Summary: Mr X complains about the Council’s handing of Mr Y’s care and support needs. Mr X complains the Council placed Mr Y in an unsuitable placement and did not arrange regular home visits. Mr X says this impacted Mr Y’s physical health and emotional wellbeing. We find the Council at fault which caused injustice. The Council has agreed to make a payment and complete a fresh care assessment.

The complaint

1. Mr X complains about the Council’s handling of Mr Y’s care and support needs. Specifically, he complains the Council:

1. Wrongly placed Mr Y in placement far away from his family home;
2. Did not provide Mr Y with the agreed weekly home visit; and
3. Did not provide suitable care to meet Mr Y’s needs.

2. Mr X says the long car journeys caused Mr Y avoidable and unnecessary physical discomfort and avoidable distress, and the lack of home visits and suitable care impacted Mr Y’s emotional wellbeing. Mr X says this has also caused him unnecessary and avoidable distress and frustration.

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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 future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), 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)
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)

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How I considered this complaint

6. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
7. Mr X and the Council had an opportunity to comment on a draft of this decision. I considered all comments received before making a final decision.

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What I found

What should have happened

Placement decision-making (part a of the complaint)

8. 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.
9. 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.

Home visit and suitable care (parts b and c of the complaint)

10. 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.
11. Where the local authority provides or arranges for care and support, the type of support may itself take many forms. These may include more traditional ‘service’ options, such as care homes or homecare, but may also include other types of support such as assistive technology in the home or equipment/adaptations, and approaches to meeting needs should be inclusive of less intensive or service-focused options.

What happened

12. Mr Y has care and support needs and does not have capacity to make his own decisions. He lived in a residential care placement, Care Provider A, which was commissioned by the Council. His care plan stated staff should facilitate visits to Mr X’s home every weekend.
13. In early summer 2024, Care Provider A told the Council it was closing at the end of summer.
14. The Council reassessed Mr Y’s care needs. The Council assessed that Mr Y required one to one support within a placement setting, and two to one support within a community setting. The Council decided Mr Y’s needs could be met in specialised residential care.
15. The Council consulted with over ten specialised residential care providers in the local area. The consulted providers either could not meet Mr Y’s needs or could not organise a placement before Mr Y’s current placement closed.
16. The Council arranged a placement for Mr Y in Care Provider B, nearly 100 miles away from Mr X’s home. Mr X told the Council the distance made Care Provider B unsuitable because long car journeys caused Mr Y distress and caused him to exhibit risky behaviour. The Council told Mr X it would continue to seek a suitable placement closer to home. Mr Y moved to Care Provider B.
17. In early Autumn, the Council consulted with four local residential providers. None of the placements were available. The Council contacted Mr X and invited him to a meeting to discuss Mr Y’s care and home visits. It again told Mr X it was continuing to seek a closer suitable placement for Mr Y.
18. The Council completed a risk assessment for home visits. It identified several risks within Mr X’s home. The assessment did not show consideration for the transport to and from the home visit.
19. A social worker visited Mr Y at Care Provider B. Placement staff reported he had settled in well. Staff told the social worker he had been on several short car journeys and there were no concerns. The Council held a professionals meeting and Mr X attended. The Council was satisfied Care Provider B was meeting Mr Y’s needs. The Council told Mr X to make some changes to make his home safe for Mr Y to visit.
20. A social worker visited Mr X’s home and confirmed he had made the necessary changes. Mr X signed paperwork confirming he agreed to act in line with the risk assessment for Mr Y during his visits.
21. In November, the weekly home visits began. Care Provider B staff drove Mr Y to and from his home visits. Each drive took at least four hours and was facilitated by three staff members.
22. In January 2025, Care Provider B did not facilitate home visits for three weeks. It told Mr X it was unable to do so because of weather conditions, a vehicle issue and a staffing issue.
23. In February, Care Provider B told Mr X due to Mr Y’s behaviour during the long journeys it was unsafe to transport Mr Y to and from home visits in its available vehicle. It told Mr X he could visit or arrange for taxi transport.
24. Mr X made a formal complaint to the Council.
25. In March, Care Provider B told Mr X it was investing in a new bespoke vehicle to make transport safe for staff and Mr Y. It said it was unable to transport Mr Y to his home visit until the bespoke vehicle was available.
26. In April, Care Provider B told Mr X it could facilitate video calls between him and Mr Y. The Council responded to Mr X’s complaint. It said it was aware home visits had been suspended following concerns about the safety of Mr Y and Care Provider B staff members during transport. It said it would review and reassess Mr Y’s current circumstances, including any risks associated with the transport arrangement. It also said it would consider longer-term planning which could include the consideration of an alternative placement.
27. In May, the bespoke vehicle was available, and home visits resumed.
28. In June, the Council issued a revised care and support plan for Mr Y. It included information about Care Provider A throughout the plan and did not consider the transport arrangement or Mr Y’s longer-term care.
29. Mr Y remains in Care Placement B.

Analysis

Placement decision-making (part a of the complaint)

30. I am satisfied that once the Council became aware Care Provider A was closing, it made significant efforts to find Mr X an alternative suitable placement within the local area. I am satisfied the Council considered placements further away once it was satisfied a suitable local placement was not available. Mr Y does not have capacity to make decisions about his care package. I am satisfied the Council made the decision in Mr Y’s best interest to safeguard him from homelessness. I find no fault with the Council’s decision-making to commission Care Provider B in the short term.
31. The Council repeatedly stated it was seeking another suitable residential placement closer to Mr Y’s family home. In its complaint response the Council acknowledges the location of Care Provider B is not ideal. The Council has not provided any evidence to show it has consulted other local residential placements since early Autumn 2024. This is fault. Due to Mr Y’s complex needs, I cannot say that further consultations during this time would have resulted in the Council finding a suitable placement for Mr Y in the local area. However, I consider the Council’s lack of consultations caused Mr X and Mr Y unnecessary frustration and uncertainty.

Home visits (part b of the complaint)

32. Mr Y’s care plan stated staff should facilitate visits to Mr X’s home on a weekly basis. I am satisfied that in Autumn 2024, the Council completed a risk assessment and took appropriate action to ensure Mr X’s home was safe for Mr Y to visit. I find no fault with the Council’s decision-making regarding its decision to postpone home visits until it was satisfied the home environment was safe.
33. The Council should have addressed Mr Y’s transportation in its home visit risk assessment in Autumn 2024, particularly as Mr X raised safety concerns. I consider its failure to do so was fault. Following Care Provider B’s suspension of transportation, the Council acknowledged significant safety concerns and stated it would address these risks in Mr Y’s new assessment. I consider its failure to do so was fault. The reason Care Provider B decided it could no longer safely transport Mr Y without a bespoke vehicle was because Mr Y’s behaviour during long journeys had caused significant damage and presented risks to himself and staff. Care Provider B staff told the Council Mr Y did not display any concerning behaviour during short car journeys. I consider the changes in his behaviour during long car journeys to and from home visits indicates it is likely these journeys did cause Mr Y distress. This Council’s failure to complete a transport risk assessment has also caused Mr X avoidable distress and uncertainty.
34. There was a period of three months where Mr Y did not access his home visits whilst Care Provider B arranged a bespoke vehicle. The home visits were part of Mr Y’s care plan. Care Provider B did invite Mr X to visit instead which Mr X declined. It also suggested Mr X could arrange a taxi for Mr Y which I consider was not an appropriate suggestion. Care Provider B did not offer to facilitate video calls until April. Therefore, during this time, Mr Y was not meeting the outcomes in his care plan. Mr X made the Council aware in February, and the Council considered the situation to be a temporary change in transport arrangements. The Council did not acknowledge the home visits had temporarily stopped and did not consider the impact this had on meeting Mr Y’s care plan outcomes. This is fault. This caused Mr Y injustice because he did not have the support detailed in his care plan during this time. It also caused Mr X additional avoidable frustration and uncertainty.

Suitable care (part c of the complaint)

35. Mr X complains Mr Y’s personal care needs were not met because of his appearance during home visits. I cannot make an on balance finding on this matter because I cannot determine how Mr Y wishes to style his hair and beard.
36. In its reviewed care plan, the Council detailed additional care provided to Mr Y during two periods of time when his needs increased and he required more care at Care Provider B. I consider this demonstrates the Council and Care Provider B were responsive in meeting Mr Y’s care needs at that time.
37. However, the care and support plan issued by the Council following its final complaints response did not show consideration of transport arrangements or longer-term planning. It referred to Care Provider A throughout which indicates it contained outdated information. I am not satisfied the Council properly considered Mr Y’s current needs in its reassessment, and so I cannot be satisfied the care the Council is currently providing is the care required to meet his current needs. This fault has caused Mr X and Mr Y avoidable and unnecessary uncertainty.

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Action

38. Within four weeks of my final decision, the Council has agreed to make a payment of £250 to remedy the avoidable and unnecessary uncertainty caused to Mr X and Mr Y by its failure to consult with local care providers, complete a timely risk assessment regarding the transport arrangement and provide a proper reassessment of Mr Y’s care needs. This money could be used to facilitate positive time together during home visits. I have considered this remedy in line with our published guidance on remedies. I consider this amount to be appropriate and proportionate to the level of injustice caused.
39. Within eight weeks of my final decision, the Council has agreed to make a fresh assessment of Mr Y’s care and support needs including a risk assessment of the current transport arrangement and exploring longer-term planning with consideration of suitable alternative placements in the local area.
40. The Council should provide us with evidence it has complied with the above actions.

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Decision

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

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Investigator's decision on behalf of the Ombudsman