Summary: There was fault by the Council. It did not act soon enough to resolve Mrs X’s risk of social isolation when she had to live in part of a care home without other residents. Her son, Mr Y has acted on her behalf and this caused him distress. The Council is now regularly reviewing Mrs X’s care needs, and has increased her opportunities to socialise. The Council should also apologise to Mr Y for its lack of more urgent action.

The complaint

1. Mr Y complains on behalf of his mother, Mrs X. Mrs X and her husband Mr X live in a care home. Mr Y complains that his mother has been moved to a separate part of the care home away from his father. He says she is missing out on socialising and taking all her meals in her room, only seeing his father for short visits.
2. Mr Y says that this is distressing and is isolating his mother.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. 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)
4. 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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How I considered this complaint

5. I considered evidence provided by Mr Y and the Council as well as relevant law, policy and guidance. I have also seen the care provider’s daily care records.
6. Mr Y and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

The law and guidance

8. 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.
9. 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.

What happened

10. Mr and Mrs X live in a residential care home managed by Nugent Care (the care provider). Their place was arranged by the Council. Mrs X has dementia and her care records say that she has difficulty knowing when she is at risk. There were some incidents between Mr and Mrs X, and Mr X assaulted both Mrs X and a care worker. The care provider moved Mrs X to another part of the home where she would not see Mr X, and it raised a number of safeguarding referrals.
11. At first, Mrs X was supported to visit the communal area and other parts of the home once, and later twice per week. This was done in consultation with both Mr X’s and Mrs X’s social workers. The care provider says that this was successful at first but there were more incidents between Mr and Mrs X and so these visits stopped.
12. In October 2024, the Council reviewed Mrs X’s care plan. The assessment says that since Mrs X has been separated from her husband at the home she is much safer and more confident, but sometimes isolated. She is living on a wing with a few others and not participating with the rest of the residents. She cannot access the communal area and be with others. Under ‘what is not working’ it says that since moving to the other area, she is isolated most of the time. She has 1:1 time with staff and access to a few residents. It suggested she should have structured visits with Mr X. It says staff will continue to support her to make sure she mingles. The review suggested a meeting of professionals look at how to resolve her isolation. The case notes do not say that this meeting took place, or if it did what was decided.
13. The care provider’s case notes show that Mrs X had socialised with other residents and Mr X during activity sessions, such as music sessions, and on trips out. This happened regularly from September 2024 into early 2025. The care provider also made sure that Mrs X had social contact with the care workers, sharing a meal or playing music together. However, the case notes show that Mrs X was still spending a lot of time on her own. The Council says that Mrs X had always enjoyed spending time watching television in her room.
14. Mr Y complained to the care provider that his mother was not able to socialise and was even having meals in her room alone. The care provider told Mr Y that it was also concerned about this and was trying to meet with the Council so that it could decide how to resolve things. The Council’s case notes say that in February 2025, the care provider contacted Mrs X’s social worker very concerned that Mrs X was becoming isolated.
15. The Council called a professionals meeting in February and March 2025. These agreed changes to encourage interaction between Mr and Mrs X. The Council monitored this for the following months and reported significant improvements in their relationship. In September 2025, the care provider was able to open the communal lounge in Mrs X’s part of the home. Her daily care records show that this allowed Mrs X to socialise much more regularly.
16. The Council reviewed Mrs X’s care plan in November 2025. The review says that staff have been supporting regular contact between Mr and Mrs X. Sending cards and video calling. It also says that Mrs X continues to need one to one support to socialise with other residents.

Was there fault by the Council causing an injustice to Mrs X?

17. This is a very difficult situation. I can see that the Council and the care provider reviewed the situation in June 2024. They agreed a plan for Mrs X to visit the main part of the care home regularly to socialise with others and to maintain her connection with her husband.
18. It was for the Council to decide how to proceed. My role is to make sure that it properly considered this. The Council consulted with the care provider and took into account that Mrs X did not have capacity to make decisions about risk for herself. There is no basis for me to criticise the Council’s initial approach because it properly considered all the issues.
19. The care provider followed the plan but it led to further concerns and by the next review in October, it was clear that this was not sufficient to meet Mrs X’s needs to socialise. The Council said it needed to meet with the professionals involved in Mrs X’s care to decide how to tackle her isolation and to support her connection with her husband. However, there was no progress on this until February and March the following year, a delay of five months. This was fault by the Council. Given that concerns had been growing since June 2024, the lack of more urgent action is likely to have had a significant impact on Mrs X. Mr Y was also caused distress by the lack of progress. In response to a draft of this decision statement. The Council has acknowledged that its service fell short and it did not review Mrs X’s care plan in good time.
20. Following the professionals meetings in February and March 2025, the care provider was able to do more to encourage Mrs X to socialise with others and her husband, and eventually, it was able to open the lounge in her part of the home. I also note that the Council has kept up with regular reviews of Mrs X’s care plan, with the October 2025 review being arranged during the course of my investigation.
21. The Council says it has introduced improved case records guidance, standards and training across its adult social care service.

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Action

22. Mrs X has dementia and her health and capacity has deteriorated. It is important that the Council continues to make sure her needs are met, but I have not recommended an additional direct personal remedy for Mrs X.
23. The Council will within one month of the date of this decision:
• Apologise to Mr Y for the distress he was caused when the Council took too long to address his mother’s isolation. 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.
24. The Council should provide us with evidence it has complied with the above actions.

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Investigator's decision on behalf of the Ombudsman