. In 2022, the Parliamentary and Health Service Ombudsman and Local Government and Social Care Ombudsman published “Section 117 Aftercare: Guidance for Practitioners”. This says the care plan is central to the CPA process: “This is a record of any physical, psychological, emotional and social needs associated with the person’s mental health condition. The care plan should be prepared in close partnership with the person from the outset and reflect their needs and wishes… To ensure the care plan reflects the person’s needs, thought should be given to who needs to be involved in preparing it. Chapter 34.12 of the Code of Practice explains that, depending on the needs of the person, this could include… the carer and/or nearest relative.”

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What I found

What happened

17. On leaving hospital in late 2019, Mr X moved into supported living accommodation. The placement was funded jointly by the Council and the ICB under Section 117 aftercare.
18. Before going into hospital, Mr X had been living in another area, where he had been under the care of a different mental health team. After he moved into the supported living accommodation, Chilterns Community Mental Health Team (the CMHT), managed by the Trust, took over Mr X’s mental health care. However, based on the information available, it appears the CMHT did not take over Mr X’s care until September 2020, when he had been at the placement for several months.
19. The Council reviewed Mr X’s social care plan annually while he was at the placement. It was identified from July 2020 onwards that Ms Y had concerns about the placement. In August 2020, an alternative placement was being considered by the joint Council and ICB funding panel, and there was a plan to arrange for Mr X to view it. The CMHT continued to visit Mr X at the placement, but the records indicate it was difficult to engage him in discussions about his care.
20. A visit in January 2021 by the Council and Trust recorded that Mr X’s mental health was not improving at the placement and he was still not engaging with the CMHT or social worker. It also noted Ms Y’s concerns about the placement, and identified nutrition and keeping a habitable home as areas where Mr X needed support.
21. The Council then carried out a social care needs assessment for Mr X. This again noted Ms Y’s concerns the placement was not suitable. It also said Mr X had struggled to settle, was not engaging with staff, and would like to move to another placement. Following the needs assessment, in February 2021, the Council prepared a care and support plan for Mr X’s social care needs. Managing and maintaining nutrition, and making use of his home safely, were identified as areas of need. To achieve this, it was noted that Mr X should receive support with preparing meals, shopping for food and keeping his room tidy.
22. In April 2021, funding for a new placement for Mr X was agreed by the joint funding panel. However, the records indicate it was difficult to engage Mr X with arrangements for moving, and it is not clear what happened with the plan for a new placement after this.
23. The Trust’s records show the CMHT continued to try and visit Mr X. The CMHT tried unsuccessfully to contact Mr X to arrange a review.
24. In May 2022, the Council carried out a further review of Mr X’s social care needs. It documented the previous care plan was not effective, and the placement had broken down. It said Mr X was not being supported with hygiene and cleaning, two needs which had been set out in his care plan. During this period, Mr X’s mental state deteriorated and in June 2022 he was readmitted to hospital. After he was discharged, Mr X moved to a new placement.

Analysis

Suitability of the placement

25. When someone needs residential care or specialist accommodation, this can only be funded through Section 117 aftercare if it meets a need related to their mental health condition. In Mr X’s case, his care plan states he required specialist enhanced accommodation to meet the needs arising from his mental health condition.
26. Regarding Ms Y’s concerns that the placement was dirty and unhygienic, the records show a visit by the CMHT to the placement in November 2020 described it as disorganised and unhygienic, although this does not mention Mr X’s room specifically. The Council followed this up with a visit in December 2020 and documented the placement as clean and tidy and Mr X’s room as “acceptably tidy”. However, the records also say “it is important to note the visit was announced… current placement not able to meet the support needs [Mr X] is requiring. Request for new placement with carers on site 24/7.” As noted above, the records indicate funding for new accommodation was approved jointly by the Council and ICB in April 2021. However, Mr X did not move at that time and remained at the placement. It appears from the records that Mr X did not engage with staff in arrangements for moving. I recognise that it was difficult to engage Mr X. However, I note that after a joint visit by the Trust and Council in January 2021, an independent mental health advocate (IMHA) had been considered to support Mr X. However, I have not seen anything in the records to indicate an IMHA was put in place. Nor have I seen indications that the Council or Trust tried to involve Ms Y to support Mr X in discussions about his care plan, including arranging a new placement. This would have been in line with the Code of Practice, which says Section 117 aftercare planning may include the person’s nearest relative or other carers, in order to reflect the needs of the person. This was fault by the Council and Trust.
27. The PHSO and LGSCO Section 117 aftercare guidance, referred to in paragraph 16, says the person’s CPA care plan should set out what type of accommodation would meet the need related to their mental health condition. The Council carried out a Care Act assessment for Mr X and developed a care plan. It reviewed this annually as required. However, based on the available evidence this was not a CPA care plan as should have happened for Mr X as he was receiving Section 117 aftercare. Therefore, this care plan focused only on Mr X’s social care needs.
28. After Ms Y complained to the Council in May 2022, it allocated Mr X a new social worker to try and address her concerns. The allocated worker visited Mr X at the placement in May 2022, but the notes indicate Mr X did not engage. Mr X’s care and support plan was reviewed, and it was documented that the previous plan was not effective.
29. In response to Ms Y’s complaint, the ICB said that as a commissioning organisation, it did not have access to the supported accommodation to confirm whether it was in good order and suitable for Mr X. However, it said the information shared with the ICB was that the accommodation was suitable to meet Mr X’s needs, and had been agreed by the joint mental health panel. The ICB advised Ms Y to discuss any concerns about the placement with the multi‑disciplinary team responsible for Mr X’s Section 117 aftercare.
30. As noted above, Councils and ICBs have a joint responsibility to provide or arrange Section 117 aftercare. While I recognise the Council was the lead commissioner, as set out in the Section 117 Aftercare: Guidance for Practitioners, the ICB still retains joint responsibility with the Council, for overseeing the Section 117 aftercare and ensuring it met its aims effectively.
31. In its response to Ms Y’s complaint, the Council said that it took prompt steps to ensure Mr X’s needs were being met, once Ms Y’s concerns were highlighted to it. The Council did so by allocating a new social worker to Mr X to begin the process of finding alternative supported accommodation. However, this was not until May 2022, and as noted above, the available information indicates the Council was aware as early as July or August 2020, that there were concerns with the placement. A needs assessment by the Council in January 2021 also documented that Mr X had struggled to settle in and would like to move to another placement, and a new placement was requested in February 2021. Ms Y had also raised her concerns with the Council and the Trust several times during this period. Therefore, it appears the Council was aware of issues with the placement some time before May 2022, but it is not clear whether it took action to try and resolve this, despite its joint responsibilities with the ICB to ensure the Section 117 aftercare met its aims.
32. This was fault by the Council and ICB, in terms of a delay in acting on the concerns about the suitability of the placement and ensuring it met Mr X’s needs under Section 117. I consider there is more the Council and Trust could have done to involve Mr X in planning his care including a new placement. I am not able to say whether remaining at the placement caused Mr X’s mental health to deteriorate. However, I consider this caused injustice to Mr X, as he remained in a placement that was already known to be unsuitable for him. I recognise it was difficult to engage Mr X but I cannot see that sufficient action was taken to try and get him to engage through an IMHA or by involving Ms Y to support him.

CMHT

33. Ms Y complains that the CMHT did not monitor Mr X’s mental health, or support him as it should have done while he was at the placement. She also says as the CMHT was visiting Mr X and seeing what his accommodation was like, it had an opportunity to raise concerns about the placement, but did not do so.
34. The Trust’s records indicate Mr X’s care was transferred to it from his previous mental health team in September 2020. In its response to Ms Y’s complaint, the Trust said there should be a transfer of care meeting when people from other areas are placed in the area covered by the Trust. It said that if a meeting does not take place at the time, the Trust has put a process in place so it can contact the person’s previous mental health trust and council, to obtain the information it needs to continue the person’s care. The Trust said this would mean a more robust process was in place for meeting the person’s ongoing health needs and ensuring continuity of care. This appears to be a reasonable response and is likely to help prevent recurrence.
35. The records say Mr X did not engage with an initial appointment for assessment by the CMHT and, based on what I have seen, the Trust did not carry out an assessment or review of Mr X’s mental health while he was at the placement. The CMHT visited and telephoned Mr X regularly to provide medication, but the records indicate it was difficult for them to speak to Mr X as he would often not engage with them or leave the building when they arrived.
36. The Code of Practice referred to in paragraph 14, above, requires a named care coordinator to be allocated as part of the CPA process (Code of Practice Chapter 34.5). The care coordinator role includes preparing, implementing and reviewing a person’s care plan, and being in regular contact with the person. The records indicate the Trust started to draw up a care plan with a named care coordinator, which included a plan for what should happen if Mr X’s mental health started to deteriorate.
37. However, it appears the care plan was not completed or shared with Mr X, and it is documented he had not met the care coordinator at that stage. The records document a telephone call where a member of staff from the CMHT introduced themselves to Mr X as his care coordinator but there does not appear to have been regular contact from this staff member. Therefore, it is not clear what happened on this point. The Section 117 Aftercare guidance says that in line with the Code of Practice, the care plan should be prepared in close partnership with the person from the outset and reflect their needs and wishes. It appears from the records that this did not happen, and this was fault by the Trust.
38. In its response to Ms Y’s complaint, the Trust said it had taken significant learning from the concerns she had raised. The Trust acknowledged a named care coordinator should be allocated, to act as a point of contact for clients and their families, and to hold regular care planning meetings with the client, their families, support staff and the relevant council. I found that not putting a CPA care plan and clear arrangements for a care coordinator in place for Mr X was fault by the Trust. However, the steps the Trust has taken following the complaint are in line with the Code of Practice as set out in paragraph 14, above.
39. The Trust also said there should have been more robust processes in place to ensure people who are anxious or avoiding mental health reviews are not overlooked. The Trust said it was putting in place a new strategy to ensure that where the person does not attend a care plan review, the CMHT will involve the person’s family or support staff to improve their engagement in the reviews. The Trust also said the care coordinator would inform the placing authority about missed reviews. Again, these appear to be reasonable actions, in line with the Code of Practice, that will help prevent recurrence.
40. I have considered whether any injustice was caused to Mr X and Ms Y by the fault I have provisionally identified. As noted above, Ms Y said that living in these conditions was detrimental to her brother’s health, and led to him being admitted to hospital. She also said the situation was distressing and stressful for her. I am not able to say whether having a clearly designated care coordinator would have meant an alternative placement could have been found for Mr X. However, my view is it is likely that any ongoing concerns with the placement, and any deterioration in Mr X’s mental health, may have been more easily identified had a care coordinator been in place while he was at the placement. The absence of a clearly designated care coordinator and agreed Section 117 aftercare plan at the placement, meant Mr X did not receive the support and oversight this is likely to have provided to him. A CPA care plan should have included a comprehensive record of Mr X’s health and social care needs, and how the Trust and Council would meet those needs. It also leaves Ms Y with uncertainty about what might have happened in terms of acting on concerns about the placement.
41. In response to Ms Y’s complaint, the Trust has taken reasonable steps to prevent recurrence of the failings it has already identified in Mr X’s care. However, my view is there is more the Trust should do to provide a remedy for the impact of this on Mr X and Ms Y, and I have set this out in the Agreed Actions section, below.

Safeguarding

42. Ms Y also complained that the Trust failed to raise concerns about the placement with the commissioning organisations, the Council and ICB. She said that as the CMHT visited Mr X at the placement, it should have raised concerns. The Trust’s response to Ms Y’s complaint said it made several safeguarding referrals about the placement to the relevant local authority. This is supported by the information I have seen in the records, which shows safeguarding referrals were made. Therefore I do not find fault with the Trust on this point.

Summary

43. The records indicate the Trust and Council were aware of Ms Y’s concerns about the placement as early as summer 2020. It was documented a new placement was needed by February 2021. However, Mr X remained at the placement until he was admitted to hospital in June 2022. There are frequent notes in the clinical records to indicate Mr X was not engaging with the CMHT or social work team, despite their repeated attempts to visit him and speak to him.
44. I recognise the records say it was often difficult to engage with Mr X with the professionals involved in his care, in order to arrange a move to a new placement. However, my view is there is more the Trust and Council could have done, in terms of taking steps to engage Mr X through involving Ms Y or an IMHA, to enable him to move to a new placement sooner. There is an injustice to Mr X here as he remained in an unsuitable placement for too long.
45. I also provisionally found fault with the Trust in the lack of an agreed CPA plan or clear arrangements for a care coordinator to support Mr X.
46. I am not able to say whether Mr X’s mental health would have deteriorated had it not been for the faults I have provisionally found in this complaint. However, the lack of a CPA plan and regular input from a care coordinator with oversight of his care, is likely to have meant that Mr X did not get the support he needed. This also leaves Mr X and Ms Y with uncertainty about the impact of these failings on Mr X’s mental health. I also recognise the distress caused to Ms Y by seeing Mr X living in an unsuitable placement. I have made recommendations to address this, below.

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Agreed Actions

47. I recommended that within one month of the final decision on this complaint, the Council, Trust and ICB should write to Ms Y to acknowledge the fault provisionally identified in the Analysis section above, to apologise for this and for the impact on Mr X and Ms Y.
48. I recommended that within one month of the final decision on this complaint, the Council, Trust and ICB should, between them, make a symbolic payment to Mr X of £300, in recognition of the avoidable distress caused by the fault found in this complaint.
49. I recommended that within one month of the final decision on this complaint, the Council, Trust and ICB should between them, make a symbolic payment to Ms Y of £150, in recognition of the avoidable distress and upset caused by the fault found.
50. I recommended that within three months of the final decision on this complaint:

• the Trust should provide us with evidence it has carried out the actions it agreed to take in response to Ms Y’s complaint; and
• the Council and ICB should review their policies and procedures in relation to Section 117 aftercare, to ensure that these are in line with the Code of Practice, to prevent recurrence of the fault provisionally identified in this complaint.

51. The Council, Trust and ICB have accepted my recommendations.
52. The organisations should provide us with evidence they have complied with the above actions.

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Final decision

53. For the reasons explained in the Analysis section, above, I have completed my investigation and uphold Ms Y’s complaint.

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Investigator's decision on behalf of the Ombudsman