Summary: The Ombudsmen find Tees, Esk & Wear Valley NHS Foundation Trust and Durham County Council’s integrated care team did not confirm why it stopped home visits to Ms Y in writing. However, there was no injustice to Ms Y. The Ombudsmen find the integrated care team did not consistently follow Ms Y’s reasonable adjustments when writing to her, which caused her distress. The integrated care team’s communication was clear about Ms Y’s care and support.

The complaint

1. Ms Y complains about the actions of Durham County Council and Tess, Esk & Wear Valley NHS Foundation Trust’s integrated care team (the Care Team).
2. Ms Y said the Care Team did not meet her reasonable adjustments for her written and verbal communication. Ms Y struggled to understand their written communication, and staff ended phone calls with her which was not in line with her reasonable adjustments. Ms Y says this has been distressing and frustrating.
3. Ms Y said the Care Team’s communication about her care and support was poor. She says she struggled to get through to them and faced problems getting appointments. This caused a lack of health and social care support, missed hospital appointments, and her physical and mental health worsened. Ms Y also said she suffered a loss of dignity. At times she could not shower and was left in her own faeces and menstrual blood. Ms Y would like to receive an appropriate level of support (and communication) which meets her assessed needs.
4. Ms Y said the Care Team stopped home visits in November 2018, and the letter which confirmed that never arrived. She said her friend travelled from London to make up the shortfall in her support.
5. Also, Ms Y said Durham County Council (the Council) completed a financial assessment without involving her. The Council charged her the highest rate, leaving her in £5,000 debt.

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The Ombudsmen’s role and powers

6. 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).
7. 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 investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
9. 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

10. I have considered the complaint information Ms Y has provided in writing and by telephone. I have asked the Council and Trust to comment on the complaint, and provide supporting documentation. I have taken the relevant law and guidance into account.
11. Ms Y, the Council and the Trust had an opportunity to comment on a draft decision, and I considered their comments.

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What I found

Reasonable adjustments

12. Ms Y suffers with dyslexia, visual stress and physical and mental health issues. Staff from the Council and Trust work together in an integrated care team (the Care Team) to support Ms Y’s social care and health needs.
13. Before 2018, the Care Team asked Ms Y to attend a meeting to discuss her reasonable adjustments. She could not attend so provided them with a report from Shelter which included reasonable adjustments to help her communication with other bodies. Those included:
• Using pale yellow/green paper
• Comic Sans font (size 14)
• Numbered pages and paragraphs
• Concise paragraphs
• 1.3 multiple line spacing
• Not interrupting her when she is speaking during phone calls or face to face
• Advising her if time is limited at the start of the call
• Extra time for meetings
14. In February 2018 the Trust completed guidance to help the Care Team manage Ms Y during difficult conversations. The Service Response Plan said staff should:
• Stick to the objectives of the phone call or meeting.
• Not get defensive if Ms Y questions their practice or competence, try to return to the objective of the contact.
• End the call if Ms Y is verbally abusive and clearly communicate that to her.
15. In response to Ms Y’s complaint, the Council and Trust both said its staff agreed to Ms Y’s reasonable adjustments and went above and beyond for her. The Trust also said it understood how to manage phone calls with Ms Y. When staff felt the conversation was deteriorating, they should tell her before terminating the call. It apologised if that did not always happen.
16. During my investigation, the Council and Trust both said they agreed to Ms Y’s reasonable adjustments even though they felt the Shelter report was misleading.

Analysis

17. The Equality Act 2010 says an individual or organisation that provides a service to the public, such as councils, must not treat someone worse just because of one or more ‘protected characteristics’. Protected characterises include people with disabilities.
18. When the duty Arises, the public body is under a positive and proactive duty to look at removing or preventing obstacles to a disabled person accessing its services.
19. To make sure that a disabled person can use the service as far as is reasonable to the same standard as a non-disabled person, the service provider must make adjustments. If the adjustments are reasonable it must make them.
20. The Council’s Equality Policy (2017) says it will: “...consider reasonable adjustments and other requirements relating to disabled people”.
21. First, I will consider the Council and Trust’s written communication to Ms Y between March 2018 and May 2019.
22. From the evidence I have seen, the Council and Trust sent 20 letters to Ms Y. Most letters adhered to nearly all the reasonable adjustments. However, only four complied with all. The Council and Trust did not number the pages and paragraphs of most letters. Also, three letters did not have correct line spacing and two did not have the correct font.
23. I consider this was fault which caused Ms Y distress and frustration. The fault would have also made it more difficult for Ms Y to understand the letters. Overall, I consider the Council and Trust were equally at fault and should remedy the injustice Ms Y suffered.
24. I have reviewed the extensive verbal communication between the Care Team and Ms Y. I have considered the Care Team’s record of verbal communication (phone calls and meetings) between March 2018 and May 2019, and if they fall in line with the Service Response Plan.
25. I understand Ms Y does not accept the Care Team’s records are accurate. However, I have not seen any evidence to doubt they are not an honest reflection of the conversations then.
26. During telephone calls, the Care Team always tried to keep Ms Y focused on the reason for the call. The Care Team ended some phone calls when Ms Y was verbally aggressive. For example, in November 2018 a Community Nurse ended the call due to “[Ms Y] shouting at me [the Community Nurse]”. This was in line with the Service Response Plan.
27. Between January and May 2019, it was clear Ms Y and the Care Team’s relationship was breaking down. The Care Team ended many phone calls because the conversation was going around in circles with no resolution. The Care Team recognised Ms Y’s distress during those calls and said ending the conversations would lessen her distress. While the Care Team was not strictly acting in line with the Service Response Plan, I consider it was appropriate the Care Team removed themselves from the situation to lessen Ms Y’s distress.
28. I will now consider how the Care Team managed Ms Y’s reasonable adjustments during meetings.
29. The Care Team always provided Ms Y with extended appointments to give Ms Y time to discuss her care and support needs during meetings. Also, it set an agenda before meetings to make them as productive as possible.
30. The Care Team’s records show it found it difficult to keep Ms Y focused on the meeting agendas.
31. In December 2018, Ms Y wanted to discuss her general unhappiness with her care and support during meetings rather than discuss her mental health. The Care Team appropriately directed Ms Y to the complaints process at that time and tried to bring Ms Y round to the reason they were meeting. The Community Nurse noted: “[Ms Y] fails to focus on the outlined agenda despite [sic] at least three prompts” and “[Ms Y] proceeded to call me a ‘sorry excuse for a nurse’”.
32. I consider the Care Team acted in line with the Service Response Plan during meetings.

Communication about care and support

33. Two personal assistants (PA 1 and PA 2) supported Ms Y’s social care needs from March 2018.
34. In April 2018, the Care Team assessed Ms Y’s needs for support.
35. In July 2018, the Care Team confirmed to Ms Y it would reduce her hours of support to encourage her to be more independent. Ms Y disagreed with the outcome and it took until October 2018 for the Care Team and Ms Y to agree what support would meet her needs. That included 40.5 hours support each week from the Care Team, some of which could be used flexibly.
36. In August 2018 Ms Y ended PA 2s employment. The Care Team asked if care agencies could make up the shortfall in Ms Y’s support. In October 2018, a care agency called Helping Hands (Agency 1) agreed to support Ms Y. At the same time, the Care Team was advertising for new personal assistants for Ms Y.
37. In early December 2018 Ms Y’s social worker (the Social Worker) told their manager they were struggling to manage Ms Y’s needs and felt Agency 1’s care would break down.
38. On 21 December 2018, Ms Y told the Social Worker she was unhappy with the support she would receive from Agency 1 over Christmas but had reluctantly agreed to some support. The Social Worker told Ms Y the alternative would be a mixed gender residential placement, which Ms Y declined due to previous trauma involving men.
39. Three days later, PA 1 ended their employment with Ms Y. Agency 1 agreed to provide all of Ms Y’s care and support. Also, the Social Worker asked another care agency called Time to Care (Agency 2) to support Ms Y to social activities, who agreed.
40. Agency 2 only provided support from January to February 2019. Two carers said Ms Y was verbally abusive and they could not keep up with Ms Y in her wheelchair. Ms Y said the staff could not support her needs. Agency 1 continued to provide support to Ms Y.
41. During February and March 2019 Agency 1 and the Social Worker met with Ms Y to discuss the difficulties providing care and support. The Social Worker repeated the offer of a residential placement. Ms Y declined because she felt that solution would have worsened her mental health. The Social Worker confirmed adverts for personal assistants were online and awaiting responses.
42. In late March 2019, Agency 1 told the Social Worker the relationship between Ms Y and their staff had broken down. It would stop supporting Ms Y at the end of April 2019 because of her verbal abuse of staff which caused them distress. Staff refused to work with Ms Y.
43. In early April 2019, the Care Team told Ms Y it would not be able to support her needs until she could recruit some personal assistants. The Care Team was supporting her to do that by advertising internally and externally. The Care Team also referred Ms Y to its Support and Recovery service where two female support workers would help Ms Y secure the personal assistants.
44. In late April 2019, Ms Y regularly asked the Care Team what support it would provide when Agency 1 stopped. The Care Team offered Ms Y an all‑female residential placement, while it arranged a more permanent option. Ms Y declined the offer as it would go against medical advice about her post‑traumatic stress disorder (PTSD). Ms Y was disappointed the Care Team had not done enough to help her employ personal assistants.
45. The Care Team noted it was not aware of the PTSD diagnosis. It felt Ms Y had self-diagnosed PTSD. Ms Y would not consent for the Care Team to access her medical history, so it could not understand Ms Y’s history of mental health.
46. After Agency 1’s support ended, during May 2019 the Care Team provided some support to meet Ms Y’s needs. Ms Y repeatedly refused the temporary residential placement.

Analysis

47. Ms Y says the Care Team’s communication about her care and support was poor.
48. I have reviewed the Care Team’s contact with Ms Y between March 2018 and May 2019.
49. There were difficulties arranging appointments with Ms Y between March and July 2018, when the Care Team wanted to assess Ms Y’s care and support needs. However, I cannot say those delays were only caused by the Care Team. Ms Y wanted her advocate present at meetings about care and support so it took longer to gather all the right professionals for meetings.
50. When the Care Team decided how to meet Ms Y’s needs, I consider it clearly communicated its reasons Ms Y’s needs had reduced. The Care Team met Ms Y many times between July and October 2018 to discuss her concerns about the decrease in her care package. While Ms Y and her friend disagreed with the assessment, the Care Team communicated effectively with Ms Y to the point they agreed what support would meet her needs.
51. After PA 1 left in December 2018, the Care Team had to act quickly to ensure it met Ms Y’s needs over Christmas. Even though Agency 1 agreed to fully support Ms Y’s needs, the Care Team also agreed to fund support from Agency 2. The Care Team explained Agency 2 would support her to social activities.
52. Christmas is always a difficult time for local authorities to manage service user’s needs. I consider the Care Team worked quickly over Christmas to ensure Ms Y received the support she needed and kept Ms Y updated. This included a hospital appointment she would have most likely missed if not for the Care Team’s intervention. The Care Team’s records note Ms Y was thankful for their help.
53. After December 2018, the Care Team offered Ms Y the option of moving into a mixed gender respite placement to ensure it would meet all her needs. Ms Y said that placement would worsen her PTSD. But I cannot say the Care Team was at fault for communicating that offer to Ms Y. Ms Y told the Care Team she had PTSD since 2016, but has been unable to confirm a formal diagnosis by her previous mental health team. She has never given the Trust her consent to access her previous medical history. The Care Team could not accept Ms Y’s word that she had PTSD, which made it more difficult to consider her mental health needs as part of its support.
54. After April 2019 the Care Team was running out of ways to meet Ms Y’s needs. Nearly all care agencies in the area (apart from Agency 1 and 2) refused to work with Ms Y. I cannot agree the limited choices was due to any fault on the Care Team’s part.
55. Before Agency 1 withdrew its support, leaving Ms Y with no care, the Care Team offered her a place in an all-female residential unit. While it was not Ms Y’s preferred means of support, I consider that support would have met Ms Y’s assessed needs. However, Ms Y had capacity to decline that support.
56. Ms Y wanted personal assistants to provide the support she needed, and she wanted the Care Team to help her do that.
57. After August 2018, I consider the Care Team and the Council’s Direct Payment team spent a significant amount of time advertising on Ms Y’s behalf for personal assistants. Agency 1 also increased its support to allow her to interview personal assistants.
58. There was regular communication between the Care Team and Direct Payment team to source personal assistants for Ms Y. That communication increased when Agency 1 withdrew its support. The Care Team also sought support from two people to work solely to help Ms Y employ new personal assistants.
59. I consider the Care Team and Agency 1 communicated appropriately with Ms Y about the personal assistant adverts and offered her support where necessary.
60. Overall, the Care Team was in regular contact with Ms Y throughout the period I have investigated to discuss her care and support.

Home visits

61. On 7 December 2018 a care coordinator (the Care Coordinator) visited Ms Y at home to discuss her mental health. During the visit, Ms Y was hostile and derogatory toward her. The Care Coordinator went to leave, and Ms Y blocked her exit. Later that day, the Care Coordinator discussed Ms Y's behaviour with the Trust’s leadership team who decided to suspend home visits. The Trust sent Ms Y a letter warning her about her behaviour towards its staff.
62. On 17 December 2018 the Social Worker told Ms Y the Care Team had stopped home visits due to events on 7 December. Ms Y asked for the reasons in writing, which the Social Worker agreed to send. Over a month later, Ms Y chased the letter from the Social Worker, who again agreed to follow that up. Ms Y said it was unfair because she could not challenge the reasons the Care Team cancelled the home visits.
63. In response to Ms Y’s complaint, the Trust apologised it did not send a letter confirming its decision in writing.

Analysis

64. The Trust’s Security Procedure provides guidance to staff on how to manage patients who are verbally threatening, abusive and intimidating. The Trust can issue a warning letter to the patient to ensure it does not impact the care and the relationship with the patient. Also, to reduce the risks to staff.
65. Ms Y said the Care Coordinator was derogatory and hostile to her, which triggered flashbacks. Also, there was enough room for the Care Coordinator to pass her in the doorway. I do not doubt Ms Y’s version of events as she remembers them. However, I am more persuaded by the Trust’s evidence from the time is a fair account of what happened on 7 December 2018.
66. I consider the Trust acted in line with its policy when it issued Ms Y with a warning letter about her behaviour. The Trust decided to suspend home visits following Ms Y’s behaviour on 7 December 2018, and other times when her behaviour had fallen below the expected standard. The Trust said staff were at risk of further abuse, especially the Care Coordinator. The Trust also said Ms Y had mental capacity to understand the impact her behaviour was having towards staff. I consider the Trust appropriately considered the circumstances and impact of Ms Y’s behaviour when it decided to stop home visits between December 2018 and February 2019.
67. The Trust did not send a letter confirming why it stopped home visits. The Trust said it sent a letter to Ms Y confirming the reasons, but it could not find a copy. It was most likely saved in a different area to where it should be on its systems.
68. I consider, on the balance of probabilities, the Trust did not send a letter to Ms Y explaining why it stopped. The Trust cannot locate the letter, and I do not see what Ms Y would benefit from being dishonest about not receiving the letter. This was fault but I do not consider there was any injustice to Ms Y.
69. The Trust’s warning letter explained Ms Y was verbally aggressive and derogatory to staff. The Social Worker then told Ms Y home visits had stopped because of the incident on 7 December. Therefore, I am satisfied Ms Y would have understood the reason home visits stopped.

The financial assessment

70. In March 2018 the Council told Ms Y she would need to send evidence of disability related expenditure (DRE) to the finance team to consider as part of a new financial assessment. Her last assessment was in 2016.
71. Ms Y asked for a new financial assessment in November 2018, which the Council agreed to arrange.
72. A month later Ms Y asked the Social Worker what information she needed to gather for the financial assessment because she had DRE’s. A few weeks later, the Social Worker tried to explain what information Ms Y would need to bring to the appointment. During the phone call, the Social Worker noted Ms Y “was struggling to take this all in and asked if I [the Social Worker] would share the information with her PA [personal assistant]”. The Social Worker then told PA 1 what evidence Ms Y needed to bring.
73. In January 2019 the Council arranged to meet Ms Y at a community centre (Centre 1) to complete a new financial assessment. Ms Y went to a different community centre (Centre 2) and missed the appointment. Ms Y said she did not agree to meet at Centre 1, it must have been PA 1 who suggested Centre 2. The Social Worker agreed there was miscommunication.
74. The Council later completed the financial assessment based on information from the Department for Work and Pensions. The assessment did not consider any DRE.
75. In response to Ms Y’s complaint, the Council said the Social Worker told Ms Y what information she needed to provide for the financial assessment. The assessment was appropriate and Ms Y’s debt has accrued due to her not paying the full costs of her care.

Analysis

76. Councils can make charges for care and support services they provide or arrange. Charges may only cover the cost the council incurs. (Care Act 2014, section 14)
77. Councils must assess a person’s finances to decide what contribution he or she should make to a personal budget for care. The scheme must comply with the principles in law and guidance, including that charges should not reduce a person’s income below Income Support plus 25%. The Council can take a person’s capital and savings into account subject to certain conditions. If a person incurs expenses directly related to any disability he or she has, the Council should take that into account when assessing his or her finances. (Care Act 2014 Department for Health, ‘Fairer Charging Guidance’ 2013, and ‘Fairer Contributions Guidance’ 2010)
78. I have considered the Care Team’s records from March 2018 to January 2019.
79. The Council confirmed what evidence Ms Y needed to provide to a financial assessment in March 2018. This included evidence of DRE. The Social Worker confirmed that again in December 2018 to PA 1. I cannot say if PA 1 communicated that information to Ms Y or not. However, I am still satisfied Ms Y understood what she needed to provide months before the January 2019 assessment.
80. Ms Y said she has not provided evidence of DRE to the Council because it did not support her to gather that evidence. Ms Y’s care plan states that she should receive two hours per week support with paperwork/correspondence.
81. Ms Y was aware what information she needed to provide to the financial assessment since March 2018. I recognise the Care Team struggled to meet Ms Y’s needs in her home. However, Ms Y had 10 months to gather the relevant evidence for a financial assessment between March 2018 and January 2019. The Care Team’s records do not show Ms Y specifically sought more support to gather that evidence. I consider Ms Y had a significant amount of time to gather the evidence she needed before the financial assessment.
82. Ms Y said she did not recommend meeting at Centre 1, and the Council’s miscommunication caused her to miss the financial assessment. I do not consider the Council was at fault. The day before the financial assessment the Social Worker noted: “I encouraged [Ms Y] to attend the meeting at [Centre 1] and we discussed the arrangements made to support her with this”. I am satisfied the Social Worker clearly explained exactly what venue they would meet at.
83. Overall, I do not consider the Council acted with fault when it completed the financial assessment.

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Agreed action

84. Within four weeks, the Care Team should:
• Acknowledge and apologise to Mr Y for the distress caused by not consistently making Ms Y’s reasonable adjustments.
• Pay Ms Y £200 to recognise the distress.
• Ensure all relevant staff are aware of Ms Y’s reasonable adjustments and their responsibilities under the Equality Act 2010 in meeting them.
• Consider what steps they can take to ensure other departments (within the Council and Trust) comply with all of Ms Y’s reasonable adjustments if they need to send her letters.
85. As the Care Team includes staff from the Council and Trust, they should work out between them who will carry out the recommendations.

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Final decision

86. The Care Team did not consistently make reasonable adjustments in letters which caused Ms Y distress and frustration.
87. The Care Team was in regular contact with Ms Y and clearly communicated with her about her care and support.
88. The Care Team followed its own guidelines when deciding to stop home visits to Ms Y, and provided a robust rationale for doing so. The Care Team should have sent Ms Y a letter confirming why home visits stopped. However, there was no injustice as the Social Worker explained that verbally to Ms Y.
89. The Council clearly explained what information Ms Y needed to provide to the financial assessment. Ms Y had a significant amount of time to gather that evidence, and the Council clearly told Ms Y where the assessment would be held.

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Investigator's decision on behalf of the Ombudsman