Summary: There was fault in the way the Council’s care planning and in the provision of care and support. Therefore, Mr B may not have received all the care and support he may have been entitled to. The Council has agreed to apologise to Mr B, pay him a small financial remedy and carry out a service improvement.

The complaint

1. Mr B moved to the Council’s area in May 2023. He complained that:
• The Council failed to ensure continuity of care when he moved.
• The Council failed to properly assess his needs in June 2023 and did not properly address the concerns he raised about this assessment.
• The Council re-assessed his needs in September 2023 and said he was eligible for support by the Council but did not put the support in place until December 2023.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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What I have and have not investigated

4. I have investigated the time period from May 2023 until December 2023. I have not investigated complaints outside of this time period, as these complaints have already been investigated by the Ombudsman or are being considered for investigation.

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How I considered this complaint

5. I have discussed the complaint with Mr B. I have considered the evidence Mr B and the Council have provided, the relevant law, policy and guidance and both sides’ comments on the draft decision.

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What I found

Legal basis

6. The Care Act 2014 and the Care and Support Statutory Guidance 2014 (CASS Guidance) set out the Council’s duties towards adults who require care and support.

Assessment, care plan and personal budget

7. The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs and a personal budget which sets out the costs to meet the needs.

Eligibility

8. The threshold for eligibility is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing. Council must consider whether:
• The adult’s needs arise from a physical or mental impairment or illness.
• As a result of the adult’s needs the adult is unable to achieve 2 or more of the specified outcomes.
• As a consequence of being unable to achieve these outcomes there is a significant impact on the adult’s wellbeing.

Outcomes

9. The outcomes are:
• Managing and maintaining nutrition
• Maintaining personal hygiene
• Managing toilet needs
• Being appropriately clothed
• Being able to make use of the home safely
• Maintaining a habitable home environment
• Developing and maintaining family or other personal relationships
• Accessing and engaging in work, training, education or
• Making use of necessary facilities or services in the local community
• Carrying out caring responsibilities for a child.

What does ‘meeting needs’ mean?

10. Needs may be met through types of care and support which are available universally. Needs could be met, for example, by putting a person in contact with a local community group or voluntary sector organisation.
11. However, the duty to meet eligible needs is not discharged just because a person has another entitlement to a different service which could meet those needs, but of which they are not availing themselves. The needs remain ‘unmet’ (and so the local authority remains under a duty to meet them) until those needs are actually met by the relevant service being provided or arranged.

Making use of the community

12. In terms of ‘making use of the community’ the CASS Guidance says:
• Local authorities should consider the adult’s ability to get around in the community safely and consider their ability to use such facilities as public transport, shops or recreational facilities when considering the impact on their wellbeing.
• Local authorities do not have responsibility for the provision of NHS services such as patient transport, however they should consider needs for support when the adult is attending healthcare appointments.

Agreeing the care plan

13. The CASS Guidance says the care plan should be person-centred, with an emphasis on the individual having every reasonable opportunity to be involved in the planning.
14. Consideration of the needs to be met should take a holistic approach that covers aspects such as the person’s wishes and aspirations in their daily and community life, rather than a narrow view purely designed to meet personal care needs.
15. The local authority must take all reasonable steps to agree with the person how the person’s needs will be met in the care plan, before the authority signs off the plan.
16. If the plan cannot be agreed with the person, the local authority should state the reasons for this and the steps which must be taken to ensure that the plan is signed-off.
17. If a dispute still remains, and the local authority feels that it has taken all reasonable steps to address the situation, it should direct the person to the local complaints procedure. However, by conducting person-centred planning and ensuring genuine involvement throughout, this situation should be avoided.

Review of the care plan

18. The CASS Guidance says that if there is any information or evidence that suggests that circumstances have changed in a way that may affect the efficacy, appropriateness or content of the plan, then the local authority should immediately conduct a review to ascertain whether the plan requires revision. The Council should also carry out a review if it receives a reasonable request by the adult who the plan relates to.

Continuity of care

19. The CASS Guidance says local authorities should ensure continuity of care when adults receiving care and support move from one local authority (1st local authority) to another local authority (2nd local authority). The process is:
• The 1st local authority informs the 2nd local authority of the intended move.
• The 1st local authority provides the 2nd local authority with its assessment of the person’s needs, their care plan and any other requested information.
• The 2nd local authority carries out an assessment of the person’s needs and provides a care plan.
• If the 2nd local authority has not completed its assessment by the time of the move, then it must continue to meet the adult’s needs for care and support as identified by the first authority.
20. The Care and Support (Continuity of Care) Regulations 2014 and the CASS Guidance set out what factors the 2nd local authority should take into account, if it had not yet completed its assessment by the time the person moves:
• The care plan. The second authority should discuss with the adult how to meet their eligible needs and any other needs that the first authority was meeting that are not deemed as eligible but were included in the plan.
• Outcomes. Whether the outcomes that the adult was achieving in day-to-day life in their first authority are the outcomes they want to achieve in the new authority, or whether their aims have changed because of the move.
• Preferences and views. The preferences and views of the adult on how their needs are met during the interim period
• Any significant difference to the person’s circumstances where that change may impact on the individual’s wellbeing,

What happened

21. Mr B moved to the area of Salford City Council (which I shall refer to as the Council) from another Council’s area (which I shall refer to as council K).

Council K’s needs assessment –April 2022

22. Council K’s needs assessment of Mr B said Mr B had physical and mental health conditions which affected his ability to meet outcomes. Mr B needed care and support to meet 6 out of the 10 eligible outcomes.
23. Mr B’s mental health and physical conditions caused fatigue, tremors and spasms and Mr B needed support in:
• Nutrition.
• Personal hygiene.
• Maintaining a habitable home environment.
24. Mr B’s mental health conditions and, in particular, his agoraphobia and Post-traumatic stress disorder (PTSD) meant he was unable to leave his home. This affected his ability to meet these outcomes:
• Developing personal relationships.
• Accessing work, training, education.
• Making use of the local community.

Council K’s care plan – June 2022

25. Council K’s care plan said Mr B was entitled to 15 hours support a week (provided by direct payments). He should also receive a daily 20-minute visit from a care agency to support him with personal care.

Events from May 2023 onwards

26. Council K made a referral for Mr B to the Council on 19 May 2023 and informed the Council of Mr B’s move to the Council’s area. Council K sent Mr B’s needs assessment and care plan to the Council.
27. A note dated 24 May 2023 said: ‘Support plan from [council K]. [Mr B] had a direct payment but felt his assessed contribution was too high so he chose to not receive any support. Care calls in place but he felt no need to start the same at point of moving to Salford.’
28. Mr B contacted the Council on 30 May as the move had taken place and he said he needed urgent support. He could not go outside because of his agoraphobia and needed to pick up his medication and had to visit his GP. Mr B made further calls to the Council over the following weeks asking for urgent help and said he suffered falls because of the lack of support.
29. The Council and council K held a meeting on 13 June 2023 to discuss Mr B. There are no minutes of the meeting but these are the Council’s officers’ recollections of what was said:
• Council K told them that the support set out in the care plan had not been put in place. However, a Council K officer completed Mr B’s shopping for him on a regular basis. Council K’s social worker also drove Mr B to the Council’s area to view the flat and later helped M B to move into the flat.
• Council K said Mr B needed support around his mental health, medical and psychological issues, rather than support from social services and that the Council’s assessment may well be that Mr B did not meet the eligibility criteria for support under the Care Act.
30. Council K said, in June 2025:
• Council K never provided commissioned support as Mr B did not agree to pay the contribution towards the care package because of a dispute over disability related expenditure.
• Council K agreed, as a goodwill gesture, that its reablement service would support Mr B with a weekly shop to increase his independence (1pm on a Wednesday). Mr B sometimes declined this support as he said he had no money for shopping. At other times, the reablement officer would sit with Mr B and chat with him.
• Mr B did not receive support with shopping during the 6 weeks before his move, although he did request food parcels which the social work team provided.

Council’s needs assessment – 16 June 2023

31. The Council’s social worker assessed Mr B’s needs for care and support on 16 June 2023 and said he only had one eligible need and therefore was not entitled to support from the Council. They said:
• Managing and maintaining nutrition/making use of the community. ‘Mr B confirmed that he makes his own meals and drinks. [Mr B] reports that he provides his own shopping, he advised that he uses a taxi to go to the local delivery. [Mr B] confirmed he would be able to order an online delivery.’ Mr B also informed them of his plan to attend an event in town on 17 June 2023.
• ‘Mr B reports he is able to independently have a shower, but advises he can be at risk of falling when he exits the shower.’ Mr B was waiting for a grab rail to be installed.
• Maintaining a habitable home environment. This was identified as an eligible need as Mr B struggled to maintain the home environment.
• Mr B was independent in all other areas: toileting needs, getting dressed, living in a safe home, personal relationships, work training and education.
32. The assessment concluded that Mr B’s needs should be met by mental health professionals and that the NHS should assist in attending medical appointments.

Telephone call – 20 June 2023

33. The social worker informed Mr B of the outcome of the assessment and gave Mr B the details of a befriending service and of a charity that helps people with mental health issues. Mr B was informed that his case would be closed.
34. The Council sent Mr B a copy of his assessment on 26 June. Mr B started to send complaints to the Council after receiving the assessment.

Meeting with Mr B – 14 July 2023

35. The Council held a meeting with Mr B. The aim was for Mr B to ‘share his feelings regarding the assessment’ and to discuss his complaints.
36. Mr B said the assessment was factually incorrect and said:
• He was unable to leave the house without support. He had not left his home unaccompanied for 15 years because of agoraphobia and PTSD.
• He was unable to attend meetings or appointments without support. He was unable to go to the shops, take a taxi or public transport because of his agoraphobia and PTSD.
• The assessment said he was going to attend an event in town unaccompanied. That was not true. He attended the event but was accompanied.
• He was unable to make meals without support. A friend had helped him in this respect.
• He could not wash himself without support.
• He was unable to maintain relationships without support.
• He could not maintain his house as he was unable to move items.
• He had continued to receive support from Council K. Council K ended his full support package in April 2022 but continued to complete shopping visits and support with appointments and other support he required.
37. The Council said the factually incorrect statements could be amended. But the support Mr B wanted was not something it could provide as the Council promoted ‘strength-based working’. Mr B could do his own shopping online and the Council would not support anyone with health appointments. The manager who shared the meeting said: ‘the assessment completed stands and if he wanted to appeal this, he could.’
38. Mr B asked why the manager would deny him a reassessment when the assessment was full of lies and incorrect information, for example his ability to go outside unsupported. Mr B asked the manager whether they disbelieved him. The manager replied that they would not say, but the assessment was signed off by them. If Mr B disagreed, he could appeal and this would then be considered by Senior Management.

Mr B’s complaint – June 2023

39. Mr B made several complaints to the Council from June to September 2023 which I have summarised. Mr B said:
• The transition of his care package from council K was not in line with the Care Act. He could provide evidence of the support he received from council K up until the day of the move but the Council refused to look at the evidence.
• The social worker’s assessment of his needs consisted of 5 or 6 questions, did not properly assess his needs and was full of untruths and was fabricated. He was unable to achieve any of the outcomes the Council said he could achieve. When he explained this to the Council, the Council refused to engage with him to change the assessment and refused a re-assessment.
• He was alone in his flat, unable to go out, had suffered falls, was unable to go to his doctor, was not eating and needed support urgently. His flat was cluttered and the ambulance service said it was a health hazard.
40. In the following weeks, Mr B continued to call the Council for help. The police and the ambulance service became involved as Mr B had several falls and said he was suicidal and the Council received safeguarding referrals regarding Mr B.

Council’s response – 28 July 2023

41. The Council’s manager responded to Mr B’s complaint on 28 July (there were later responses but these were essentially the same) and said:
• Mr B was never in receipt of services from Council K. A member of Council K’s Adult Social Care team visited Mr B regularly but that was not a commissioned service.
• The Council carried out a comprehensive assessment of Mr B’s needs and Mr B was offered signposting and befriending services.
• The Council would not support Mr B with shopping but would signpost him to community services who could support him in this respect. Mr B was advised to do online shopping.
• Mr B had only one eligible need (maintaining a habitable environment) and he needed two eligible needs to be eligible under the Care Act.
• The Council did not support people to attend health appointments as this was the role of the NHS.

Assessment of needs – 14 September 2023

42. In September 2023, the Council changed its position and decided to re-assess Mr B’s needs for support. The social worker now concluded Mr B was eligible for support to meet six outcomes:
• Nutrition. Mr B was mostly eating cereal and only had a cooked meal if a friend prepared it for him. He was unable to go into the community to shop for food and his friend was shopping for him.
• Personal hygiene. Mr B only showered when someone was present as he could suffer falls. He could not apply the necessary creams to his body because of physical conditions.
• Being able to make use of the home safely / maintaining a habitable home. Mr B’s home was very cluttered and he was struggling to keep his home clean without support.
• Maintaining relationships. Mr B was socially isolated as he had moved to a new area. He was unable to make new social connections in the community as he could not go out without a person with him.
• Making use of services in the local community. Mr B was unable to leave his home without the support of another person.

Further developments

43. The social worker discussed the case with their manager on 21 September 2023 and it was agreed that the Council would organise a deep clean of Mr B’s property. Mr B would be transferred to the Integrated Care Team which would undertake support planning. The social worker rang Mr B on the same day and informed him of the outcome of the assessment. Mr B continued to ring in the following weeks as he was waiting for the case to be allocated to the Integrated Care Team and the support package to start.
44. Mr B’s social worker wrote a note on 10 October 2023 which said:
• ‘[Mr B] was allocated to me to follow about the outcome from the social care assessment. I was advised that I need to explore community options to meet [Mr B’s] needs and that commissioned support would not be considered.’
45. The social worker explained this to Mr B who disagreed with this outcome and raised further complaints.

Safeguarding enquiry – 6 November 2023

46. The Council continued to receive safeguarding referrals regarding Mr B and decided that the threshold for a section 42 enquiry was met as Mr B may be at risk of self-neglect in the following areas:
• Personal hygiene.
• Nutritional needs.
• Environmental. The Home was cluttered and therefore Mr B was at risk of trips and falls. There was also a fire risk and a risk that it would be difficult for him to escape the home if there was a fire.
47. The safeguarding officer visited Mr B on 1 December 2023 and it was agreed that the safeguarding referral would be closed. The Council would take actions which included the cleaning of the property and putting in place a care plan which would be discussed with Mr B before implementation.

Care plan – 18 December 2023

48. The Council provided Mr B with a care plan and said he was entitled to 10 hours per week support from 18 December 2023. The plan also said staff should support Mr B with decluttering/organising and with cleaning the property.
49. The Council hired a care agency to provide the support.

Analysis

50. The Ombudsman cannot carry out an assessment of Mr B’s needs nor can it say what his care plan should have been. I can only investigate whether there was fault in the Council’s actions and I have done so by comparing what the Council should have done according to the law, guidance and policies and what it did.
51. The Council had not yet assessed Mr B’s needs for care and support when Mr B moved to the Council’s area at the end of May 2023, so the Council had a duty to continue to meet Mr B’s needs for care and support as identified by council K.
52. I acknowledge that, in Mr B’s case, it was difficult to establish what needs council K had identified. I accept that Council K did not put in commissioned support, (paid support by an external agency), but council K did put in support from its own resources (from the reablement and adult social care teams).
53. I note the Council considered the documents it had received from council K and so that was good practice and was in line with the regulations.
54. However, the regulations say the Council should also have considered (see paragraph 20):
• Mr B’s views on his care plan and how to meet eligible needs
• The outcomes that Mr B achieved and wanted to achieve
• Mr B’s preferences and views
• Any difference in circumstances now that he had moved
55. It is not clear when the Council decided not to provide any support to Mr B while he waited to be assessed but I could not find any evidence the Council spoke to Mr B before it made that decision or how it made the decision.
56. All I could find was the note dated 24 May 2023 which included the sentence: ‘Care calls in place but he felt no need to start the same at point of moving to Salford.’ This appears to be based on a conversation with council K but it was not clear.
57. The Council should have documented more clearly how it made the decision, in line with the CASS Guidance and the regulations, not to provide a service to Mr B while he waited for an assessment. And the Council should have spoken to Mr B before it made that decision. Of course, I cannot say what the outcome would have been if the Council had done so.
58. I note the Council held a meeting with council K on 13 June 2023, and this was good practice, but that was weeks after the Council had decided not to provide support to Mr B.
59. The Council assessed Mr B’s needs on 16 June 2023 and concluded he only had one eligible need (maintaining a habitable home environment) and he was therefore not entitled to support under the Care Act. This was a considerable change from the previous and later assessment where Mr B was assessed as having eligible needs to meet 6 outcomes.
60. That did not mean there was fault, of course. But I note that the assessment of June 2023 was short and that a lot of the conclusions, particularly in relation to Mr B’s ability to leave his home unsupported, were based on two statements from Mr B (which he later denied) which were:
• He said he was going to an event on the following day.
• He took taxis to go shopping on his own.
61. I am of the view that there was fault in the Council’s actions after Mr B raised concerns about the assessment.
62. The Council held a meeting with Mr B on 14 July 2023 where Mr B said there was a lot of missing information and factual inaccuracies in the assessment (paragraph 36) and that he was unable to perform the tasks which the Council said he could perform, for example going outside unsupported.
63. Mr B made a lot of valid points and the manager who chaired the meeting agreed to change the factual inaccuracies in the assessment but said this made no difference and the only option for Mr B was to make a formal complaint. The manager said Mr B’s complaint would be considered by Senior Management.
64. Mr B complained and continued to ask for a re-assessment in the following weeks and the Council denied the reassessment. I note that the Council’s complaint response dated 28 July 2023 was written by the same manager who chaired the 14 July meeting. There was fault in that respect as Mr B had complained about this manager and as the manager had promised Mr B during the 14 July meeting that his appeal/complaint about the assessment would be considered by senior management. There was no evidence that senior management considered the appeal/complaint.
65. The notes showed that the Council continued to hold the position that Mr B was not entitled to a reassessment throughout most of August and then the Council suddenly changed its position. There was no explanation for this change in decision or why this decision was not made earlier.
66. In my view there was fault in the Council’s delay of two months in offering a reassessment and its failure to properly explain how it considered the points that Mr B made about the assessment from the meeting in July onwards and why this did not trigger either a change in the assessment or a reassessment.
67. The Council changed it position in the assessment of 14 September 2023 and agreed that Mr B was unable to achieve 6 outcomes, without support, similar to what council K had said. I note that this assessment was a lot more detailed than the assessment dated 16 June 2023. It went into great detail about Mr B’s physical and mental challenges, considered each outcome in detail setting out what support Mr B needed and what he could achieve.
68. However, there was then further fault as the Council refused to provide a service to Mr B until December 2023.
69. There was no clear explanation from the documents I saw, why this decision was made. I accept that a council can rely on free services in the community to meet a particular need rather than commission services. But, when it does so, the Council must ensure that the services exist and that they will meet the need. I cannot find evidence that the Council ensured that the services existed and that they were in place before it decided not to commission a service for Mr B. That was fault.
70. I note the Council only put in place the care package after Mr B made further complaints and there was a safeguarding enquiry which said he was at risk of neglect.
71. In terms of injustice, Mr B missed out on care and support, from 14 September onwards as the assessment said he was entitled to support. And I accept that it is possible that, if there had not been the delay in the reassessment, that Mr B could have been assessed earlier as requiring support, although I cannot say that with absolute certainty. I accept that this would have caused great distress to Mr B.
72. The aim of the Ombudsman’s remedy is to put the person in the position they would have been if the fault had not happened. In cases such as this one, where that is not possible and there is no direct financial loss resulting from the fault, the Ombudsman can recommend a small symbolic sum to represent the injustice caused by the fault. I recommend the Council pays Mr B £400.
73. I also recommend the Council reminds relevant officers of their duties to carry out a review assessment in certain circumstances. The Council has said that it has already reminded officers that complaint responses should not be sent by anyone whose practice has been questioned in the original complaint.

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Action

74. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise in writing to Mr B.
• Pay Mr B £400.
• Remind relevant officers of the Council’s duties to carry out a review as set out in the CASS Guidance.

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Decision

75. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman