Summary: Mr X complained the Council has repeatedly failed to follow its policies and procedures which has resulted in a failure to safeguard his daughter, Miss Y. We found the delays in completing care needs assessments and in following up on Miss Y’s requests regarding how her needs were met is fault. As were the delays and failure to properly consider whether, and how the post adoption support service could support Miss Y. The delay in responding to Mr X’s complaint was also fault. These faults have caused Miss Y and Mr X frustration and uncertainty. The Council will apologise and make payments to Miss Y and Mr X and will review relevant processes.

The complaint

1. Mr X complained the Council has repeatedly failed to follow its policies and procedures which has resulted in a failure to safeguard his daughter, Miss Y. Specifically Mr X complains the Council has:
• Ignored their requests for information and support since June 2022 and has at times behaved inappropriately towards Mr and Mrs X and Miss Y.
• failed to meet Miss Y’s care needs. The Councils has assessed Miss Y requires support with her personal care, but the Council has not made any provision to support this.
• failed to ensure Miss Y receives the support set out in her support plan. Mr X say Miss Y should have access to day activities at a day service in the holidays, but the Council does not always book this in time so the provision is full and Miss Y cannot attend.
• failed to properly consider and act upon Mr and Mrs X’s request to apply to the Adoption Support Fund for funding for an assessment and therapy for Miss Y.
2. Mr X also complains the Council took over a year to respond to his complaint.

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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. 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)
5. 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(i), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

7. We expect people to complain to us within 12 months of them thinking the Council has done something wrong. Mr X complained to the Ombudsman in August 2024. We would normally therefore only consider events since August 2023. In this instance however, it is clear that Mr X’s complaint to us was delayed by the way the Council dealt with his complaint.
8. In the circumstances I have exercised discretion to consider events in the 12 months prior to Mr X’s complaint to the Council in June 2023 up to August 2024 when Mr X contacted us. Although this matter is ongoing, we would not investigate matters since August 2024.

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How I considered this complaint

9. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
10. Mr X and the Council have an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

11. Miss Y lives with her parents Mr and Mrs X, who are her main carers, and her sister. She has an EHC Plan and is in full time education at a local college. Miss Y also has a care and support plan which provides monthly respite, day service provision during college holidays and transport between settings.
12. In June 2022 Mr and Mrs X asked for emergency respite as they were unwell and unable to support their daughters. Miss Y and her sister went to stay in supported living accommodation. This was initially arranged for a week but was then extended until 8 July 2022 with Miss Y’s agreement.
13. On 12 July 2022 Mr and Mrs X chased the Council for an update on when Miss Y and her sister would return home. The Council told Mr and Mrs X it was working with Miss Y to formulate a plan and discuss her options. And that the Council’s role was to support Miss Y in being as independent as possible in her decision making.
14. Mr and Mrs X asked for a timescale for Miss Y’s return and for copies of Miss Y’s care needs assessments and information about the options for care plans. They also asked for details of the social worker’s meetings with Miss Y so that they could attend and support her with decisions and changes to the current respite and care plans.
15. Mr and Mrs X were unhappy the social worker made an unannounced visit to the supported living placement and would not allow them to join the discussion with Miss Y via a video call. They told the Council they were Miss Y’s chosen advocates, her communication partners, and her family. The Council’s records show the social worker felt the situation was causing Miss Y distress so they ended the visit. Mr and Mrs X asked for an update regarding Miss Y’s respite and said their earlier requests for information had been ignored.
16. The Council responded on 26 July 2022. It explained a social worker was building a rapport with Miss Y to gather information to complete an assessment. This could take three or four visits/ meetings to determine Miss Y’s level of need for support, views, wishes and capacity to make decisions regarding certain aspects of her life. In particular it was assessing Miss Y’s ability to decide about where she wished to live short term, how support is provided and how she wishes her finances to be managed.
17. The Council offered to meet with Mr and Mrs X to discuss their concerns and explain the processes adult social care have to adhere to. It told Mr and Mrs X the plan was for Miss Y to remain in supported living and attend a day service for some days over the holidays whilst the assessments and work to support future options continued. The Council set out the areas it wanted to discuss/ gather more information on.
18. Miss Y remained at the supported living placement until 15 August 2022 when she told the Council she wanted to move back home. Mr and Mrs X say Miss Y has said weeks earlier that she wanted to return home, but the Council had ignored her.
19. The Council completed a care needs assessment in September 2022. Mr and Mrs X, Miss Y’s college, the supported living provider, the residential respite unit and day service provider all contributed to the assessment. The Council sent a copy of the draft assessment to Miss Y and Mr and Mrs X on 14 September 2022. It then contacted Mr and Mrs X in November 2022 to arrange a meeting to discuss the assessment.
20. Mr and Mrs X provided a list of suggested amendments to the assessment in January 2023. The Council included some amendments. It says that where it did not make the requested changes this was due to information being provided by other agencies and their professional observations regarding Miss Y’s care and support needs. The Council sent the completed assessment to Mr and Mrs X in May 2023.
21. In November 2023 a social care assessor contacted Mr and Mrs X to arrange a meeting to discuss reviewing Miss Y’s care needs and care and support plan. The assessor visited Miss Y and Mr and Mrs X on 17 November 2023. Their records of the visit note the day service did not have any availability over the Christmas break so the family requested an alternative be found. Miss Y also asked the assessor to look into changing the respite provider as the current provision was too noisy. Miss Y also felt different respite to her sister would be beneficial.
22. The notes also record that Mr and Mrs X felt the care plans needed to change as their GP had said Miss Y needed support with toileting but the providers and the Council were not listening to this. The assessor confirmed this could be explored during the review.
23. Mr and Mrs X also requested a Multi-Disciplinary Team meeting. The assessor advised this was not currently needed but that may change during the process.
24. In December 2023 the Council identified an alternative day service with availability in the Christmas break. Miss Y also attended this provision for two days in the February half term break and four days a week over the summer break.
25. In January 2024 the Council advised Mr and Mrs X that the assessor could no longer continue with the planned review. It said a new social worker would be allocated to complete this. The Council did not allocate a new social worker until June 2024 and the review did not take place until August 2024. The Council sent Mr and Mrs X a draft assessment on 22 August 2024 and invited their comments. The assessor explained the assessment reflected the long term plan to move to supported living. It did not therefore show Mr and Mrs X’s involvement and support reflected in the formal sections. The assessor also confirmed they were clarifying Miss Y’s medical conditions with her GP.
26. The Council says the assessment has yet to be finalised. Miss Y continues to live at home with Mr and Mrs X as the Council has not yet identified a suitable supported living placement.

Adoption support

27. Mr and Mrs X say they have repeatedly asked for adoption support over several years. They requested support for a multi-disciplinary assessment (MDA) for Miss Y. Mr and Mrs X hoped this assessment would identify appropriate therapeutic provision and recommend Life Story Work. Mr and Mrs X considered Company 1 were best placed to carry out this assessment as they had already completed an assessment of Miss Y’s sibling.
28. The Council completed a post adoption support assessment which it sent to Mr and Mrs X in late 2022. Mr and Mrs X provided comments and requested amendments to the assessment in February 2023. The Council agreed the assessment and authorised an MDA in April 2023. The records say this would need to go out to tender and as Company 1 are not an approved provider, the Council would be unable to commission them to undertake any work.
29. The Council invited tenders from over 20 providers but did not receive any responses.
30. In November 2023 a new post adoption support social worker was allocated to try and find an assessment. Mr and Mrs X reiterated that they wanted to use Company 1. The Council says it repeatedly told Mr and Mrs X it does not work with this provider. Mr and Mrs X say they were open to using other providers if they could provide therapy in an appropriate way and support Miss Y through the process.
31. The Council sent referrals to other providers, but they either did not have availability or felt they were not the right service. The social worker also contacted other services and teams involved with Miss Y’s care, including the NHS’ Intensive Assessment and Treatment Team (IATT) Learning Disability Team.
32. The social worker’s record of a conversation with the learning disability nurses states the nurses were confused by Mr and Mrs X’s request for an MDA as they were working with Miss Y. Their team had access to a range of professionals including psychiatry, occupational therapy, learning disability nurses and clinical psychologists.
33. The post adoption support worker also attended Miss Y’s EHC Plan review and multi-disciplinary core group meetings. The records of these meeting show the social worker questioned how an assessment would be useful if IATT were carrying out an assessment of Miss Y’s needs. They noted the post adoption service could put therapy in place but there would be risks associated with this given Miss Y’s needs, particularly her mental health needs. In addition, Miss Y’s learning disabilities could make engaging with therapy challenging.
34. To move matters forward the Council says it agreed it would look for Therapeutic Life Story Work. It identified two providers in July 2024 who offered to work with Miss Y and provided Mr and Mrs X with details of one of the provider’s proposal in August 2024.
35. Mr and Mrs X raised concerns about the provider’s ability to complete the complex work and level of research that would be required. The provider then withdrew their offer.
36. Since complaining to us Mr and Mrs X have met with the second provider. This provider has also withdrawn their offer as they did not have the resources to meet the complexity and level of work involved. They were also concerned that the life story work would not reduce Miss Y’s emotional instability but rather could make her more confused and unstable.
37. A new social worker and their manager met with Mr and Mrs X and Miss Y in March 2025 to discuss the provision of therapeutic life story work. The records note that whilst Miss Y was clear she wanted to engage in therapeutic life story work there were concerns about her level of understanding of what this would entail. And also of the potential impact on her well-being and mental health when discussing traumatic and upsetting events from her childhood.
38. It was agreed the social worker would engage in direct work with Miss Y to explore this is a sensitive way and to aid her understanding.

Complaints

39. On 20 June 2023 Mr and Mrs X made a formal complaint to the Council. They complained the Council had repeatedly failed to follow its policies and procedures which had resulted in a failure to safeguard Miss Y and had caused her harm. They did not provide any specific details of their concerns.
40. Mr and Mrs X asked the Council to apologise for the failings in Miss Y’s case and to explain how they had happened. They also asked the Council to learn from these mistakes and take steps to improve its practice.
41. The Council acknowledged the complaint but did not respond at this stage. Mr and Mrs X chased a response in February 2024. The Council apologised this had not been followed up by the appropriate manager and confirmed an alternative manager would now consider the complaint.
42. It then responded on 16 July 2024 and again apologised for the significant delay in responding. It explained the Council believed the previous service manager had addressed Mr and Mrs X’s concerns through discussions at the time. However this was not the case and the matter remained unresolved.
43. The Council explained it had reviewed its records and noted that since 2020 there had been four Care Act assessments, five Mental Capacity Assessments, 11 Care and Support Plans and 13 transport plans for Miss Y. It said the social care offer during this time had been largely based outside of full time education, providing transport to and from college, a residential respite break once per month and transport to and from activities in the college holidays.
44. It said the Reaching for Independence team had also commissioned enabling support and a period of supported living with a view to building independent living skills for Miss Y once college comes to an end.
45. The Council noted its duty under the Care Act 2014 was to assess eligible needs and then work with the person to plan how the needs would be met. It considered it had met its duties. The Council told Mr and Mrs X that if they did not agree, they would need to provide specific examples of where the Council had failed to follow policies or procedures.
46. In addition the Council noted it had attempted to gain further information from Mr and Mrs X regarding their safeguarding concerns but had been unable to. The Council confirmed it would be happy to meet with Mr and Mrs X to discuss their concerns.
47. As Mr X was not satisfied with the Council’s response, he has asked the Ombudsman to investigate his concerns. He wanted the Council to complete a care needs assessment appropriately and accurately and to put in place provision so that the support they provide is replaced, or they are appropriately compensated for their time over the years since Miss Y turned 18.
48. Mr and Mrs X have subsequently confirmed their primary concerns are to ensure the care plan includes support for Miss Y’s personal care. Mr and Mrs X say they have told the Council they are unable to continue providing this, but no alternative support has been arranged. They are also keen to ensure Miss Y receives an assessment and therapy via the adoption support fund.
49. In response to our enquiries the Council says it carried out several Care Act Assessments and reviews in recent years. The Council does not consider there have been any delay in completing these assessments and reviews.
50. The Council notes Miss Y’s most recent assessment says Miss Y reported she needed support with reaching her back and washing her hair, which Mr and Mrs X provided when needed as did the respite provider when she was there. Mr and Mrs X encourage Miss Y to shower on a daily basis and offer support. The assessment also said Miss Y was independent with her dressing needs. The Council does not consider it has failed to support Miss Y’s personal care needs.
51. It acknowledges that Mrs X told the care assessor in August 2024 that they needed support in the morning and that they were unable to continue in this role. The Council says it was agreed the best way forward was to progress with supported living options. It says in subsequent discussions Miss Y confirmed she still wanted to explore supported living. There were no further discussions regarding personal care in the morning.
52. The Council acknowledges there has been difficulty in sourcing supported living accommodation. It says this is partly due to Mr and Mrs X’s specific requirements and Miss Y’s wishes regarding the location of supported living. This has reduced the opportunities available. Mr and Mrs X dispute requesting any specific requirements.
53. Pending a move to supported living the Council says it meets Miss Y’s care and support needs by continuing to commission respite, day service provision and transport.
54. In relation to adoption support funding, the Council says the family requested an assessment through a provider who is not approved to provide this service through Devon Procurement. It was therefore unable to provide this service. The Council pursued an alternative provider, but the family did not want to explore this. It then explored Therapeutic Life Story Work and identified two providers. Mr and Mrs X contacted both providers and made a number of enquiries. Both providers then withdrew their offer of support and the Council has been unable to identify other providers willing to support the family. The Council says an adoption social worker is in the process of completing a support assessment.

Analysis

55. It is clear from the documentation available that the Council has assessed Miss Y’s care needs and reviewed her support plans on a regular basis. There have however been delays in completing the assessments, particularly where there has been a change in social workers.
56. Mr and Mrs X are involved in the assessment and reviews and are given the opportunity to comment on draft documents. Mrs and Mrs X do not always agree with the views of other organisations that contribute towards the assessment. But we would expect the Council to take account of the views of all those involved in Miss Y’s care and support when completing the assessment.
57. Miss Y’s care assessments note that Mr and Mrs X support Miss Y with elements of her personal care as does the respite provider. There is no reference, in the information provided, to Mr and Mrs X being unable or unwilling to continue to provide this support, or to Miss Y requesting it is provided by someone else. Should Mr and Mrs X inform the Council they are unable to continue to provide this support, we would expect the Council to consider how Miss Y’s needs would be met.
58. Miss Y did however ask the Council to investigate an alternative respite provider so that she could have time away from her sister. There is no record of whether or how the Council pursued this. I consider this to be fault.
59. Miss Y has had access to residential respite each month, and day services during the college holidays. The level of provision in the holidays has varied as the support plans have specified between two and four days provision a week. It is unclear why the number of days changed between support plans, but there is no evidence Miss Y did not have access to some provision each college break in the period I am considering. When the usual provider was not able to offer a place in December 2023, an alternative provider was identified. Miss Y then continued to use this service.
60. There have also been delays and periods of drift by the post adoption service. There were delays in completing assessments and periods of inactivity in identifying and contacting providers regarding an assessment or therapeutic life story work. These delays amount to fault.
61. It is unfortunate that despite approaching multiple providers none are able to or have agreed to work with Miss Y, but I do not consider this to be due to fault on the part of the Council.
62. I also note there has been a lack of clarity and consistency about the post adoption support team’s role in an assessment. Although an MDA was initially agreed, officers have since questioned whether an assessment is necessary given the other services involved with Miss Y’s care and the multi- disciplinary assessments they have completed. There are also concerns about Miss Y’s understanding of what the therapeutic life story work will involve, and the impact of this work on her well-being and mental health.
63. Direct work should now have begun with Miss Y to explore this, but I consider this should have been considered sooner. The failure to properly consider whether, and how the post adoption support service could support Miss Y and any risks this may present, at the outset, is fault.
64. The delay in responding to Mr and Mrs X’s complaint is also fault. Due to miscommunications and changes in staff, the Council took over a year to respond to Mr and Mrs X’s complaint. Delays of this nature are clearly unacceptable and will have added to Mr and Mrs X’s distress and frustration.
65. Having identified fault I must consider whether this has caused Miss Y, or Mr and Mrs X an injustice. The Council’s delays in carrying out and completing care needs assessments has caused frustration and uncertainty. This has been exacerbated by the failure to ensure Miss Y receives support with her personal care from someone other than her parents while she still lives at home. And by the delay in identifying a suitable supported living placement.
66. The delay and lack of clarity regarding appropriate and available support via the adoption support fund has also caused unnecessary distress and frustration.

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Action

67. The Council has agreed to:
• apologise to Miss Y and Mr and Mrs X for the distress and uncertainty caused by the fault identified. 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.
• pay Miss Y £250 to recognise the frustration and distress she has experienced as a result of the delays and lack of clarity.
• pay Mr X £250 to recognise the frustration and distress he has experienced as a result of the delays and lack of clarity.
• review its process for monitoring outstanding social care assessments to ensure it identifies overdue assessments and takes appropriate action to avoid future delays.
• review how it monitors and records complaints to ensure it issues responses to all formal complaints, even if it believes the issues have been resolved.
68. The Council should take this action within one month of the final decision on this complaint and provide us with evidence it has complied with the above actions.

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Decision

69. I find fault causing injustice. The Council has agreed actions to remedy injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman