Summary: Mrs B complained about the Council’s failure to approve 2:1 support for her son Mr C at one of his placements for over a year. We found fault in the actions of the Council which caused Mrs B frustration and distress. The Council has agreed to apologise to Mrs B and increase the symbolic payment to her to £500.

The complaint

1. Mrs B complained that Kent County Council (the Council) repeatedly refused to put in place 2:1 support for her son Mr C which placed him and others at risk of harm and caused significant distress and frustration to Mrs B.

Back to top

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(1), as amended)

Back to top

How I considered this complaint

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

Back to top

What I found

6. Mrs B’s adult son, Mr C, has complex needs. He attends several different provisions during the week with transport provided.
7. In June 2024 one of the provisions (Placement Z) requested that C’s support be increased from 1:1 to 2:1 due to an increase in difficult behaviour resulting in harm and risk of harm to himself, staff and other service users. Mr C’s social Worker (SW), Mrs B and Placement Z provided evidence to the Council to substantiate the request. The Council’s Panel considered the request on 19 July 2024. It rejected the request on the grounds that no other service had requested 2:1 support. Placement Z funded the extra support itself to protect its staff and other service users.
8. Mrs B appealed the decision. The appeal Panel upheld the decision but suggested further exploration was needed as Mr C presented differently at Placement Z than at his other placements. The Panel also discussed implementing a package of direct payments (where money is given to the service user to arrange their own support) and Mrs B could fund the difference in support if Mrs B wished Mr C to remain at Placement Z (at a cost of between £9,000 and £27,000 per year).
9. In August 2024 one of Mr C’s other placements provided details of times he had required 2:1 support.
10. In September 2024 Mrs B escalated her appeal. In October 2024 the Council recommended a review of Mr C’s care package and for SW to observe him in the two settings. SW completed the observations by early November, but struggled to arrange a review with all parties present until 13 January 2025. At this review Placement Z reported that Mr C’s behaviours had reduced a little.
11. SW presented Mr C’s case again to the panel on 17 January requesting 2:1 support. The Panel did not approve the request but requested more information on the costings from Placement Z. SW said that if 2:1 was needed urgently she would try and get temporary approval from her manager. On 20 January the Panel considered the case again and approved 2:1 support for two weeks.
12. On 20 January Placement Z sent three incident reports where three members of staff were injured during an incident with Mr C when he only had 1:1 support and his behaviour escalated violently.
13. Mrs B appealed the decision on 21 January and Placement Z expressed their dissatisfaction with the decision. It said some of its female staff were refusing to work with Mr C due to concerns about his unpredictable behaviour.
14. In February 2025 Placement Z requested 2:1 support as the incidents were still occurring. Mr C’s personal assistant from another placement provided evidence to support the request for 2:1 support.
15. The Panel considered the case again on 7 March but refused the request questioning how an extra person could prevent Mr C’s violent behaviours. Both Mrs B and Placement Z expressed dissatisfaction with the decision and said the Council had misunderstood the point of 2:1 support which was about managing risk, promoting safety and providing proactive support.
16. On 21 March Mrs B made a formal complaint to the Council. She said the Council’s failure to provide 2:1 support, amounted to disability discrimination, and was a failure to provide reasonable adjustments. She said the Council had ignored incidents resulting in injuries to staff and Mr C. It had also repeatedly ignored SW’s recommendations. She said Mr C had previously received 2:1 at a different placement in 2021 for a temporary period only, but his behaviour had improved. She said the statutory guidance said that funding panels should not be used to override professional recommendations or restrict care cost alone.
17. In April 2025 a different social worker (SW2) observed Mr C at Placement Z and another placement. They recommended 2:1 support for a defined period followed by a review.
18. In May 2025 the Council sent a letter to Mrs B apologising for the delay in responding to the complaint.
19. On 11 June the Council agreed to complete an updated assessment of Mr C’s needs, behaviours and risks. Mrs B complained to us.
20. On 22 July the Council sent Mrs B another letter apologising for the delay in responding to the complaint. The Council agreed to fund 2:1 support while a further assessment and care plan was completed. It backdated the funding to 20 January 2025, the point at which SW had requested 2:1 support.
21. The Council sent another complaint delay letter to Mrs B in August 2025. It responded to the complaint on 7 October 2025, saying:
• Mr C’s care package had not been reviewed since 2021. It noted a review had been held on 13 January 2025. It apologised for the delay in doing this.
• It upheld the complaint about not providing 2:1 support at an earlier point. It said this was connected to the failure to review Mr C’s needs to enable better decision-making about the type and level of support Mr C needed. It noted the risks to Mr C were mitigated by the extra support Placement Z had put in place. It apologised to Mrs B.
• It upheld the complaint that given the professional views expressed about the need for 2:1 support since January 2025, it should have acted sooner to obtain an independent assessment to inform the decision-making.
• It did not uphold the decision that cost considerations had been prioritised, saying that the decisions did not centre around cost but the need for robust information about his eligible need and how to meet them in the least restrictive way. But it apologised for the delay in assessing and recommending support.
• It offered Mr C £200 as a goodwill gesture and Mrs B £200 for her time, frustration and stress.
22. In responding to my enquiries, the Council has reviewed the case and agreed to backdate the funding for 2:1 support for Mr C at Placement Z to 2 July 2024 (the date when Placement Z first reported that Mr C urgently required 2:1 support).
23. The Council has also explained that the complaint response was delayed partly due to capacity issues in the complaints team because and organisational change, which led to request to review Mr C’s assessment. The complaint response was finalised once the reassessment was complete.

Analysis

24. The Council has acknowledged it took too long to provide 2:1 support for Mr C at Placement Z. This was partly due to its failure to carry out a review of his care and support needs since 2021 and a failure to obtain an independent view of his needs at Placement Z. This was fault which caused Mrs B injustice: she was caused frustration and distress over a 12 month period, repeatedly asking for support, appealing the refusals and being asked to fund the extra support herself at a cost of thousands of pounds a year.
25. The Council also took too long to respond to Mrs B’s complaint. While I understand the reasons given and the need to carry out a reassessment, I consider the Council could have sent the response sooner; seven months was too long. This exacerbated Mrs B’s frustration and distress. Although I do understand the Council agreed part way through this period, in July 2025, to provide funding back to January 2025, which mitigated the injustice to some degree.
26. I note that Placement Z provided the 2:1 support itself for much of the period and consider the £200 the Council offered to Mr C is a reasonable recognition of the injustice he was caused by the uncertain arrangements. However, the payment of £200 is insufficient to recognise Mrs B’s injustice for over a year. And consider £500 is a more appropriate amount.

Back to top

Action

27. In recognition of the injustice caused to Mrs B and C I recommended the Council within one month of the date of my final decision:
• apologises to Mrs B and increases the symbolic payment to £500.
28. The Council has agreed to my recommendation and should provide us with evidence it has complied with the above actions.

Back to top

Decision

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

Back to top

Investigator's decision on behalf of the Ombudsman