Summary: Mr X complained about the Council’s handling of concerns about disrepair and risk in Ms Y’s supported living placement. He said she was at risk of harm and did not receive the support she needed. We found fault by the Council for causing delays in the statutory assessment processes for Ms Y, in its complaints handling, and it delayed progressing repairs with her landlord. As a result, Ms Y experienced a risk of harm and had a loss of care and support. Mr X also experienced an injustice. The Council agreed to apologise and make payment to acknowledge the impact its faults had on them and make service improvements.

The complaint

1. Mr X complained about the Council’s handling of his adult social care concerns relating to family member, Ms Y, who lives in supported accommodation arranged by the Council. He said the Council:
• caused delays and failed to properly address issues of disrepair in Ms Y’s accommodation with her landlord and ensure she was safe;
• caused delays to assess Ms Y’s care and support needs to establish whether residential care is more suitable for her needs; and
• caused delays to assess whether Ms Y has the mental capacity to make specific decisions about her care and support.
2. Mr X said, as a result, Ms Y’s current accommodation is not safe for her, in particular due to it being in disrepair and with limited support. He said this has caused him distress and frustration. He wanted the Council to complete assessments of Ms Y's care needs, her mental capacity, and safety in the accommodation.

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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. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
5. 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)
6. We cannot investigate complaints about the provision or management of social housing by a council or a registered social housing provider. (Local Government Act 1974, paragraph 5A schedule 5, as amended)
7. 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)
8. 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

9. I have investigated Mr X’s complaint about the Council’s handling of disrepair concerns in Ms Y’s accommodation and requests for Adult Social Care assessments from Spring 2024 to May 2025. This was when Mr X brought his complaint to our attention. However, I have had regard to the events which subsequently occurred.
10. I have not investigated Mr X’s concerns prior to Spring 2024 as this relates to matters which occurred more than 12 months before it was brought to our attention. Nor any events which occurred from June 2025 which he may dispute or disagree with as the Council did not have the opportunity to address these through its complaints process.

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How I considered this complaint

11. I considered evidence provided by Mr X and Council as well as relevant law, policy and guidance.
12. 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

Relevant law

Care Act Assessment

13. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
14. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.
15. 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.
16. 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.

Mental Capacity Act

17. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
18. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
19. The person assessing an individual’s capacity will usually be the person directly concerned with the individual when the decision needs to be made. More complex decisions are likely to need more formal assessments.
20. If there is a conflict about whether a person has capacity to make a decision, and all efforts to resolve this have failed, the Court of Protection might need to decide if a person has capacity to make the decision.

Safeguarding

21. 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. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

Council complaint procedure

22. Councils should have clear procedures to deal with social care complaints. Regulations and guidance say they should investigate and resolve complaints quickly and efficiently. A single stage procedure should be enough. The council should include in its complaint response:
• how it considered the complaint;
• the conclusions reached about the complaint, including any required remedy; and
• whether it is satisfied all necessary action has been or will be taken by the organisations involved; and
• details of the complainant’s right to complain to the Local Government and Social Care Ombudsman.

(Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)

23. Regulations do not say how long a complaint investigation should take. But they do say an expected timescale must be explained at the start, usually in discussion with the complainant. If the complainant does not want to discuss this, the responsible body must decide the timescales and confirm them to the complainant in writing. The body must keep the complainant informed of progress during the investigation ‘as far as reasonably practicable’. If the responsible body has not provided its response after six months (or after a longer period agreed with the complainant), it must write to the complainant to explain why. (Regs 13 and 14, Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)

What happened

24. Ms Y lives in supported housing arranged by the Council with a social landlord. She has physical and mental health conditions which impacts her ability to manage her daily life and to keep herself safe. The Council has issued a care and support plan which sets out the support she should receive in and outside her accommodation.
25. Mr X is a relative of Ms Y who has an interest in her wellbeing. He has power of attorney for her property and finances.
26. Mr X raised concerns about the safety of Ms Y’s bathroom to her landlord. In Spring 2024 he informed the Council about the issues with the bathroom and explained this was a safety risk for Ms Y. He asked the Council to get involved to ensure the landlord completed the necessary works and assessed any risks to her safety.
27. The supported living provider also asked the Council to complete a reassessment of Ms Y’s care and support needs. This was because it believed her need and behaviours had changed since the last Care Act assessment. It also raised concerns about Ms Y’s bathroom.

The Council’s handling of disrepair and Ms Y’s safety

28. Mr X complained to the Council in June 2024. He explained the landlord had not taken appropriate action and shared the outcome of his complaint to the landlord with the Council. He said the Council had not taken any action to hold the landlord to account and ensure Ms Y was safe in the accommodation.
29. The Council considered the concerns raised. It noted the landlord had previously done works to the bathroom and suggested it may be due to Ms Y’s use of the bathroom. It said it had reported and chased the repairs with the landlord.
30. In Autumn 2024 the Council’s allocated social worker visited Ms Y and spoke with Mr X. A disrepair concern was identified which required action by the landlord. It was agreed Ms Y was not the cause of the disrepair concern. The Council met with the Landlord and repair works was agreed to be followed up. The following events subsequently occurred:
• Mr X was informed by the Council about the required repair works to be completed by the landlord;
• the Council asked the landlord for updates on repair works;
• in January 2025 the Council called the Landlord to chase the works. The Landlord said it had reviewed the disrepair in Autumn 2024 and found no issues in the bathroom;
• In Spring 2025 the Landlord visited Ms Y’s accommodation. However, no works to resolve the bathroom issues has taken place.
31. The Council responded to Mr X’s complaint in January 2025. It apologised for the delay in its response and explained it was an oversight this had not been sent. It upheld Mr X’s complaint as its allocated social worker had not followed up on the disrepair issues between Spring and Autumn 2024. Contact had since been made to review Ms Y’s care and support plan, and a visit and follow ups regarding the disrepair had been progressed with the landlord. It explained it had taken learning from the case and addressed this with the social worker.
32. Mr X was not satisfied with its response but did not wish to raise another complaint. He asked the Council for a call to discuss and resolve the concerns. A call took place after a delay due to Mr X and the Council missing each other’s attempts.

Ms Y’s needs and mental capacity assessments

33. In Autumn 2024, the Council also agreed a review of Ms Y’s care and support plan was needed. The review started in September 2024. Mr X told the Council it should carry out a risk assessment, needs assessment, and a mental capacity assessment for Ms Y. This was because she needed more care and support, the supported living placement was not suitable, and she lacked capacity to make decisions about her care and support.
34. The following events subsequently occurred regarding review and assessments of Ms Y’s care and support:
• In late 2024 the Council’s case notes show it intended to look for alternative placements for Ms Y which could better meet her changing needs. This could be in a different supported living or a residential care home. However, Ms Y still lives in the same supported living accommodation;
• In early 2025 the Council carried out a reassessment of Ms Y’s needs. The finding was her needs had changed and more support should be put in place, at least until a different placement was sourced. Further visits which included an occupational therapist took place. However, the care support was first put in place in September 2025. This included substantial 1:1 support;
• A mental capacity assessment took place in Summer 2025 where Ms Y had an advocate to support her. There was then a short delay due to awaiting GP information. A best interest decision was made shortly after. Mr X disputes this decision with the Council; and
• The Council safeguarding risk assessment was completed by an occupational therapist in October 2025. Some risk considerations were made during visits since January, some equipment was provided to support Ms Y in Summer, and a falls risk assessment was completed in September 2025. She was also referred to a fall’s intervention service.
35. Mr X said Ms Y remains in the same supported living accommodation which he believes is unsuitable and further repairs has not been completed by the landlord. He said Ms Y had a fall in Autumn 2025. He also does not agree with the outcomes of some of the assessments the Council have since completed.

Analysis and finding

Disrepair and Ms Y’s safety in the supported living accommodation

36. Mr X has brought a complaint to Ms Y’s landlord about its handling of the disrepair in the accommodation. While I cannot consider the disrepair issues, as these were for the landlord to resolve, I can consider how the Council worked with the landlord and how it considered her safety and wellbeing whilst in the accommodation.
37. The Council has accepted it was at fault for its failure to progress the disrepair concerns from Spring to Autumn 2024 with the landlord and consider how this impacted Ms Y. This was fault. It has apologised and taken steps with the individual officer to ensure such issues do not reoccur.
38. I found the Council was not at fault for the landlord’s delays or failure to complete further repairs to Ms Y’s bathroom from August 2024. This is because it visited Ms Y, agreed repairs were needed, shared the information with the landlord and Mr X. It subsequently chased the landlord. The property does not belong to the Council, it would therefore not be appropriate for the Council to have completed the repairs.
39. However, the Council had an ongoing responsibility to ensure Ms Y was safe in the accommodation and to review this when it became aware of the concerns. In particular as it was aware she was unable to do so herself due to her needs and lack of ability to do so.
40. I acknowledge some risks were considered from early 2025, an occupational therapist became involved from May 2025, and some mitigations were put in place in Summer 2025. However, I found the Council caused significant unnecessary delay to properly consider and complete an assessment of the risks the accommodation had on Ms Y and put in place mitigations it found appropriate.
41. While I understand Ms Y did not experience any actual harm during the period of my investigation. I am satisfied she was exposed to a risk of harm for longer than she should have been, and Mr X experienced distress, uncertainty, and had time and trouble as a result.
42. The Council has since completed its assessment of the risks the accommodation has on Ms Y and put in place the mitigations it has found necessary. I cannot consider the outcome of this, as this occurred after Mr X’s complaint to the Ombudsman and we cannot criticise such decision if properly made.

The Council’s assessments of Ms Y needs and capacity

43. The Council’s received a referral from the supported living provider in Spring 2024 to reassess Ms Y due to her changed needs. Mr X also asked the Council to assess her shortly after.
44. I found fault by the Council for causing unnecessary delays in the process to:
• review Ms Y’s care and support plan. This is because it was first started nearly 4 months after the Council received the request;
• complete a needs assessment for Ms Y. This was first completed in early 2025, around 4 months after the review had taken place which confirmed it was necessary to complete the assessment, consider mental capacity, and to review the placement;
• arrange appropriate care and support as decided in Ms Y’s needs assessment until September 2025, which meant she did not have the support the Council had agreed she should have for nearly 9 months; and
• complete Ms Y’s mental capacity assessment, which was first completed in July 2025. Although a small part of the delay was due to Ms Y’s GP, the delay lasted around nine months.
45. I am satisfied Ms F experienced an injustice as a result. This is because she did not have the care and support she was entitled to in the supported accommodation in line with her changed needs. I found, but for the Council’s delays, this should have been in place and available to her from late 2024. Mr X also experienced distress, uncertainty, and had time and trouble to get his concerns addressed by the Council as a result.
46. In addition, the Council found it should source a more suitable accommodation for Ms Y in late 2024 to meet her changing needs. However, she has remained in the same supported living accommodation. Normally this would be fault. However, I was conscious:
• any injustice would be the same, or similar, to its failure to ensure she had the care and support she was entitled to;
• I cannot say whether the accommodation was unsuitable for Ms Y, if the Council had not caused delays to assess and arranging her additional care and support, and put in place mitigations to keep her safe in her bathroom; and
• Mr X and the Council currently disagree about what accommodation or placement is most appropriate for Ms Y, as she now has a significant amount of care and support in her accommodation. I cannot consider this as this is a new issue, I also note this is a decision the Council is entitled to make if it has properly considered the matter.

Complaints handling

47. Mr X complained to the Council in Summer 2024. The Council did not share its response until early 2025. I acknowledge it said this was an oversight, and the Care Act review and other communication took place. However, this was fault which caused Mr X some additional uncertainty and frustration.
48. Mr X raised further concerns to the Council in early 2025, but asked it to address these outside the complaints process in the hope this would make the process quicker. I have therefore not found fault in how the Council handled this under its complaint process.

Service improvements

49. We made service improvement recommendations relating to delays in the care and support review and needs assessment processes on a similar case which the Council actioned in early 2025. As this relates to the same period of my investigation, I have not made any recommendations regarding such delays.

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Action

50. To remedy the injustice the Council caused to Ms Y an Mr X, the Council should, within one month of the final decision:
1. apologise in writing to Mr X to acknowledge the injustice its faults caused them;

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.

2. pay a symbolic payment of £500 to Ms Y to acknowledge the loss of care and support she would have been entitled to but for the Council’s delays;
3. pay Ms Y an additional £500 to acknowledge the unnecessary risk of harm she experienced as a result of the Council’s delays to properly assess and mitigate risk in her supported living placement; and
4. pay Mr X £350 to acknowledge the unnecessary distress and uncertainty he experienced as a result of the Council’s faults, including the time and trouble he had as a result of its poor complaints handling.
2. Within three months of the final decision the Council should also:
1.  
2.  
3. review why the Council’s assessment of Ms Y’s mental capacity was delayed, and share with the Ombudsman an action plan, or steps it has already taken, to ensure such assessments are completed in a timely manner. This is to ensure those who lack capacity have the relevant help in the care and support processes and any support is appropriate to their needs and wishes.
4. review why the Council failed to respond to Mr X’s complaint over a six-month period, and share with the Ombudsman the steps it intends to take, or has taken, to ensure such delays and oversight do not happen.
3. The Council should provide us with evidence it has complied with the above actions.

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Decision

53. I have completed my investigation with a finding of fault by the Council for causing unnecessary delays in its complaints handling, the Care Act review, needs assessment, and mental capacity assessment processes for Ms Y, which caused her and Mr X an injustice.

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Investigator's decision on behalf of the Ombudsman