Summary: A woman complained that a council and clinical commissioning group did not work together to meet her care needs after she fell. She said this caused her health to worsen. The Ombudsmen find that the council failed to respond properly to her request for more support hours. There was a fault with the clinical commissioning group’s communication. They have agreed to take action to remedy this.

The complaint

1. A woman I will call Ms P complained about the service she received from Nottinghamshire County Council (the Council) and Mansfield and Ashfield Clinical Commissioning Group (the CCG) following a fall in April 2018. She complained that the Council and CCG failed to work together to provide the care she requires to meet her complex needs. She said the failure of the Council and CCG to support her meant her physical and mental health deteriorated.
2. Ms P also complained that the Council would not agree to fund her visiting her family in Ireland with a carer.

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What I have investigated

3. I have investigated the complaint about the way the Council and the CCG responded after Ms P fell. At the end of this statement I have explained why I have not investigated the other part of the complaint.

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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)). If it has, they may suggest a remedy. 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.
5. 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 for both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA
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)
7. The Ombudsmen cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. The Ombudsmen cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant responsible organisation has to make. Therefore, my investigation has focused on the way that the decisions were made. 

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How I considered this complaint

9. I considered information provided by Ms P and information provided by the Council and CCG, including health and social care records and complaint files.
10. I shared a draft of this decision with the parties to the complaint and considered their comments.

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What I found

Legal and administrative context

Community Care Assessment

11. 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. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve.
12. 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. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.
13. Where more than one agency is assessing a person, they should all 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 coordinated assessment.

Community Care Eligibility criteria

14. The eligibility threshold for adults with care and support needs and carers is set out in the Care and Support (Eligibility Criteria) Regulations 2014. The threshold is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing. For a person to have needs which are eligible for support, the following must apply:

1. The needs must arise from or be related to a physical or mental impairment or illness.
2. As a result of the needs, the adult must be unable to achieve two or more of the following outcomes:
• managing and maintaining nutrition;
• maintaining personal hygiene;
• managing toilet needs;
• being appropriately clothed;
• being able to make use of their home safely;
• maintaining a habitable home environment;
• developing and maintaining family or other personal relationships;
• accessing and engaging in work, training, education or volunteering;
• making use of necessary facilities or services in the local community including public transport and recreational facilities or services; and
• carrying out any caring responsibilities the adult has for a child.
3. As a consequence of inability to achieve these outcomes, there is likely to be a significant impact on the adult’s well-being.

15. Where councils have determined that a person has any eligible needs, they must meet those needs. When the eligibility determination has been made, councils must provide the person to whom the determination relates (the adult or carer) with a copy of their decision.

Review of Assessment/Care Plan

16. Section 27 of the Care Act 2014 gives an expectation that councils should conduct a review of a care and support plan no later than every 12 months. A light touch review should be considered six to eight weeks after the plan and personal budget have been agreed. The review should be performed in a timely manner proportionate to the needs to be met. In addition to the duty on councils to keep plans under review generally, the Act provides a duty on councils to conduct a review if a request for one is made by the adult or a person acting on the adult’s behalf.

Section 117 Aftercare

17. 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 and social care needs arising from or related to the persons 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 persons mental disorder under S117 cannot be charged for. This is known as section 117 aftercare.

What happened

18. Ms P has physical and mental health difficulties, including limited mobility because of a stroke and heart problems. She is entitled to section 117 aftercare. She receives care and support from a care agency arranged by the Council.
19. In April 2018, Ms P had a care package of 27 hours per week. This included support with personal care, shopping and laundry, support to attend health appointments and support with social inclusion.
20. On 10 April Ms P fell and broke her arm. The following day, the Council noted that it would contact her to find out whether she had additional support needs. Ms P’s care agency told the Council that for some time Ms P had used her support hours for social activities to cover her health appointments, which had increased over the past few months. Her care agency told the Council this left Ms P with little time for support with domestic tasks or social activities. She would now need extra health appointments because of her broken arm. The Council allocated a social worker (the Social Worker) to carry out an urgent review.
21. The Social Worker visited on 20 April to review Ms P’s social care needs. She noted she was coping well with her broken arm, but Ms P did not feel she had enough hours to manage her health appointments as well as social activities. Her care agency said they generally managed to make the 27 hours work but sometimes they provided additional unpaid support. Ms P and the Social Worker disagreed about whether the CCG was jointly funding her care, and the Social Worker agreed to check this. The social care review was not completed.
22. The Social Worker contacted the CCG. The CCG said Ms P’s care was fully funded by the Council and the CCG would only review this if there was a significant change in Ms P’s circumstances. This was because health and social care managers had agreed that “historical cases that were 100% funded aftercare will not be reassessed now”. The CCG advised the Social Worker that assistance to get to health appointments was a social care need, not a health need. It said the Social Worker should make a referral to the CCG if Ms P’s needs had changed.
23. In early May, the Social Worker told Ms P they would arrange a joint health needs assessment with the CCG. Ms P said she wanted an increase of 6 hours to attend her health appointments.
24. On 18 May, the Social Worker told Ms P she wanted to arrange to visit her with a nurse from the CCG. Ms P said she wanted the increased hours in place first. The Social Worker said any increase in her hours would need to be agreed by senior managers after the assessment. Ms P told the Social Worker she has having to cancel some health appointments because she could not manage them within her hours without having to sacrifice other tasks like her shopping.
25. On 23 May the Social Worker’s manager (the Team Manager) told Ms P they could not guarantee that she would get the extra 6 hours she wanted because this would depend on the outcome of the forthcoming assessment.
26. The following day, the CCG told the Council it had advised Ms P that the referral to the CCG was because of her increased needs, but they could not guarantee that her care hours would increase until they had done the assessment and discussed her request for more hours with senior managers.
27. On 11 June, a nurse from the CCG, the Social Worker and the Team Manager visited Ms P. The nurse did a health needs assessment. She recorded that Ms P felt her social care needs were being met but that her health needs were not being met as she felt she did not have enough hours of support to help her attend her health appointments, which had recently increased. She wanted another 6 hours of support a week for this and said she could not attend all her appointments otherwise. The nurse told Ms P she was doing the assessment to determine whether the CCG would jointly fund Ms P’s care, not to decide whether her hours would increase.
28. On 15 June Ms P called the Council, unhappy that the CCG had not considered the assessment yet. She wanted the Council to decide whether she could have the 6 hour increase to her support. The Social Worker told Ms P the Council was waiting for the outcome from the CCG. Ms P said the care should be agreed and the Council should work out the funding for it later. She said she felt stressed because she was clock watching whenever she went out with her carers. She was asking the carers to do her shopping for her because it was quicker, but it meant she did not get out of her house. She did not know how she would manage to attend her forthcoming health appointments.
29. A few days later, the CCG told the Social Worker that its nurse had recommended that the CCG fund 30% of Ms P’s care. However, if the Council did not decide to increase Ms P’s care package the CCG would not contribute to the cost, since it would class this as an existing care package. Under the local agreement (referred to in paragraph 22) it would then stay with the Council to fund. The CCG said it did not think it unreasonable to provide Ms P with another six hours. It said the Council would still save money if it increased Ms P’s care package and claimed 30% from the CCG. The Social Worker said she would discuss this with her manager.
30. The Council recorded on 25 June that it had decided to review Ms P’s social care needs to understand more about her health appointments before it made a decision. The Social Worker told Ms P. She recorded that Ms P screamed and became hostile and critical of social care.
31. On 27 June, Ms P rang the Council to make a complaint. She said the Social Worker agreed in April that her needs had increased but she needed to discuss this with the Team Manager. Then, she heard that the Team Manager was referring her case to the CCG for funding. She had still not received any decision or extra hours. The Council had now told her she needed a new assessment, when it had already done an assessment in April. She said the Team Manager wanted to see whether her existing hours could be rearranged to cover support with her hospital appointments, but she felt she could not do this and still have hours left for personal and domestic tasks.
32. The Team Manager rang Ms P to say he and the social worker wanted to visit Ms P to review her care package. Ms P refused the visit, and said she wanted to meet with the social services director. She told the Team Manager she had cancelled her hospital appointments.
33. The Council’s records of mid-July say the Council and CCG should jointly meet with Ms P to see what she needed and how the Council and CCG should split the funding, but Ms P was not willing to have another meeting. The CCG told the Council it had told Ms P that she needed an assessment to see whether she needed more hours, and that it had explained to her that support to access health appointments is a social care need rather than a health need.
34. The Team Manager rang Ms P to ask about her health appointments. Ms P rang the Council’s complaints team to say she was unhappy with the Team Manager pressuring her for this information. She said the Council was not taking into account that she had slowed down since her last review and needed to use her wheelchair more. She said the Team Manager told her the Council did not identify that she needed more hours at her April review, but this was untrue because the Council asked the CCG for additional funding. Ms P then told the Council she would be prepared to have another review, but only if it was by a specific member of staff from another team.
35. Ms P’s care agency contacted the Council on 17 July. It expressed concern that Ms P had not received the funding for additional support hours for health appointments. It said Ms P’s health was deteriorating because she could not attend appointments, and the matter was causing Ms P “considerable undue stress”.
36. On 18 July, the Council’s records say a senior manager agreed to increase Ms P’s care package by six hours a week to help her get to appointments. This was for a 4 month period to allow time for further work with Ms P to ensure her needs were met. Ms P said she only agreed to this if it was with someone she trusted, naming a particular member of staff.
37. The Council responded to Ms P’s complaint on 26 July. It said it did not identify at her April review that she needed an additional 6 hours support a week. It said it found she had managed to attend the additional hospital appointments using her existing hours, though it acknowledged this affected the time she had available for social activities. The Council said neither Ms P or her care agency reported that her care needs were not being met. It wanted to look at the best means of supporting her to attend hospital appointments in future.
38. Regarding Ms P’s view that her health and mobility had declined, the Council said it would look at this at a review, but it was difficult to do this since Ms P refused to meet with it and refused consent for it to consult with health professionals about her needs. It said to try to resolve the dispute, it agreed to put 6 hours additional support per week in place for four months from 6 August to allow time to complete a review and agree Ms P’s long term needs.
39. When she received the response, Ms P called the Council to dispute that the 6 hours were not agreed in April. She said she had not refused to meet with the Council, she had agreed to meet with a specific member of staff. She asked for her care to be reviewed by that member of staff or a neighbouring local authority.
40. The Council wrote to Ms P again on 27 July. It said the CCG had not agreed to fund any additional hours, and its referral to the CCG was not related to Ms P’s request for 6 additional hours. It said it did not agree to the specific member of staff or the other local authority reviewing her care, but said it had allocated an experienced social worker to support the Social Worker.
41. Records of early August say Ms P was low in mood and tearful. Her GP felt the trigger was her dispute with social services over her care hours. Ms P fell and injured her hip, and because of the combination of this and her other physical health needs she became bedbound.
42. Later in August, Ms P got a letter from the CCG advising that it would jointly fund her care. The CCG agreed to pay 30% of the cost. Ms P thought this meant her care hours would increase by 30%. The Social Worker explained that the CCG was contributing 30% of the cost of Ms P’s care, and her hours were not increasing further. The Social Worker said they would update Ms P’s review when her physical health had stabilised.
43. On 31 August, the Social Worker asked Ms P’s care agency whether they could meet Ms P’s needs within her agreed hours if they provided shorter, more frequent calls. The agency said it could but Ms P did not want this. She felt the Council should increase her hours because of the recent funding from the CCG.
44. Ms P brought her complaint to the Ombudsmen on 5 September. She said social workers visited her after she broke her arm. They said she may need more care hours and they would contact the CCG about this. Ms P said she told the Council she needed the additional hours straight away and should not have to wait for the CCG to agree them. The CCG refused the request, then agreed to fund 30% of her care in July. She said she previously had 27 hours per week, and with a 30% increase she should have 35.1 hours per week. She contacted the Social Worker for an urgent review because her care package did not cover the additional care she needed after her hip injury. She said the Council suggested she had more frequent, shorter visits but this would make her more isolated. She said as a result of these events her mental health got worse.
45. On 14 September, Ms P took part in a review of her social care assessment and support plan. Her care agency said it considered that Ms P’s needs could be met within the existing 33 hours per week. As Ms P was bedbound, she could not access community facilities or attend health appointments. Ms P said she felt she should have an increase in her care hours in line with the amount of funding from the CCG. The Social Worker explained that the CCG’s contribution to the funding did not mean Ms P’s care hours increased.

Findings and analysis

46. The Council recorded on 4 July that at the review in April it found that there was no immediate need to increase Ms P’s hours because her broken arm did not affect her personal care, and the “CHC assessment” was part of an ongoing review of her support needs.
47. The Council did find that Ms P did not need more personal care because of her broken arm, but both Ms P and her care agency told the Council in April that her health appointments had increased and that before her broken arm she had already been using the hours allocated for other tasks to manage her appointments. Her appointments would increase because of the broken arm. The Council failed to identify that this meant her broken arm did potentially affect her care needs.
48. The Council recognised that Ms P was using the hours allocated to meet other assessed needs to manage her health appointments. But it does not seem to have recognised the potential impact on whether her other needs were met.
49. There was no good reason for the Council to require involvement from the CCG to review Ms P’s social care support hours. As the CCG correctly told the Council, a need for support to attend health appointments is a social care need. Even if the Council felt it should seek funding from the CCG towards the cost of Ms P’s care package, it should have properly assessed her social care needs and funded any additional hours she needed first. People should not have to wait for organisations to negotiate funding arrangements with one another before their needs are met.
50. The Council and CCG’s communication with Ms P in May and early June reasonably led her to believe that the planned health needs assessment was to enable a decision about whether her support hours were increased. It is therefore unsurprising that Ms P was frustrated on learning that the Council and CCG decided after the health needs assessment that she needed another assessment. The Council decided in July that it needed more information about Ms P’s health appointments. It could have got this any time from April.
51. Ms P’s belief that the CCG’s agreement to fund 30% of her care costs meant she should get 30% more care hours was mistaken. The agreement was that the CCG would fund 30% of the cost of the care hours the Council considered she needed. But the outcome of the April review was that Ms P felt she needed more hours and the Social Worker agreed to contact the CCG. The Social Worker told Ms P in June that it was waiting for the outcome of the CCG’s health needs assessment before they decided whether she should have more hours. Therefore, I can understand why Ms P reached this belief.
52. The Council put the additional hours Ms P requested in place in July, which was a resolution to Ms P’s immediate concern of not being able to access all her health appointments.
53. The Council was entitled to consider whether Ms P’s care agency could meet her needs with her existing hours if they were rearranged. If Ms P felt this would increase her social isolation, she could have asked the Council to consider with her how her needs for social engagement could best be met.
54. I find that the Council is at fault for failing to adequately respond to Ms P’s change in circumstances in April by properly considering whether it needed to increase her social care hours. I find that this led to a delay from April to July before the additional hours were agreed. The Council’s response to Ms P’s complaint said neither she nor her care agency had reported that her needs were not being met. This is incorrect. The records show that they had reported this several times. Therefore, there was fault with the complaint handling. This matter caused unnecessary stress and distress to Ms P. Her GP linked this to a deterioration in her mental health. This is an injustice to her.
55. I find that the CCG’s communication with Ms P contributed to the confusion about whether the outcome of the health needs assessment might result in more support hours for her. It therefore contributed to the stress and distress this caused her. I have not otherwise found fault with the CCG.

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Agreed action

56. Within one month the Council will write to Ms P to apologise for the impact of its faults on her. It will copy this letter to the Ombudsmen. It will pay her £250 to acknowledge the unnecessary distress and time and trouble she was caused.
57. Within two months the Council will review its practice and procedures for responding to reports that someone has increased needs, to ensure that it assesses the person’s needs and puts any additional services they need in place promptly. It will write to Ms P to explain what it has done, and copy this letter to the Ombudsmen.
58. Within one month the CCG will write to Ms P to apologise for the impact of its fault on her.

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Decision

59. I find that:
1. The Council is at fault for failing to properly respond to the change in Ms P’s circumstances in April 2018 and for including inaccurate information in its complaint response. This caused unnecessary stress and distress, which is an injustice.
2. The CCG is at fault for miscommunication with Ms P about an assessment. This contributed to the stress and distress she experienced, which is an injustice.
60. I consider that the actions the Council and CCG have agreed to take will satisfactorily remedy the injustice I found. Therefore, I have completed my investigation.

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Parts of the complaint that I did not investigate

61. I did not investigate Ms P’s complaint that the Council did not fund her visiting her family in Ireland with a carer because I have not seen evidence that this was an assessed need, and it is unlikely that we would find fault here.

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Investigator's decision on behalf of the Ombudsman