Summary: There was fault in Miss C’s health and social care assessments: they were delayed and Mr C, her father, did not receive timely copies. This meant he did not have the chance to challenge inaccuracies. As a result, there was a delay in Miss C receiving specialist healthcare to increase her independence. The Council and Trust will apologise, pay Miss C £250 and review the learning disability partnership’s policies and procedures to ensure they refer to current law and guidance.

The complaint

1. Mr C complains for his daughter, Miss C about Cambridgeshire Learning Disability Partnership, run by Cambridgeshire County Council (the Council) and Cambridgeshire and Peterborough NHS Foundation Trust (the Trust). He says he first saw Miss C’s 2016 assessment in June 2018. The assessment was factually incorrect because it said Miss C did not have a learning disability and had caught up with developmental milestones by age three. The outcome of the assessment was Miss C did not meet the criteria for support from specialist NHS leaning disability services.
2. Mr C says his daughter missed out on specialist services between 2016 and 2018 as a result of the decision she was not eligible. He seeks a payment to recognise this.

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The Ombudsmen’s role and powers

3. We have the power to consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, twe 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, we may suggest a remedy. Our recommendations might include asking the organisations to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisations take action to stop the same mistakes happening again.
6. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we 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. I considered Mr C’s complaint to us, the responses to his complaint from the Council and documents described later in this statement. The parties received a draft of this statement and I took their comments into account.

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What I found

8. A council must carry out an assessment for any adult with an appearance of need for 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. It must also involve the individual and where appropriate their carer or any other person they might want involved. An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs.
9. The Care Act spells out the duty to meet eligible needs (needs which meet the eligibility criteria). A council can meet eligible needs by providing or arranging care and support at home, in a care or nursing home or in other ways.
10. An adult’s needs are only eligible where they meet all three of these conditions:
• the adult’s needs arise from or are related to physical or mental impairment or illness;
• as a result of the adult’s needs the adult is unable to achieve two or more specified outcomes (see below);
• as a consequence, there is, or is likely to be, a significant impact on the adult’s well-being.
11. Specified outcomes are:
• managing and maintaining nutrition.
• managing personal hygiene.
• managing toileting needs.
• being appropriately clothed.
• being able to make use of the adult’s home safely.
• maintaining a habitable environment. 
• developing or 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.
• carrying out caring responsibilities for an adult or child.

12. If a council decides a person is eligible for care following an assessment, it should prepare a care and support plan which specifies the needs identified in the assessment, says whether and to what extent the needs meet the eligibility criteria and specifies the needs the council is going to meet and how this will be done. The council should give a copy of the care and support plan to the person.
13. The care and support plan must set out a personal budget. A personal budget is a statement which specifies the cost to the local authority of meeting eligible needs, the amount a person must contribute and the amount the council must contribute.
14. A person who is eligible for care and support may ask the authority to arrange their care for them. Or instead, they may ask for a direct payment. This is a payment to the person which they can use flexibly to meet their needs.
15. Cambridgeshire Learning Disability Partnership (CLDP) is run by an agreement between the Council and the Trust. It provides county-wide health and social care services to adults with learning disabilities. CLDP is responsible for delivering functions under the Care Act 2014 on behalf of the Council as well as for delivering specialist NHS health services for learning disabled adults. The CLDP has a shared NHS and council budget to deliver services. The partnership agreement between the Trust and the Council notes people with a learning disability:
• May have specialist health needs met by health staff in CLDP but not be eligible for social care support;
• May have social care needs met by social care staff in the CLDP but non-specialist health needs that are met by general NHS services;
• May have both social care and specialist healthcare needs met by CLDP health and social care services;
16. The Council is responsible for managing complaints about CLDP services.
17. The current eligibility criteria for CLDP services were issued in 2011. They are being updated at the moment. CLDP services are available to adults who have been recognised as having a learning disability, which is:
• A significantly reduced ability to understand new or complex information or to learn new skills (significant impairment of intellectual functioning);
• A reduced ability to cope independently; and
• Age onset before 18 with a lasting effect on development.
18. The criteria go on to say that a person may be eligible for adult social care support if they have needs which meet eligibility criteria for social care. They go on to refer to guidance which was in force before the Care Act 2014, but which have since been replaced by the criteria set out in paragraphs 10 and 11.
19. CLDP’s operational guidance revised in April 2018 says “Health needs are free at the point of contact through the NHS and determined by the diagnostic criteria of a learning disability. Where a diagnosis is not available, it is determined through an assessment of an individual’s developmental history and based on professional judgement of the likelihood of a person having a learning disability. Access criteria are in place. People with learning disabilities have to meet the threshold to receive social care support, this is assessed in line with the Care Act 2014.

Assessments for specialist health services will be undertaken by a qualified health practitioner based on information provided by the referrer”

20. Before 2018, CLDP held separate case files for health and social care. Health records were in paper files and social care records were on a computer database Since 2018, all records are on one computer database.

What happened

21. Miss C has learning and physical disabilities and has been receiving a direct payment from the CLDP since 2009.
22. A health access assessment completed in 2016 said there was no medical diagnosis of learning disability available from childhood records and most of Miss C’s difficulties were due to dyspraxia (a condition affecting motor skills and co-ordination) and low motivation and did not require specialist health services.
23. An occupational therapist (OT) from CLDP completed an activities of daily living assessment in September 2016. At the end of the assessment, the OT ‘queried whether Miss C met the criteria for LDP services’ and was going to seek advice from management.
24. A social worker started a social care assessment in January 2016. The assessment form indicates it was completed in October 2017 but not signed off until August 2018. The social worker posted a copy to Mr C in August 2018. The social care assessment said:
• The CLDP was reviewing her health history for evidence of a learning disability
• Miss C was eligible for social care services and required support in seven of the areas set out in paragraphs 10 and 11 including managing nutrition, maintaining personal hygiene, maintaining a habitable home and maintaining relationships.
25. On receiving a copy of the social care assessment, Mr C complained to the Council. The Council upheld Mr C’s complaint. Its response explained:
• She did not meet the criteria for specialist CLDP health services, but was eligible for social care support;
• It accepted its decision on eligibility for health services was based on insufficient information;
• Source information from NHS services was no longer available and its assessments contained inaccurate information which was copied on to the social care assessment. The CLDP would carry out a new health access assessment;
• It was sorry for other factual errors on the assessment form. Usually these would be identified once the person or their representative had a copy. The social worker would update the assessment and send him a copy;
• It accepted there was a delay in completing the social care assessment. It was sorry for the delay.
26. The OT and social worker advised Mr C and Miss C at the end of October 2018 that she did have a significant learning disability and would benefit from support from the OT. The OT carried out a series of visits over the following months to observe Miss C, assess her skills and focus on developing new skills and more independence in the kitchen and with personal care. The OT also arranged for a specialist physiotherapist to assess Miss C. The physiotherapist recommended two sets of exercises.

Comments from CLDP

27. CLDP told me:
• It allocated a social worker to Miss C at the beginning of 2016. Miss C had been offered her own place. The social worker met with Miss C over the next 7 months to re-assess her needs in preparation for moving. But the content of those meetings was not recorded other than the proposed date of visits. The social worker reviewed the care and support plan;
• It could not locate a copy of the 2015 care and support plan, though Miss C had been getting a direct payment of £10,700 a year since before 2015. The intention was to stop the part of the direct payment that was being used to provide transport and leisure activities. However, the direct payment continued and was not amended until the most recent assessment and care and support plan in June 2019;
• Miss C had never received specialist NHS services from the CLDP as no specialist health needs had been identified. Her social worker referred her to the specialist occupational therapist (OT) in 2016. The OT queried whether Miss C met the criteria for specialist health support and started an assessment to determine her eligibility for health services from CLDP;
• The OT asked for information from Miss C’s GP. The GP typed a letter in December 2016, but the CLDP did not receive it until January 2017;
• The OT wrote to the GP saying there was no evidence Miss C had a formal diagnosis of a learning disability, she caught up with developmental milestones and so did not meet the criteria for having a learning disability or receiving support from the CLDP;
• The CLDP had reviewed the records available in light of the Ombudsmen’s investigation and decided the information used to conclude Miss C was not eligible, was inadequate;
• Mr D got a copy of the social care assessment in 2018. He refused to sign it as he considered it had inaccuracies.
• It had now reviewed the case and obtained accurate information. Miss C was eligible for health support;
• It was reviewing the access criteria, the review was due to finish in September 2019;
• Miss C was reassessed and a care and support plan and personal budget agreed in June 2019;
• Its records policy in 2016 was not to retain health documents if a person was not eligible for health services. The policy has since changed and now all documents were uploaded on to the database;
• It accepted there was a delay in Miss C receiving health support.
• Miss C continued to receive care and support. Although the OT and living skills assessments were delayed, since completion of these, there has been no reduction in the care and support indicating her ability to increase her independence has not been affected.
28. Mr C told me:
• Miss C’s learning disability was diagnosed in childhood and well-documented. The occupational therapist in 2016 did not complete an activities of daily living assessment, just a number of questions;
• Miss C had a different social worker before the 2016 social worker;
• Miss C should have been getting specialist health support sooner;
• The reason the CLDP could not find the 2015 care and support plan was because one did not exist. One was done two years before and the next was in 2016.

Was there fault and if so did it cause injustice?

29. CLDP has accepted its health eligibility assessment was flawed and based on inadequate information. Basing an assessment on inadequate information was fault. Miss C and Mr C should have received a copy of the healthcare eligibility assessment at the time it was drafted in 2016. The failure to share a copy with them was a further fault and denied Mr C the opportunity to challenge inaccuracies at the time. The source information has been deleted, which was in line with records policy at the time and was not fault.
30. Social care assessments should be completed within a reasonable timescale. Taking over two years to complete and authorise an assessment was far too long and was fault. The social worker also failed to record what she had done during visits to complete the assessment. This was poor record keeping and was also fault.
31. There was a delay of about two years in Miss C receiving specialist OT support to increase her independence because of the faults described above. Miss C is now receiving that support, however she missed out on a chance to potentially increase her independence sooner.

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Agreed actions

32. The Trust and Council should, will, within one month of the final decision:
• Apologise and
• Pay Miss C £250 to recognise the loss of opportunity identified in paragraph 31.
33. I note some of the CLDP’s policies refer to social care eligibility criteria which are no longer in force and that a review is taking place. I recommend the review includes redrafting policies to ensure current law is referenced. This should be completed within three months of my final decision.

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Final decision

34. There was fault in Miss C’s health and social care assessments: they were delayed and Mr C, her father, did not receive timely copies. This meant he did not have the chance to challenge inaccuracies. As a result, there was a delay in Miss C receiving specialist healthcare to increase her independence. The Council and Trust should apologise, pay Miss C £250 and review the learning disability partnership’s policies and procedures to ensure they refer to current law and guidance.
35. The Trust and Council have accepted my recommendations. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman