Summary: Mr X complained the Council failed to meet his eligible care needs for three months and it failed to attend borough council meetings about his housing. We found there was a lack of care provision which was Service Failure by the Council. We also found there was a failure to attend housing meetings after agreeing to do so. This was a lack of partnership working. The fault by the Council led to distress to Mr X. The Council agreed to apologise, make a distress payment and work on an action plan to avoid the same issues happening again.

The complaint

1. Mr X complains that the Council failed to meet his eligible care needs for three months and failed to go to housing meetings it had agreed to attend. As a result of the lack of support, Mr X could not maintain his living environment and he was served a Notice Seeking Possession of his property by his landlord. The lack of attendance at housing meetings caused a delay in considering supported housing for him. The situation has been upsetting and stressful for Mr X.

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

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How I considered this complaint

5. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
6. Mr X 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

Care and Support Statutory Guidance

7. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says reviews should take place at least every 12 months. It states the first planned review should be an initial ‘light-touch’ review, six to eight weeks after agreeing and signing off the plan and personal budget. This is to provide assurance to all parties that the plan is working as intended and to help identify any teething problems. All reviews should be carried out as quickly as is reasonably practicable, proportionate to the needs to be met.
8. The Care and Support Statutory guidance also place an express duty on a council to co-operate if requested to do so in specific cases by a partner authority. The guidance also sets out a general duty to co-operate in the exercise of its adult safeguarding functions, to prevent neglect or abuse. The guidance states that observant professionals and other staff making early, positive interventions with individuals can make a huge difference and prevent the deterioration of a situation or support network. It states agencies should implement robust risk management processes to help prevent concerns escalating and requiring intervention under safeguarding processes.

What Happened

Meeting Mr X’s care needs

9. Mr X is an adult with Autism who receives a package of care, organised by the Council. The care is mainly to help Mr X maintain his home environment. It also includes prompts to maintain good nutrition.
10. The Council commissioned a new care company (Care Company A) to provide care for Mr X. The new provider was supposed to start providing care on 10 June 2024. With Mr X’s agreement, Care Company A would be providing slightly less support hours.
11. Care Company A say they told the Council that they had been refused entry by Mr X. It is unclear when this occurred. Care Company A also say the Council told them to pause the start of the care plan. The Council says it has no record of communication about refused entry and no record of an instruction to pause the care. In any event, no care was provided from 10 June.
12. The Council told us, historically, Mr X had been able to manage his own support and he had direct contact with his carers to plan their visits. This happened without intervention from the Council. However, Mr X told us that when his new carers did not come, he did not know whether to tell people or not. He told us he decided to stay quiet. The care review report in May 2024 stated that Mr X had not always engaged with his previous carers.
13. The Council should monitor all newly commissioned care. It has a policy to carry out a six-week review. This should have taken place around mid-July in Mr X’s case. If it had taken place, the failure to start Mr X’s care would have been apparent and it could have been rectified. The review did not happen, and it is evident that Mr X’s care package with Care Company A only started on 10 September.
14. Regrettably, there is evidence that Mr X was stressed and struggling to maintain his home environment in the meantime. This was foreseeable as maintaining his home was the main reason that he needed care and support.

Mr X’s housing situation

15. In July 2024, Mr X’s landlord served him with a notice seeking possession (NSP). They stated they required the property back at the end of the tenancy. The landlord told the borough council that this was because they wished to sell the property and there had been no rent arrears or anti-social behaviour concerns. However, the landlord noted there were a lot of things in the property and it was not in the best condition. The borough council says Mr X told them in July 2024 that he was not engaging with any services.
16. After the NSP was served, in July Mr X made several calls to the Council referring to housing difficulties and the need to find new accommodation. The Council referred him to the Citizens Advice Bureau (CAB) and to the borough council.
17. In mid-July a care worker (who assisted Mr X with employment), also contacted the Council. They expressed concern about his housing situation and stated Mr X was very distressed.
18. The borough council contacted the Council at the end of August regarding the condition of Mr X’s property and to discuss his care and the NSP.
19. In early September the borough council told the Council they were considering whether supported housing was required for Mr X. On 16 September the borough council asked social workers to complete a referral form for Supported Living, which they did. They also asked the Council to send a social worker to a Supported Living Assessment Meeting (SLAM) on 19 September. The Council stated the request for someone to attend the meeting had been referred to a manager and a duty social worker would attend.
20. On 23 September the CAB asked the Council and borough council what the outcome of the SLAM was. They advised them that Mr X was very anxious about his housing situation and the prospect of supported living, which he did not want. He preferred living independently.
21. The borough council explained that it could not assess Mr X for supported living at the meeting because a social worker did not attend. The Council apologised to the borough council for not attending the SLAM and stated a duty social worker would attend the next meeting on 17 October.
22. Ahead of the October meeting the Council asked the borough council what the social worker’s role at the meeting would be. The borough explained they needed a social worker to present the case for supported living and the social worker would be able to help them understand Mr X’s needs and abilities. The Council acknowledged this.
23. The CAB proactively contacted the Council leading up the next meeting, to check that someone would attend. A social worker forwarded this to the duty team.
24. On 17 October, again, a duty social worker did not attend the SLAM meeting.
25. In response to the Council’s subsequent queries, the borough council explained that a social worker’s attendance at the SLAM meeting was imperative and the Council could not send a written response instead. The borough council stated supported living providers would be in attendance and would have questions about Mr X’s care needs. The borough council noted Mr X was concerned about the prospect of supported living but indicated other options may be difficult due to availability and cost so it needed to be considered.
26. The Council told us it has no record of the November SLAM meeting taking place or sending a representative. The borough council told us Mr X’s case was not discussed at the 21 November meeting but there were no further notes on its records about why. The borough council explained that it had resolved Mr X’s housing without him going into supported housing. It stated it offered him a new tenancy and it had arranged for assistance from a floating housing support worker where it was required. Mr X confirmed that he signed a new tenancy at a different property. He moved into it in January 2025. As this was not supported living, it was in accordance with his wishes.

Mr X’s complaint (made by the CAB on his behalf)

27. The CAB raised a complaint on Mr X’s behalf. They raised the lack of care provision and explained Mr X found it far more difficult to maintain his property without help. They stated the absence of care contributed to his landlord seeking possession of his property. They noted, despite various contacts with the Council, there was a delay identifying he had no care. They also expressed concern that the Council failed to attend meetings to provide input on his housing situation, having agreed to do so. This led to Mr X having a distressing emotional reaction which he described as an autistic meltdown. They sought redress for Mr X.
28. The Council’s response to the complaint acknowledged that Care Company A had not started providing Mr X’s care as they should have. However, it stated the reasons for this were inconclusive and it had no record of pausing the care as the provider had claimed. The Council stated it appreciated the impact this had on Mr X but the Council implied he contributed to the problem by not bringing the issue to the Council’s attention sooner. It says it put the care in place as soon it was told that Care Company A was not providing it.
29. The Council stated it was not responsible for meeting Mr X’s specified accommodation needs. This was the responsibility of the borough council. It stated it could not always commit to attend meetings and its view was that written assessment documents should be sufficient for the borough council to proceed without them. It stated the borough council’s decision not to proceed in a social worker’s absence was disproportionate.
30. The Council acknowledged that it had agreed to attend the meetings, and it apologised for not doing so. But it regarded the learning from the issue was that its staff should have discussed the request with a manager before agreeing to attend, and it believed it should not have committed to attend. This is because it may have urgent and high-risk situations to deal with, other clashing invitations or a problem with staffing levels. It repeated its view that the meeting could have gone ahead anyway and only partially upheld the complaint because it failed to meet expectations.

What should have happened

31. The Council sent us a copy of an email which shows it did arrange for Mr X’s care to begin with Care Company A from 10 June. The care provider claims the Council instructed it to pause the care, which the Council has no record of doing. Given it is not clear what caused the non-provision, but as Mr X did not receive the care he needed, I have regarded the failure to provide the care as Service Failure by the Council. ‘Service failure’ is fault by a council, but it is expressed in this way when a council’s failure was affected by circumstances outside its control.
32. However, statutory guidance requires councils to review care plans at an early stage and the Council’s policy is to carry out a review after six weeks to comply with this. Early reviews are specifically required to ensure there are no teething issues and that the care is meeting need. No review took place in Mr X’s case. The Council stated this was because Mr X did not have a set social worker. It stated because the duty social work team handled Mr X’s case, the review was missed. The failure to review Mr X’s care in mid-July was further fault.
33. I have no doubt a review in Mr X’s case would have highlighted that Care Company A were not providing Mr X’s care as they should have been. This would have rectified the issue in mid-July. The lack of review meant that Mr X’s care was not restarted until 10 September.
34. The evidence suggests that the lack of care provision was not the direct cause of the Notice Seeking Possession served by Mr X’s landlord. However, I found there was a lack of professional curiosity by the Council when housing issues were first raised by Mr X and a support worker in July and then the borough council and CAB in August. The Council implied that no-one told it that the care it commissioned was not being provided, so it could not have addressed it sooner. However, there was a clear link between the care being provided by the Council and Mr X’s housing situation. It would have been appropriate for the social workers to establish why he was having to consider new housing and any difficulties Mr X had. In doing so it could have established if this related to Mr X’s need for help to maintain his home, which it was supposed to be supporting him with. Had it sought to further understand what was happening with Mr X, it would have given itself another opportunity to identify its lack of care provision.
35. It was concerning that the Council failed to co-operate appropriately with the borough council when specifically requested to do so. This was when the borough council was considering if Mr X needed supported housing. The Care and Support Statutory Guidance places a duty on councils to co-operate with one another. I found the repeated failure to attend the SLAM, after it agreed to, to discuss Mr X’s care needs was also fault. This delayed decisions on Mr X’s future housing and left him distressed and anxious.
36. I found the Council’s approach to the CAB’s complaint was also poor. The Council did not consider why no review had taken place and the tone of its response implied Mr X was responsible by failing to tell the Council that care provision was missing. I acknowledge that, if Mr X had raised the lack of care it would have been resolved sooner. However, Mr X is a vulnerable adult with Autism. The Care and Support Statutory guidance sets out how observant staff can head off potential safeguarding issues and in any event, statutory guidance requires early light-touch reviews of care for good reasons; to ensure those with care needs are having them met.
37. Both the key issues (the lack of care review and the failure to attend agreed meetings) stem from the fact that the duty team (rather than a named social worker) were responsible for addressing Mr X’s social work needs. The Council stated it had identified that requests for meetings in future needed to be referred to a manager so as to avoid clashes with other priorities. The Council suggested its error was in agreeing to attend. However, the evidence shows that the borough council’s original request was referred to a manager. So, it is not clear how referral to a manager would prevent a recurrence of this situation for other people. In addition, the borough council explained it needed social work input, and that attendance at a meeting rather than a written submission was necessary because providers may have questions.
38. I have recommended that the Council creates an action plan to address the ways that the duty team’s actions in Mr X’s case fell short and how it can ensure its processes, resourcing and interactions with other partner agencies are sufficient to adhere to the council’s policies and adequately support those service users that do not have a named worker in addition to dealing with urgent priority issues.

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Action

Within four weeks of our final decision:

39. The Council should apologise to Mr X for the fault we have identified in this decision. The apology should adhere to our guidance on making effective apologies. This can be found on our website, within our Guidance on Remedy here.
40. The Council should make payment to Mr X of £400. This is to recognise the avoidable distress and uncertainty caused by the Council’s service failure and fault. This was caused by the lack of care provision and the Council’s non-attendance at borough council housing meetings, which delayed decisions about his future housing.

Within eight weeks of our final decision:

41. The Council should produce a written action plan to address the issues we have highlighted with the duty team. It should determine what actions are needed to ensure care reviews take place when a case is with the duty team, how it will ensure duty team staff show professional curiosity when addressing queries about service user’s circumstances and, most importantly, how interactions and partnership working with other partner agencies and councils will be improved. The Council should present the action plan to an appropriate scrutiny committee, setting out what steps the Council intends to take to avoid the issues reoccurring for other service users.
42. The Council should provide us with evidence it has complied with the above actions.

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Decision

43. I find fault causing injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman