Summary: Mr B complained about the Council’s action in respect of the care of his mother Mrs C. We have not found any fault in the way the Council made its decision that Mrs C should stay in her own home with a care package, the time it took to find a care home, or the care provided by the care agency.

The complaint

1. Mr B complained on behalf of his mother, Mrs C, that the Council:
• disregarded Mr B’s frequent requests for his mother to go into a care home;
• changed social workers too often, so there was a lack of continuity over assessing Mrs C’s care needs; and
• failed to take action over the poor care the care agency was providing.
2. Mr B said this caused him distress and uncertainty over whether his mother was safe and left Mrs C at risk of harm.

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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. 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)
5. 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

6. I have exercised to investigate events from November 2023 when Mr B raised concerns about Mrs C’s needs increasing.

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How I considered this complaint

7. I considered evidence provided by Mr B and the Council as well as relevant law, policy and guidance.
8. Mr B 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

Assessment

9. 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.
10. 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.

Reviews

11. 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

12. 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.

Best interest decision making

13. 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.

What happened

Background

14. Mrs C has health conditions and was living in her own home with a package of care, including attending a day centre several times a week. In 2022 the Council had taken various steps to mitigate the risks to her being at home including an increase in care calls, redirecting her post, disconnecting the oven (she could use the microwave), installing a bogus caller alarm and informing the local taxi service and the Police of her needs.
15. In July 2023 a care assessment concluded she was able to manage all her personal care tasks but needed help with cleaning and social contact. She was refusing assistance with preparing lunch and only wanted a chat and a hot drink.
16. Mr B had lasting power of attorney for Mrs C for both health and welfare and property and finance, meaning he could make decisions on her behalf if Mrs C did not have the capacity to do so.

November 2023

17. In November 2023 Mr B raised concerns about Mrs C’s behaviour towards the carers and ability to keep herself safe at home. A social worker visited and suggested using a virtual care system. Mrs C agreed to try this to help with isolation but then did not connect the system when it was delivered. Mr B said he felt Mrs C need to go into residential care. The social worker disagreed and said Mrs C was able to manage personal care, medication and meals and wished to stay in her own home.
18. In early January 2024 the social worker arranged for Mrs C to visit some sheltered housing with Mr B. In May 2024 Mr B confirmed that he wanted her to move to the sheltered accommodation, but Mrs C did not.
19. At the end of July Mr B’s partner contacted the Council to cancel Mrs C’s care visits. The Council spoke to the care agency who were concerned that Mrs C may not fully understand why she needed the care visits and could be vulnerable. The Council agreed to carry out a review of Mrs C’s care needs before agreeing to changing the care package.
20. In mid-August the care agency said Mr B had cancelled care visits over the previous two weeks. The social worker said they would visit the family and Mrs C the following week. They tried to arrange a visit with Mr B and Mrs C but without success.
21. At the end of September 2024, the social worker established from the care agency that the care visits had restarted on 15 August, but staff had concerns about Mrs B’s isolation on the days they did not visit. The social worker again agreed to carry out a review on 8 October. However, the review did not go ahead because Mrs C was at the day centre and Mr B did not attend. The social worker made some unsuccessful attempts to contact Mr B before the case was reallocated to a new social worker at the end of October.
22. The new social worker contacted Mr B to set up a review, but he felt her care package was fine and did not need any changes. He said he could not attend a review due to his work commitments, but he thought residential care would be more appropriate for her.
23. In early November 2024 the day centre said it was considering giving notice to Mrs C due to her aggressive behaviour towards staff and other residents. The social worker discussed providing 1:1 support at the day centre to see if Mrs C’s behaviour improved, but the day centre declined saying it would not resolve the problem. It then gave notice to Mrs C, ending the placement on 28 November.
24. The social worker increased Mrs C’s care visits as an interim measure and started a review of Mrs C’s care needs on 11 December. They spoke to Mr B and his partner and the care agency. They concluded Mrs C did not have the capacity to make decisions about her care and in consultation with Mr B, they made a best interests decision that residential care was the best option. While measures could be put in place at home to mitigate the risks, there were too many risks to manage simultaneously, including her non-compliance with care calls, verbal aggression and vulnerability at home. The social worker increased the care calls (three times a day plus some extra social calls) to cover the Christmas period and started to look for a residential care home place in early January 2025.
25. The social worker contacted 26 care homes without success. One home said it may be able to offer a place but then said it did not have any suitable beds available and was unsure if it could meet Mrs C’s needs. There was also a question over the cost of the care and whether the family would be required to pay a top-up fee.
26. Before these issues could be resolved Mrs C fell at home in late January 2025. When Mr B found her, she had been on the floor for a significant number of hours. She was admitted to hospital and had a hip replacement.
27. She was discharged several weeks later to a different care home. This was confirmed as a permanent placement in July 2025.

Complaint

28. In April 2025 Mr B complained to the Council about the delay in finding Mrs C a care home place and the poor care provided by the care agency for the previous year.
29. The Council responded on 27 May. It apologised for the trauma of the fall but did not find fault in the actions of the social workers. They had followed the mental capacity act over a number of years, looking for the least restrictive option and involved Mr B fully in the assessments. Once the day centre placement ended the Council, together with Mrs C’s family, agreed that a care home was the best option for her and started to look for a placement. Unfortunately, before one was found, Mrs C fell.

Analysis

Care package or residential care

30. It is not my role to conclude what type of care Mrs C should have been receiving; that was a decision for the Council to make. In July 2023 the Council assessed Mrs C and concluded she could manage her personal care and medication and was enjoying attending the day centre several times a week. She wanted to stay at home and there was insufficient evidence that she could not manage this safely. Various safety measures had been installed the previous year.
31. In November 2023 when her needs were increasing a social worker visited Mrs C, spoke to Mr B and other family members and agree to arrange a visit to some sheltered housing for Mrs C to consider. They also installed a virtual care communication system, but Mrs C did not wish to use it. The social worker concluded that Mrs C could still manage her personal care needs, but recognised Mr B’s wishes for some more support by considering the sheltered housing. Unfortunately, Mrs C did not wish to move there. I have not found fault with the Council’s actions here.
32. Between January and July 2024 Mr B did not raise any concerns about Mrs C’s care. Following Mr B’s request in July 2024 to cancel the care visits and the care agency’s concerns that this may leave her vulnerable to self-neglect, the social worker tried to arrange a review of Mrs C’s care needs to conclude what would be the best care option for her. Despite the social worker’s attempts to arrange a review in August, September and October, they were unsuccessful, in part due to a lack of engagement from Mr B.
33. When a new social worker took over in November 2024 and contacted Mr B, he said he did not feel Mrs C’s care needs had changed and he could not attend a review due to work commitments. The social worker agreed to carry out the assessment with Mrs C and the care agency. At the same time Mrs C’s situation changed significantly as the day centre gave notice due to her aggressive behaviour. The social worker consulted with all parties including Mr B and his wife and the care agency, carried out a mental capacity assessment followed by a best interests decision that Mrs C needed permanent residential care. I find no fault in the decision-making process here.
34. The Council had identified a possible care home within six weeks of the best interests decision, and a place had been offered. Unfortunately, Mrs C fell and was admitted to hospital before the placement could be finalised. Given this included the Christmas period I do not consider there was any avoidable delay.

Number of social workers

35. I appreciate that the high turnover of social workers was unsettling for Mr B, but I have not identified any fault arising from the changes. The case notes are detailed and continuous and there is no evidence the changes caused any delays.

Poor care

36. Mr B did not raise any concerns about the care agency or the care visits until April 2025, after Mrs C had moved to a care home. He had raised concerns about Mrs C’s non-compliance with care visits and aggressive behaviour towards care staff and him. The care agency’s care records indicate that visits were made regularly and the required care provided, when Mrs C would allow it.
37. There is insufficient evidence to conclude there was fault causing injustice arising from the quality of care.

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Decision

38. I find no fault.

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Investigator's decision on behalf of the Ombudsman