Summary: Y complained about various aspects of the Council’s involvement with his care and support. We found there was some fault with the Council’s communication with Y. We also found a care provider failed to keep appropriate records. There was also a failure to properly consider and explain its position regarding reasonable adjustments Y requested about document formats. We did not find fault with how the Council or a care provider addressed safeguarding issues or involved Y in care assessments. We recommended an apology and actions to put things right.

The complaint

1. Y complains:

1. Safeguarding procedures were not followed correctly regarding issues Y and his mother raised about care provision and service from their care provider from April 2024.
2. That his care assessment lacked detail about his moving and handling needs.
3. He was not provided with a copy of his care and support plan and he was not fully involved in care and support planning. He questioned if the home care service provided was the most appropriate.
4. He wanted to challenge the decision to decline funding for transport for short breaks and wanted funding to make adaptations to his wheelchair.
5. His communication preferences were not respected (the Care Provider initially declined to use Text Relay) and documents were not sent in a format he could read independently.
6. He wanted to understand what had happened with his Education Health and Care Plan.
7. He wanted the Council to explain why he was not able to keep a therapy bed, purchased to assist his care while in college.
8. That he felt coerced into making a decision to accept alternative accommodation following an incident involving Mrs X on 30 January 2025.

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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. The law says we cannot normally investigate a complaint when someone has a right of appeal, reference or review to a tribunal about the same matter. However, we may decide to investigate if we consider it would be unreasonable to expect the person to use this right. (Local Government Act 1974, section 26(6)(a), as amended).
4. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
5. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. 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

7. We are investigating the events of the complaint from April 2024 to June 2025 when the Council responded.
8. We have not considered the actions of the police. We have no jurisdiction to do so.

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How I considered this complaint

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

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What I found

Safeguarding

11. The Care Act 2014 sets out a clear statutory framework for protecting adults with care and support needs from abuse or neglect. It places a strict legal and professional duty of care for care workers to report potential abuse.
12. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement.

Equality Act

13. The Equality Act 2010 provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. It offers protection, in employment, education, the provision of goods and services, housing, transport and the carrying out of public functions.
14. The Equality Act makes it unlawful for organisations carrying out public functions to discriminate on any of the nine protected characteristics listed in the Act. They must also have regard to the general duties aimed at eliminating discrimination under the Public Sector Equality Duty. One of the protected characteristics is disability.

Council Guidance on Safeguarding

15. The Council provides guidance on reporting safeguarding incidents. This is detailed and provides examples of things that should be reported formally.
16. The guidance is extensive but includes:

• Isolated incidents of accidental over or under prescribing of medication. It states these should not be reported as safeguarding matters if there has been no impact, pain or distress (for example in a near-miss).
• Unexplained marks or injuries and incidents of violent behaviour or physical abuse. These should be reported.
• Sexualised physical contact which causes distress should be reported.

Education Health and Care Plans

17. A child or young person with special educational needs may have an Education, Health and Care (EHC) Plan. This document sets out the child/young person’s needs and what arrangements should be made to meet them. The EHC Plan is set out in sections. We cannot direct changes to the sections about their needs, education, or the name of the educational placement. Only the Tribunal or a council can do this. 
18. Councils must arrange for the EHC Plan to be reviewed at least once a year to make sure it is up to date. The council must complete the review within 12 months of the first EHC Plan and within 12 months of any later reviews. The annual review begins with consulting the child’s parents or the young person and the educational placement. A review meeting must then take place. Following the review meeting the council must issue a decision to either amend, maintain or cease to maintain the EHC Plan. This must happen within four weeks of the meeting. (Section 20(10) Special Educational Needs and Disability Regulations 2014 and SEN Code paragraph 9.176) 

Background

19. Miss X lives with her disabled son Y. I understand the Council provides Direct Payments to Y to enable him to employ Personal Assistants (PAs) and, at the time of this complaint, the Council separately commissioned general care and support visits from a care provider. Y needs assistance with personal care, dressing, food preparation and maintaining his home environment.
20. In April 2024, Care Provider A began providing care for Y. They continued to provide care until February 2025.

Y’s Safeguarding Concerns

21. Miss X and Y told us that they raised a number of concerns about the way Y’s care was being provided by Care Provider A soon after it began. Y noted that Care Provider A had considered his care documents to be fairly basic. Y raised the following points:

Moving and Handling

22. On 4 April he asked for a copy of the Moving and Handling plan.
23. Y chased for the Moving and Handling plan on 11 April. He was concerned about his wellbeing and that of the carers. There appears to have been a delay responding to this point. A social worker picked up Y’s concerns in July after a period of leave. On 12 July the Moving and Handling plan was sent to Y. The social worker explained a referral would be needed if changes were needed and explained how Y could request this.
24. The Council recorded an email was received from Y on 26 November stating he was now happy with the moving and handling plan and he had sent it over to Care Provider A.

Medication

25. On 4 April Y also asked for an up-to-date record of his prescription medication showing the relevant dosage. On 9 April the Council stated Care Provider A was putting together an electronic Medical Administration Record (eMAR) that the carers would have access to.
26. I understand, initially, Miss X assisted Y with medication. Care records indicate Care Provider A were assisting by May 2024.
27. In mid-June, there was a ‘near-miss’ incident where Y had to stop the carers giving him too much of one of his tablets. There is no record of this in the records Care Provider A sent to us at the time this occurred. However, I understand Miss X did raise this with Care Provider A.
28. In August, Y stated there was no need for the Council to send the information he had requested about his prescription medications because the eMAR was being created. However, it seems evident that details of Y’s medications were available on the prescribing labels and medication charts were being kept. There is a note these were shared with Y after a query in August. Documents in September confirmed that one of the carers’ roles was to measure out Y’s medication and leave it in a pot for him to take.
29. In January 2025 the Council’s records noted that Y had stated he no longer wished Care Provider A to assist with medication. Miss X would do this instead. He referenced the near-miss and call times as reasons, and general dissatisfaction with the care provided.

Call Visit Times

30. Care Provider A’s records show Y raised a concern about the care visit times around ten days after the service started. The care manager agreed to get this resolved. The records indicate that a manager called back the following day and confirmed the times that carers would visit.
31. Assisting with medication was part of Y’s care needs. He explained that his medication needed to be taken at specific intervals, so timing of the care visits was important. The Council indicated that the timing of care calls was resolved by Care Provider A quickly. I note that Miss X was still assisting Y with melatonin as taking it at the last care visit would still be too early and other occasional timing issues remained.
32. In June Miss X asked to cancel lunchtime calls permanently. This was referred to Y’s social worker and the care package amended from the following Monday.

October 2024 Care Incident

33. In early October 2024 there was an issue with Y’s personal care where he felt sexually violated by one of his carers (Carer B).
34. Y says Miss X told the other carer that he was no longer comfortable receiving care from Carer B. He was not sure if this was relayed to the office staff. Miss X told us the issue was reported to a care manager at Care Provider A. She says it was not investigated.
35. Care Provider A’s response to Y’s complaint acknowledged contact with Y in October 2024 about this incident, but they stated Y expressed some discomfort about care received from Carer B and suggested some training, but he had provided no details of the incident.
36. Care Provider A say they were contacted by Y in mid-November 2024 stating he no longer felt comfortable receiving care from Carer B. At that time, again, no specific details of the incident were provided. Care Provider A told Y they may struggle to cover all his care shifts without Carer B, so they suggested the other carer (working as a pair with Carer B) could take the lead with Carer B still involved. Y agreed this would be okay.
37. The records the Council sent us from Care Provider A do not record any complaint or concern being received about Carer B. They record other feedback and general contacts about care visits during October and November 2024, but no reference to this incident or Y reporting being uncomfortable.

January 2025 Incidents

38. In early January 2025 Care Provider A stated, when carers visited to provide care early in the new year, Miss X disclosed that her relationship with Y had been strained over Christmas. Y had been verbally and physically abusive to her and she had punched Y. Care Provider A raised this as a safeguarding alert. Miss X was not made aware it had been reported. Care Provider A stated that they had attempted to contact Miss X without success.
39. The Council started a safeguarding investigation.
40. At the end of January 2025 Care Provider A identified bruising on Y which had not been there at the previous care visit. Both Miss X and Y acknowledged this had been caused when Y lashed out as Miss X and she had then hit him.
41. The Council continued its safeguarding investigation alongside police involvement, which we cannot consider.

Y’s 2025 Complaint

42. While the safeguarding process was ongoing, Y raised a complaint which set out various concerns about his care and other issues he had raised from April 2024. Several of Y’s concerns were recorded as separate safeguarding issues. These were the personal care incident from October 2024 involving Carer B. (The Council were only made aware of this incident when Y included it in his complaint) and the near-miss with medication that occurred in summer of 2024.
43. In March, the police ceased its investigation into the incidents between Miss X and Y. It did this because it noted the Council’s involvement in ongoing safeguarding and support for Y, and because the process of investigating was causing Y distress as he did not wish it to continue.
44. The Council confirmed to Y that it would not be making any more enquiries about the incidents involving Miss X and it would explain its safeguarding decisions to Y in due course.
45. In April 2025 the Council wrote to Y to provide the outcome of the safeguarding enquiries. The Council noted:

• Care Provider A were asked to remove Carer B from the rota, which they responded to, but they were not told the details of the October 2024 incident so no safeguarding alert was raised at that time. The Council noted Carer B had changed careers, so there was no ongoing risk and it would take no further action. It noted Y should contact the police if he considered a crime had taken place.
• The Council referred to the report Y had made about a near-miss with medication. It set out the action Care Provider A had taken. Care Provider A acted to provide further training for the carer concerned in November 2024, and monitoring Carer B’s work. The Council was satisfied this was an appropriate response, so no further actions were required. The Council also agreed it would raise a number of other these issues (about timing of calls and other things) as commissioning feedback about Care Provider A.
• In relation to the January incident between Miss X and Y, the Council noted, after considering the issue and the impact that the investigation was having on Y, the police decided to take no further action. The Council noted ideas for improving Y’s current situation and that these were being incorporated into Y’s new care plan, Y had identified a new care provider and there were ongoing discussions about respite. It also noted Y was having a carer assessment and other issues were being considered outside of the safeguarding process.

46. The Council’s response to Y’s complaint noted there had been numerous calls and emails between Y and Care Provider A to discuss difficulties and find solutions. There was evidence that conversations had taken place involving his social worker. We saw the emails concerned.
47. The Council noted that Care Provider A had not been aware of the significance of the incident in October. The Council found that there was no clear evidence that safeguarding thresholds had been met in respect of the other issues been raised about the quality of care, and the Council was satisfied these had been responded to.

B) Inadequate Moving and Handling Plan

48. The Council provided us with a copy of a moving and handling plan for Y. A plan was provided in October 2023 and reviewed in April 2024 around the time that Care Provider A started providing care for Y.
49. The plan contains comments from Y about how issues should be dealt with, for example, how he should be handled and moved and the impacts of his disability in his movement.
50. As we set out in paragraph 22, Y asked several times for a copy of his Moving and Handling Plan from April 2024. There is evidence that Y raised concerns about how moving and handling was being carried out and he proposed a review.
51. There was a delay sending Y a copy of the plan until July 2024. At that point, a social worker made it clear how Y could seek a review of this by making a referral. The case notes also show that an Occupational Therapist carried out a prompt visit in July and ordered a different model of hoist when Y raised an issue with it.

He was not provided with a copy of his care and support plan and he was not fully involved in care and support planning. He questioned if the home care service provided was the most appropriate.

52. Y stated that he did not feel fully involved with care planning and he did not get an opportunity to sign off his previous plan. He explained that it was difficult for him to read/access documents that were not saved in ‘Word’ format.
53. The Council’s response to Y’s complaint looked at its care records. It stated the case notes going back to late 2024 indicated that regular contact had been maintained with Y and his concerns had been addressed by his social worker. However, the records for the previous period were not as detailed.
54. Overall, the Council considered that care plan reviews noted Y’s comments and that they had been reflected, in Y’s own words in the care plans created. The Council provided us with evidence that issues raised by Y had been responded to and requests, such as preferences of carer had been respected. We have seen the care records and care reviews.
55. The Council acknowledged that Y had felt unable to be fully involved because the format of care plans was not compatible with software he used. It acknowledged this issue and stated it was working with its IT team to find a solution to this issue to provide documents in ‘Word’ format.
56. The Council also explained why it had considered Care Provider A were able to meet Y’s needs. It noted they were a general domiciliary care provider able to support adults of all ages.

He wanted to challenge the decision to decline funding for transport for short breaks and wanted funding to make adaptations to his wheelchair.

57. The Council’s complaint response indicated this issue had been resolved because the Council had agreed to fund transport costs for short breaks.
58. As this issue has been resolved we have not considered it further.

His communication preferences were not respected (the Care Provider initially declined to use Text Relay) and documents were not sent in a format he could read independently.

59. Y complained that Care Provider A had refused to use a text relay service that he wished to use to communicate with them.
60. On 5 July Y asked the Council to add Text Relay to his records as a communication preference. Text relay allows a service user to type what they wish to say and this is relayed by the third party service to the person they are calling.
61. Care Provider A’s records show that Y contacted them using text relay in early July to discuss his care arrangements. Y’s care coordinator was uncomfortable continuing the call because a third party was involved on the call and they were discussing Y’s personal information. Care Provider A offered to speak to Miss X or to visit Y at home to discuss any concerns he had. The call was ended.
62. Y later complained that his care coordinator declined to use the text relay service. He considered that was a breach of the Equality Act.
63. Case notes on Care Provider A’s systems show the Care Coordinator spoke with Y’s social worker to check if using text relay represented a breach of confidentiality. The social worker stated it did not, as Y had full capacity to understand the service and that the third party involved would hear confidential information as part of its use. Care Provider A noted this and there is evidence from Care Provider A’s records that the service was being used with Y following this.
64. As we note above, the Council acknowledged that documents needed to be shared in ‘Word’ format and told Y it would work to find a solution for this. I note in the meantime, while not ideal, Y’s PAs could assist him to go through documents.

He wanted to understand what had happened with his Education Health and Care Plan.

He wanted the Council to explain why he was not able to keep a therapy bed, purchased to assist his care while in college.

65. Y’s complaint stated that Section F of Y’s Education Health and Care Plan (EHC Plan) was not clear and he sought an extension of the EHC Plan for ten years if possible.
66. Y also commented that the EHC Plan made no reference to a therapy bed that was purchased for him to use at college. He understood the bed would move with him, not remain at the college. However, this did not happen.
67. The Council’s response explained that EHC Plans can remain in place and provide support in an educational setting up to age 25. However, they legally end after the age of 25 and the Council could not extend this. The Council proposed holding a review meeting to discuss the content of the EHC Plan.
68. In terms of the therapy bed, the Council stated its SEND Service Manager stated the Therapy Bed could be offered to Y’s college when Y no longer needed it.  The Council stated at no time had the Council advised Y that the bed would belong to him personally.

That he felt coerced into making a decision to accept alternative accommodation following an incident involving Mrs X on 30 January 2025.

69. The Council’s response to Y’s complaint referred to wider issues that he had raised when making his complaint. This included the issue of being coerced to accept independent living accommodation – specifically from the police. The Council agreed this, and several other issues should not be investigated when it considered Y’s complaint. Y’s concerns about these issues were noted but not investigated by the Council.
70. We cannot investigate the actions of the police.
71. In response to our enquiries on the complaint, the Council explained that it had conversations with Y about living independently. It set out various conversations it had with him between February 2024 and July 2025. The Council noted at various times Y had shown interest in living independently.
72. As at 2024, care provision was in place to support Y while living at home, as that was his wish. During 2025 discussions had taken place about a potential move locally. Y was supported by his PA to complete housing forms and the Council offered to explain and assist with the process of moving locally, but out of borough, if this was needed.

Y’s Complaint

73. Miss X raised a complaint with the Council in December 2024. This concerned issues with Y and herself, as a carer. She stated she and Y had both suffered with suicidal ideation. On receipt of the complaint officers signposted Miss X’s comments to the crisis team.
74. The Council later defined the complaints and separated out issues affecting Y from those affecting Miss X. Y made his own complaint to the Council on 27 February 2025.
75. The Council responded to Y’s complaint (and issues raised on his behalf by Miss X) on 13 June 2025. It responded to a complaint from Miss X on 20 June 2025. This decision statement only concerns issues affecting Y.

Was there fault by the Council

Safeguarding

76. There is evidence that various issues were being reported about Y’s care from April 2024 when Care Provider A began providing it. I found no fault in the Council’s view that the majority of these would not be sufficient to require safeguarding alerts. For example, issues with the timing of care visits and chasing for a copy of the moving and handling plan.
77. It is not clear from the Council’s safeguarding report when Care Provider A were made aware of the near-miss with medication. But there are several examples of contacts not being recorded in Care Provider A’s records which it later refers to (I refer here to reports made about the October 2024 incident with personal care). I found on balance, it is likely that the near-miss with medication was reported to Care Provider A at the time. As a result, it should have been recorded in Care Provider A’s records.
78. However, the Council’s guidance on reporting safeguarding incidents does not require a safeguarding report to be made on an isolated mediation incident, where no harm has been caused. As Y corrected the carer, no harm was caused on this occasion. I note that, in any event, Care Provider A took appropriate action to address this later in 2024, which the Council then considered as part of its wider safeguarding enquiries.
79. As I say above, the records Care Provider A sent us via the Council do not record reports that Y made about being uncomfortable with Carer B in October and November 2024. I found the failure to keep these records amounts to fault. It makes it less clear what was said and when.
80. On the basis of the evidence we have seen I found it is unlikely, on balance, that Care Provider A were made aware of the full details of the incident at the time it occurred. So, I found there was no failure to make a safeguarding report on Care Provider A’s part. When the extent of the concern was made clear I found the Council considered this appropriately as part of its investigation. Safeguarding is concerned with risk and the Council decided this was no longer a risk and no further action was needed. This is a decision it was entitled to reach.
81. Miss X told us that Care Provider A made earlier safeguarding reports about her, which were not made known to her. She considered that this affected how the incident at the end of January 2025 was dealt with.
82. The Council’s safeguarding records show that a report was made at the start of January. It appears this was being considered when the second report was made at the end of January. While Miss X was not aware of the first report, I found this did not affect the actions being taken.
83. Both reports in January were significant. Care providers are under a duty to report any potential abuse they become aware of. There was no doubt that the threshold for the Council considering a safeguarding enquiry was met on both occasions because care workers become aware of physical altercations between Miss X and Y. So, I have no grounds to question the consideration the Council gave to this as a safeguarding matter. For the same reason, I have no grounds to question Care Provider A’s decision to contact the police. This was a decision they were entitled to make. We cannot consider the actions of the police that followed.

Care & Support Plan/Involvement in Care Planning

84. Y stated he was not provided with a copy of his care and support plan and he was not fully involved in care and support planning. We found there was evidence of correspondence and contacts with Y using various methods to respond to queries by both Care Provider A and the Council.
85. We did not find there was a failure to involve Y in his care reviews or care planning.
86. I found there was fault with the format of documents supplied to Y. This could have impacted how Y was able to go through care records and raise queries. Y requested documents be sent, as ‘Word’ documents because he has software that assists him to go them. The Council was in agreement to doing this but Y raised the issue in his complaint of February 2025. At the point the Council responded to his complaint in June 2025, this had not been remedied. The Council should have considered this more formally as a reasonable adjustment request. Its failure to provide documents in this format is fault by the Council. The Council told us, it had since resolved the issue (in August 2025), and it explained how Y could access documents in a format that is compatible with software he uses.
87. I have noted that while Y was not able to go through the documents himself, it was possible for PAs to go through them with him. This limits the impact to some degree, but Y explained this takes longer and it is not Y’s preference because it affects his independence.

Moving and Handling Plan

88. Y stated his care assessment lacked detail about his moving and handling needs. We cannot determine whether the content of Y’s manual handling plan was appropriate or needed amendment at the time Y raised his queries. This would be a decision for occupational therapists and social workers involved in Y’s care. However, it was clear that Y had some concerns and wanted to see the plan and consider if it needed revision. There was a delay in providing it to him. I found this was fault. The in turn delayed Y’s opportunity to follow this up in an informed way and to make a referral for a review.

Funding for Transport – Short Breaks

89. The Council’s complaint response indicated this issue had been resolved so we did not consider it further.

Communication & Use of Text Relay

90. Y complained that Care Provider A refused to use Text Relay and as a result, he considered they breached the Equality Act. There is evidence that a manager at Care Provider A declined to complete a call with Y when, it seems, text relay was being used for the first time. Their case notes indicate they were concerned about the involvement of a third party. They checked this with the Council subsequently and having satisfied themselves that it would not be a breach of Y’s confidentiality, the evidence is that Care Provider A then agreed and did use text relay when communicating with Y.
91. Y is entitled to request reasonable adjustments under the Equality Act and, by law, Care Provider A is obliged to consider how any substantial disadvantages Y has can be overcome by making adjustments such as using the text relay that Y requested. I recognise that Care Provider A’s reluctance may have been frustrating for Y. However, I do not consider Care Provider A’s actions amount to fault in this instance. I say this because its approach was one that appeared to come from caution, and relatively soon after the initial call, Care Provider A agreed to use the service, once its initial concerns had been alleviated. The care provider also offered to meet Y’s needs in a different way, by visiting him.
92. As we say above, there was also a failure to provide documents in the format Y requested as an adjustment.

Education Health and Care Plan (EHC Plan) & Therapy Bed

93. Y’s concerns about his EHC Plan related to the content and how long it should be in force for.
94. As the Council stated in its complaint response, the law dictates how long EHC Plans can continue; until age 25. The Council cannot extend this further.
95. EHC Plans should be reviewed annually and any appropriate changes made. I note that Y’s current EHC Plan was last reviewed in March 2023. The failure to carry out an annual review since March 2023 is fault. However, I note the Council agreed to conduct a review following Y’s complaint. A new plan was issued in December 2025 to note a new educational placement. However, it is not clear if an EHC Plan review was conducted at that time.
96. I have recommended the Council carries out the review within the next four weeks if it has not already done so.
97. We cannot address any concerns Y has about the EHC Plan content. This is because someone can appeal to a Tribunal if they disagree with what an EHC plan says. Because there is another body set up specifically to deal with appeals about EHC Plans we have no jurisdiction to consider complaints, or parts of complaints that relate to their content.

That he felt coerced into making a decision to accept alternative accommodation following an incident involving Mrs X on 30 January 2025.

98. We noted that council officers did have conversations with Y regarding moving and living independently. However, there is no suggestion that Y was coerced by the Council. I understand Y’s concerns largely related to the police in this regard. We cannot investigate or comment on the actions of the police. We found no fault by the Council in this element of Y’s complaint.

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Action

99. Within four weeks of our final decision:
100. The Council should apologise to Y for the fault we have found in this investigation. The apology should adhere to our guidance on making effective apologies. This can be found on our website, within our Guidance on Remedy here.
101. The Council should carry out an Education Health and Care Plan review and send written confirmation of its intention to either maintain, amend or cease the plan, as appropriate. The Council should also explain Y’s rights of appeal.
102. The Council should provide us with evidence it has complied with the above actions.

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Decision

103. I find fault causing injustice.

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Investigator's decision on behalf of the Ombudsman