Summary: Mr X and Ms Y complained about the Council’s handling and decisions around their adult child’s (Z) care and support, care placement, and mental capacity. We found no fault in the process the Council followed to reach its decisions on the substantial matters complained about. It therefore reached decisions it was entitled to make. There was some fault relating to a review meeting and delayed complaints handling. The Council will apologise to acknowledge the impact this had on Mr X and Ms Y.

The complaint

1. Mr X and Ms Y complained about the Council’s handling and decisions around their adult child’s (Z) care and support needs following her transfer from a care home to a supported living placement in February 2022. They said the Oxford Health NHS Foundation Trust (the Trust) acting on behalf of the Council had:
• unjustifiably refused to carry out a Care Act reassessment. This was despite a fundamental change of care as Z went from living in a care home to going to supported living accommodation;
• failed to arrange and monitor any proper support plan for Z at her supported living placement;
• wrongly refused to refer Z for an updated psychiatric assessment as it was last done in 2016 and they raised repeated concerns about Z’s declining mental health;
• failed to refer Z for psychological therapy;
• failed to make satisfactory arrangements for review meetings on 2 and 9 March 2023. This included failing to adequately prepare for the meetings. They also said it had caused delay in sharing minutes of the meetings or the notes were inaccurate;
• disagreed with its view on Z mental capacity; and
• failed to respond appropriately to their complaint.
2. Mr X and Ms Y said, as a result, they believe Z had not received the support she needed, and they have experienced distress and uncertainty as a result.

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The Ombudsman’s role and powers

3. 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)
4. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.

We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).

6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
7. 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

8. Mr X’s and Ms Y’s complaint relates to matters which occurred several years ago. This is more than 12 months before it was brought to our attention, the complaint is therefore late.
9. I have found it appropriate to exercise my discretion to consider their complaint from February 2022, which was when Z was placed in the supported living placement. This is because they raised their concerns with the Trust and were told to progress their complaint with the Parliamentary and Health Service Ombudsman which resulted in a significant delay in the complaint coming to our attention.
10. I have not investigated any concerns Mr X and Ms Y had about the Trust or the Council’s handling of Z’s accommodation or care support prior to February 2022 or after the Council’s complaint response in April 2025. These matters are either late or were not part of the complaints I have considered.
11. In addition, Mr X and Ms Y are entitled to bring a complaint in their own right as they have an interest in Z’s wellbeing. However, they do not have Z’s consent to bring a complaint, nor do Z agree with their views. I have therefore only considered the impact their concerns had on them.

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How I considered this complaint

12. I considered evidence provided by Mr X and Ms Y and the Council as well as relevant law, policy and guidance.
13. Mr X and Ms Y and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

Needs assessments

14. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
15. An adult with possible care and support needs or a carer may choose to refuse an assessment. In these circumstances councils do not have to carry out an assessment. Where a council identifies that an adult lacks mental capacity and that carrying out a needs assessment would be in the adult’s best interests, it must do so.
16. The Council’s Adult Social Care Policy says it will not undertake a new needs assessment for a person if it is of the view their needs have not changed since its previous assessment.

Care Plans

17. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.
18. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.
19. The Council’s policy says reviews should include the person to whom the review relates, their carer or any person the individual wants involved. If the individual lacks capacity, any person who appears to the Council to be interested in the person’s welfare.

Mental Capacity

20. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
21. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:

• because they make an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

22. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
23. An assessment of someone’s capacity is specific to the decision to be made at a particular time. When assessing somebody’s capacity, the assessor needs to find out the following:

• Does the person have a general understanding of what decision they need to make and why they need to make it?
• Does the person have a general understanding of the likely effects of making, or not making, this decision?
• Is the person able to understand, retain, use, and weigh up the information relevant to this decision?
• Can the person communicate their decision?

24. The person assessing an individual’s capacity will usually be the person directly concerned with the individual when the decision needs to be made. More complex decisions are likely to need more formal assessments.
25. Section 15 of the Act covers the best ways to settle disagreements and disputes about issues covered in the Mental Capacity Act 2010. This includes decisions about capacity and the care and support a person should receive. It encourages disagreements to be settled quickly and effectively. This may be through:
• mediation;
• Informal discussions. The guidance suggests discussing a matter with the family, possibly getting a second opinion or independent expert advice, arrange a meeting, listen to and acknowledge concerns;
• formal complaints, inc LGSCO;
• where other ways of resolving disagreements are not possible, through the Court of Protection.
26. If there is a conflict about whether a person has capacity to make a decision, and all efforts to resolve this have failed, the Court of Protection might need to decide if a person has capacity to make the decision.

Best interest decisions

27. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
28. If there is a conflict about what is in a person’s best interests, and all efforts to resolve the dispute have failed, the Court of Protection might need to decide what is in the person’s best interests.

The Court of Protection

29. The Court of Protection deals with decision-making for adults who may lack capacity to make specific decisions for themselves.
30. The Court of Protection may need to become involved in difficult cases or cases where there is disagreement which cannot be resolved in any other way. The Court of Protection:

• decides whether a person has capacity to make a particular decision for themselves;
• makes declarations, decisions or orders on financial or welfare matters affecting people who lack capacity to make such decisions;
• appoints deputies to make decisions for people lacking capacity to make those decisions;
• decides whether a Lasting Power of Attorney or Enduring Power of Attorney is valid; and
• removes deputies or attorneys who fail to carry out their duties.

What happened

31. I have set out a summary of the key events which occurred. This is not intended to include everything that happened.
32. Mr X and Ms Y’s child (Z) is an adult who has been diagnosed with health conditions. The last Care Act assessment took place in 2019 where the Trust found supported living accommodation would be suitable for her. Mr X and Ms Y disagreed.
33. Z lived in a residential care home until early 2022. She had a care and support plan which sets out her needs and the support she should receive. This was updated at the time.
34. Ms Y has a general power of attorney to manage Z’s finances. Mr X and Ms Y has disputed Z’s mental capacity with the Trust previously. In late 2019 the Trust had found:
• Z did not have capacity to make decision around her care and support as she lacked an insight into her care needs if she was in her own accommodation. No one has a power of attorney for health and welfare; and
• Z had capacity to make decisions around where she wants to live and with whom she shares information. She had for some time wanted to move to more independent accommodation and refused for some of her information to be shared with Mr X and Ms Y.
35. In early 2022 Z was moved into a supported accommodation in line with her wishes and the 2019 needs assessment.
36. In June 2022 the Trust carried out a Care Act review of Z’s care and support plan. Mr X and Ms Y asked for a reassessment of Z’s needs. However, the Trust found a reassessment was not required, and informed Mr X and Ms Y. An amended care and support plan was issued and some additional support was put in place for Z.
37. In November 2022 a further review meeting took place for Z, which included Mr X and Ms Y and the allocated social worker for Z. They raised concerns about the support Z was receiving and requested a psychiatric assessment of Z’s mental health. The Trust explained it found psychological therapy was more appropriate for Z and there had been some issues with Z’s support due to timetabling and staff turnover at the supported accommodation. However, it intended to arrange therapy, and Z’s support programme was restarted.
38. Shortly after Mr X and Ms Y asked the Trust to arrange a reassessment of Z’s care and support needs. They said this should have taken place already as her needs had changed and she had moved from a residential to a supported placement.
39. The Trust did not agree a reassessment was needed, but agreed to carry out a Care Act review of Z’s care and support plan in Spring 2023.
40. A review meeting was arranged for March 2023. However, the meeting was cancelled by the social worker without notice and rescheduled for the following week.
41. This meeting subsequently did take place. Mr X attended remotely. Ms Y could not stay at the meeting as Z refused for the windows to be opened. They said no supported living staff had been invited, no paperwork about Z’s care and support had been made available, and the social worker was unprepared and she therefore agreed to postpone and reschedule the meeting again.
42. However, a few days later the Trust shared a record from the meeting and explained no further review meeting would be arranged. This was because Z did not wish to have further review.

Mr X’s and Mrs Y’s complaint

43. In March 2023 Mr X and Ms Y complained to the Trust about its handling and decisions around their adult child’s (Z) care and support needs following her transfer from a care home to a supported living placement in February 2022. They said it had:
• unjustifiably refused to carry out a care act assessment. This was despite a fundamental change of care as Z went from living in a care home to going to supported living accommodation;
• failed to arrange and monitor any proper support plan for Z at her supported living placement;
• wrongly refused to refer Z for an updated psychiatric assessment as it was last done in 2016 and they raised repeated concerns about Z’s declining mental health
• failed to refer Z for therapy after it had said it would do so in November 2022;
• failed to make satisfactory arrangements for review meetings on 2 and 9 March 2023. This included failing to adequately prepare for the meetings. They also said it had caused delay in sharing minutes of the meetings or the notes were inaccurate; and
• disagreed with its view on Z mental capacity.
44. In response, the Trust acknowledged the complaint and said it would respond. Two weeks later, it apologised for a delay in responding due to staff leave. A month after receiving the complaint, it told Mr X and Ms Y it had considered the complaint. However, their concerns were a reoccurring theme of past issues which had previously been responded to, and it would therefore not investigate the complaint further. It signposted them to the Parliamentary and Health Service Ombudsman (PHSO).
45. In August 2023 Mr X and Ms Y asked the PHSO to consider their complaint. The case was subsequently with the PHSO until August 2024, when it found it could not consider the matter as the Trust was acting on behalf of the Council. The complaint should therefore be considered by the Local Government and Social Care Ombudsman. During this time the Trust shared how it had considered the complaint and its reasons for not investigating the complaint further with the PHSO.
46. In September 2024 Mr X and Ms Y brought their complaint to our attention. As we had not seen a final complaint response from the Trust or the Council, we asked for this to be completed.
47. An annual review of Z’s care and support plan took place. It was then agreed a reassessment of her needs should take place.
48. In December 2024, the Council confirmed the Trust was acting on its behalf around Z’s care and support.
49. Mr X and Ms Y subsequently made a new complaint to the Council. This related to the same matters as brought to the Trust, but also included:
• since September 2024 the Trust had told them Z now had capacity to decide matters relating to her care and support. This was contrary to previous views including those of independent experts and there had been no change in Z’s medical situation;
• they did not agree for a reassessment to take place before the mental capacity disagreement had been resolved first;
• the meeting notes from the September 2024 review was inaccurate;
• the Trust’s had failed to respond to their complaint and the referral to the PHSO had caused significant delays; and
• a request for a change of social worker, and a new mental capacity assessment followed by a Care Act reassessment with an independent mental capacity advocate involved.
50. In February 2025 the Council told the Ombudsman it would respond to the complaint by the end of the month. It explained this response was delayed due to the amount of information and officer leave.
51. In April 2025 the Council responded to Mr X and Ms Y’s complaint. This was a final complaint response. It did not uphold the complaint and explained:
• the Trust’s decision not to carry out a reassessment was professional judgement following three Care Act reviews. This was that Z did not have a significant change in need.
• a psychiatric assessment was not the most appropriate route to support Z. The Trust had explained its reasons for progressing a psychological route, including why this subsequently did not take place as Z did not wish engage.
• Z’s care and support plan had been reviewed for her supported living placement and set out the support she should receive, including 1:1 support;
• the Trust had reached decisions around Z’s mental capacity. Since its assessment in 2019, Z had been found to have capacity to make decisions regarding her care, support, and signing a tenancy. Reviews had indicated no change in mental state which would change this position. Also, a Care Act advocate had previously been considered, but Z had been found to be able to share her own views;
• the notes from the September 2024 review contained Mr X and Ms Y’s comments as shared with the social worker. It also referred to the Trust’s previous response which explained it had made it clear meeting records were of actions only, and not full meeting notes;
• Z’s allocated social worker would not be changed as she had a good relationship with Z and her work was to the standards expected; and
• the Trust had responded to their complaint and explained why it would not investigate the complaint further in May 2024.
52. Mr X and Ms Y asked the Ombudsman to consider their complaints to the Council and the Trust.

Analysis and findings

Z’s mental capacity

53. Mr X and Ms Y complaints relates to the Trust and the Council’s handling of their adult child’s social care support. The underlying issues of their complaint stems from their disagreement with the decisions made around Z’s mental capacity for decision making, and their views of what is most appropriate accommodation and care support for Z.
54. I have considered whether there was fault in the way the Council considered Z’s mental capacity. I have not found fault by the Council. In reaching my view, I was conscious:
• the needs assessment and Mental Capacity assessments around 2019 found Z had capacity to make decisions about information sharing and accommodation. This was considered crucial to Z’s welfare by the Council and other experts at the time. Z had for many years been clear and consistent in her desire for a more independent placement;
• Z did not have capacity to make decisions about care and support at the time. It was decided Z should be placed in supported living accommodation with a care package;
• in Summer 2022 the Council considered Z had capacity to make decisions around care, accommodation and information sharing. It is clear Mr X and Ms Y disagrees with the Council views, which they shared in and outside reviews of Z’s care and support planning;
• its reviews of Z’s care plans show how it considered her ability to share her views, which it found she was able to do as there was no evidence to suggest she was unable to make decisions about her care and support. It also considered what Mr X and Ms Y, and people supporting Z’s views were; and
• mental capacity decisions are time specific and must be kept under review. The fact Z had been found to lack some capacity in decision making around her care and support in 2019, did not prevent the Council from reaching a different view in 2022. It was entitled to do so based on Z’s ability to share views and understanding later on; and
• the Council has kept Z’s mental capacity under review throughout, including in its reviews of her care and support plans.
55. I understand Mr X and Ms Y disagrees with the Council’s view around Z’s capacity. However, without fault in the process the Council followed to reach its views, I cannot question its decision making.
56. This includes its views Z had capacity to decide who to share information with. Z had been clear she wanted to restrict the information shared with Mr X and Ms Y. The Council correctly adhered to her wishes and only shared information Z agreed to.
57. In addition, I understand the Council’s social worker offered Mr X and Ms Y to meet with her and the lead Mental Capacity officer, and this offer still stands. It has also explained its view to them. I would not expect the Council to be required to do more.
58. It is not for the Ombudsman to decide who is right or who is wrong. As Mr X and Ms Y disagrees with the Council’s findings around Z’s capacity, they can either take up the offer to discuss this further with the Council or ask the Court of Protection to reach a view on Z’s capacity.

The Council’s decisions around Z’s assessments and support

59. I have considered Mr X and Ms Y’s concerns about the Council’s decision making and refusal of their requests for assessment and referrals for Z.
60. I have not found fault by the Council. This is because:
• its refusal to carry out a new needs assessment for Z was based on Mr X and Ms Y’s disagreement Z should be placed in supported living. This decision was made and considered in 2020, and X’s best interest was considered at the time as well. There was no identified change in Z’s needs or wishes, and a reassessment was therefore not required in 2022;
• it carried out reviews of Z’s care and support plan following the move to the independent living accommodation. During these it had regard to Z’s views and wishes, including Mr X and Ms Y’s views and those supporting Z. Its social worker met with Z and remained in contact with supported living staff, any concerns about Y’s wellbeing was considered; and
• it shared its views why a psychiatric referral would not be made, and a psychological route for support was preferred. While this did not lead to therapy, this was not due to a failure by the Council but Z’s lack of desire to engage. This meant the proposed support could not be progressed further.
61. These were professional judgement decisions the Council was entitled to make, without fault in the process it followed, I cannot criticise its decision making.

Review meetings

62. Mr X and Ms Y’s complaint includes the Council’s handling of the review meetings of Z’s care and support.
63. I found some fault by the Council. This was its handling of the initial meeting in March 2023 which had to be cancelled as Z had not been informed Mr X and Ms Y would be present. This meant they had made themselves available for the meeting, and they experienced some frustration as a result. In addition, there was some delay in providing agreed notes from an earlier meeting. An apology should be provided for the impact this had on them.
64. I have not found fault in the Council’s handling of the subsequent meetings in March 2023 and Autumn 2024. This is because:
• the Council had been clear only actions would be provided, and it could only share information Z agreed with. It would therefore not share detailed notes;
• the meetings were for Z’s benefit and her wishes had to be considered. This included who would be present. The Council were entitled to reach its view it was best for supported living staff not to be involved at the same time due to the impact this would have on Z and their relationship with her. However, the social worker obtained their views shortly after the meeting;
• Z wishes for windows to be closed and delayed start to a meeting was not within the Council’s control. While this meant Ms Y felt she could not stay, this was not fault by the Council;
• the Council was not required to share documents and records before the meeting with Mr X and Ms Y as it was of the view X had capacity and she did not consent to sharing her information. While I acknowledge this made it difficult for them to share their views, this was not due to fault by the Council; and
• although it agreed to hold a further review meeting in March 2023, Z shared her views she did not want further meetings at the time, and it adhered to her views. This did not mean Mr X and Ms Y did not have the opportunity to share any concerns or views they had either in the meetings or directly to the social worker.
65. In addition, I understand Mr X and Ms Y disagrees with the notes they received from some review meetings. However, their disagreement with the notes received has been included in Z’s file. I cannot reach a view on whether the Council’s notes are correct or not. The approach to include Mr X and Ms Y’s views in the file was therefore an appropriate way to address this.

Complaints handling

66. Mr X and Ms Y’s complaint in 2022 was made to the Trust acting on the Council’s behalf. The Trust’s Policy says it will acknowledge a complaint and discuss the matter informally with a complainant, if this does not resolve the complaint it will then provide a response.
67. I acknowledge the Trust did not offer Mr X and Ms Y to discuss the complaint. However, in this case I do not consider this to be fault. This is because of the history and its view their concerns were a reoccurring theme from a complaint it had previously responded to. This was also what it explained to them in its complaint’s response.
68. However, the Trust wrongly signposted Mr X and Ms Y to the PHSO, which was the incorrect Ombudsman service. This was fault which caused an extensive delay in the complaint coming to our attention. However, the vast majority of this delay was due to the PHSO and not the Trust or the Council. I therefore consider the impact of the fault to be limited, and an apology to be appropriate to acknowledge the impact this had.
69. Mr X and Ms Y’s complaint to the Council in December 2024 related to the Trust’s handling of their complaint, their ongoing concerns, and new requests. I have not found fault in the Council’s response. However, I have considered whether it was fault by the Council to reply under stage two of its corporate complaints policy and the delay in providing its response.
70. I found the Council considered which complaints process to use and whether this should be a stage one or stage two response. It reached its decision based on the history of complaints, complexity, and need for a senior manager to respond. This was a decision it was entitled to make, and I found it appropriate in the circumstances to provide its final response to avoid further delays.
71. However, it took nearly five months for the Council to provide its complaint response. I found this to be fault. While I acknowledge it needed to obtain information from the Trust, staff, and review extensive information, this was substantially longer than the timescales set out in its corporate complaints policy. I am satisfied an apology is appropriate as the substantial parts of the complaints have not been upheld.

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Action

72. To remedy the inconvenience the Council caused to Mr X and Ms Y, the Council should, within one month of the final decision:
1. apologise in writing to Mr X and Ms Y to acknowledge the inconvenience its faults caused them;

We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.

73. The Council should provide us with evidence it has complied with the above actions.

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Decision

74. I completed my investigation with a finding of no fault on the substantial matters complained about. However, there was some fault in relation to a review meeting and delayed complaints handling. The Council will apologise for the inconvenience this cause Mr X and Ms Y.

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Investigator's decision on behalf of the Ombudsman