Summary: Mr X complained the Council failed to carry out a full and proper assessment of his mother’s care needs. He also complained the Council failed to ensure his mother had appropriate home adaptations available when she moved into a new home, and that it closed its case prematurely. Mr X says the Council’s actions caused significant avoidable distress to his mother and to himself. We found some fault by the Council. The Council has agreed to provide an apology and a symbolic payment and to produce guidance for its staff.

The complaint

1. Mr X complained on behalf of this mother, Mrs Y, that the Council failed to carry out a full and proper assessment of her care needs. He also complained the Council failed to ensure Mrs Y had appropriate home adaptations available when she moved into a new home and prematurely closed its case without following up on her care needs. Mr X says the Council’s actions caused significant avoidable distress to Mrs Y, leading to a deterioration in her mental and physical health. He says this also caused him significant stress and frustration. Mr X would like the Council to ensure Mrs Y has appropriate care and support and for her to feel safe in her home.

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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. 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)
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)

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How I considered this complaint

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

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What I found

Care Act 2014

7. Sections 9 and 10 of the Care Act 2014 (the Act) 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.
8. Sections 14 and 17 of the Act provide a legal framework for charging for care and support. Local authorities carry out a financial assessment to decide what a person can afford to pay regarding their care and support needs. The financial assessment considers a person’s income and capital.
9. The financial limit, known as the ‘upper capital limit’, exists for the purposes of the financial assessment. This sets out at what point a person can get council support to meet their eligible needs. People who have over the upper capital limit must pay the full cost of their residential care home fees. Once their capital has reduced to less than the upper capital limit, they only have to pay an assessed contribution towards their fees. Where a person’s resources are below the lower capital limit they will not need to contribute to the cost of their care and support from their capital.

What happened

10. This chronology includes key events in this case and does not cover everything that happened.
11. Mrs Y lived in a care home, Care Home A, which provides nursing and residential care. Mrs Y paid the full cost of her care home fees during this time.
12. In early 2025, the Council received a request for a financial assessment for Mrs Y as the level of her capital had reduced.
13. In April 2025, the Council visited Mrs Y at Care Home A. The Council told Mrs Y it had reviewed her care records and considered she did not appear to have significant care and support needs, other than needing support with the administration of her medication. The Council said that because of this, it considered there was insufficient evidence to show Mrs Y needed to remain in a 24-hour residential care setting. It discussed alternative types of accommodation with Mrs Y, including sheltered housing/independent living accommodation. Mrs Y told the Council that before she had moved to Care Home A, she had previously viewed and liked another care home, Care Home B. Care Home B is an assisted living/extra-care setting where residents can live independently while being assisted with tasks.
14. That same month, the Council carried out an assessment of Mrs Y’s care needs. It recorded that Mrs Y was able to engage fully in the process and give clear opinion, thought and decision as part of the assessment. The Council’s assessment recorded:
• Mrs Y did not receive support towards care needs from staff at Care Home A other than assistance with meal provision and the administration of her medication.
• Mrs Y was aware she may not present with high levels of care and support needs and may need to consider options if the Council was unable to fund the placement at Care Home A.
• Care Home A provided all of Mrs Y’s meals. The Council recorded that should Mrs Y move to another home, this may need to be reviewed because Mrs Y had not been required to manage food preparation herself for many years.
• Mrs Y had reduced mobility and poor balance and required grab rails and seat raisers to make full use of the facilities in her home. Mrs Y also had a height adjustable bed.
• Mrs Y was able to access all areas of her current home with the help of the above aids and adaptations. The Council recorded that a further assessment was likely to be required should Mrs Y’s living situation change.
• Mrs Y did not feel she required 24-hour support. Mrs Y requested support to explore alternative accommodation possibilities, including the consideration of sheltered housing.
15. On 23 April 2025, the Council visited Mrs Y again. It recorded that Mrs Y had seen a frailty nurse and that she felt more confident about living in the community and the services available to her. The Council assisted Mrs Y in completing an application form for Care Home B.
16. On 20 May 2025, the Council visited Care Home B with Mrs Y. The Council recorded that Mrs Y was able to view three apartments before deciding on one. Care Home B confirmed it could support Mrs Y and offered her a placement with care provision. The Council recorded that Mrs Y would pay the full cost of the care charges.

What happened next

17. Mrs Y moved into Care Home B on 9 June 2025. Mr X says a height adjustable bed was delivered for Mrs Y on the same day. Mr X says however, the bed did not have side rails as had previously been the case at Care Home A.
18. The following day, the Council wrote to Mrs Y to say the involvement from its social care practitioner was no longer required and had ended.
19. On 16 June 2025, Mrs Y called the Council to say she was finding it very hard at Care Home B. Mrs Y said this was because she had not received the home adaptations ordered by the Council (a shower chair and toilet seat raiser). The Council told Mrs Y it would see if it could fast-track delivery of the adaptations.
20. The following week, Mrs Y was admitted to hospital. Mr X says Mrs Y was discharged a day later and returned to Care Home B. Mr X says when Mrs Y returned to Care Home B, the bed-side rails, toilet seat raiser and shower seat had been delivered.
21. Mrs Y was admitted to hospital again a few days later.

Mr X’s complaint

22. Mr X complained to the Council on 28 June 2025. He said the Council had closed Mrs Y’s case on the same day she had moved into Care Home B without checking to see how she was getting on. Mr X said the Council had deemed Mrs Y was fit for independent living but she had found it almost impossible to cope at Care Home B. Mr X also complained the Council had taken more than two weeks to arrange delivery of Mrs Y’s care equipment, namely the bed-side rails, toilet seat raiser and shower seat. Mr X said Mrs Y’s health had deteriorated dramatically since her move to Care Home B and he considered she was not able to live on her own. Mr X asked the Council to carry out another care needs assessment for Mrs Y.
23. Mrs Y was discharged from hospital and returned to Care Home B in early July 2025. The following day, the Council visited Mrs Y. Mrs Y told the Council she felt as though she had been dumped at Care Home B with little to no support afterwards. Mrs Y said she had struggled with showering, but she had now received all of the home adaptations.

The Council’s complaint response

24. On 10 July 2025, the Council provided its complaint response. It said its care assessment of Mrs Y was concluded in line with the Council’s policy, and was based on input from Mrs Y, staff from Care Home A and the frailty nurse.
25. The Council said it had ensured a height adjustable bed was in place prior to Mrs Y moving to Care Home B, but it acknowledged other equipment identified in the assessment was not present for the move date.
26. The Council acknowledged its assessor ended their involvement with Mrs Y on 10 June 2025. It said at this time, Mrs Y was receiving daily care calls and was open to the community wellbeing co-ordinator who planned to contact Mrs Y within two to three weeks. However, the Council acknowledged that best practice would have been for the assessor to review Mrs Y's progress prior to ending their involvement, and to ensure all necessary equipment was in place prior to the move.
27. Mr X remained dissatisfied with the Council’s complaint response and brought the matter to the Ombudsman.

Analysis – Mr X’s complaint about the assessment of Mrs Y’s care needs

28. Mr X complained the Council failed to carry out a full and proper assessment of Mrs Y’s care needs.
29. I have reviewed the Council’s records regarding its assessment of Mrs Y’s care needs. The care assessment record and the Council’s case notes state the Council reviewed Care Home A’s care and support records. It also held discussions with Mrs Y over several visits, having first determined that Mrs Y had capacity to understand, weigh up and retain the information discussed, and had capacity to make her own decisions. The Council also met with staff from Care Home A as part of the assessment process and discussed the care Mrs Y had received. The Council determined Mrs Y was eligible for support. I have seen no evidence to indicate the Council departed from its care needs assessment policy or relevant guidance. As a result, the Council is not at fault regarding this aspect of the complaint.

Provision of home adaptations

30. Mrs Y moved into Care Home B on 9 June 2025. The Council says a height adjustable bed was delivered prior to this date. However, Mr X says the bed did not have side rails, as was previously the case in Care Home A. The Council’s complaint response acknowledged some equipment identified in the care needs assessment was not present for the move date. Mr X says the bed-side rails, toilet seat raiser and shower seat were in situ when Mrs Y returned to Care Home B, from hospital, on 24 June 2025.
31. The Council’s response to my enquiries said Care Home B agreed to organise additional equipment, including a toilet seat raiser. The Council says this was not considered to be urgent however, because the bathroom in Care Home B had adjustable pull-down grab rails. I acknowledge the Council’s comments. However, the care needs assessment stated Mrs Y needed a seat raiser to make full use of her facilities. In addition, the Council’s case note dated 16 June 2025 stated Mrs Y was “finding it very hard” without the adaptations on order, specifically the toilet seat raiser and shower chair.
32. The purpose of the Council’s assessment was to identify Mrs Y’s care needs and to ensure the appropriate support was provided. The care assessment acknowledged that with the use of the aids and adaptations in place at Care Home A, Mrs Y could access all areas of her home. This indicates therefore, that without them, Mrs Y could not fully access all areas adequately.
33. The failure to provide Mrs Y with the required aids and adaptations at the time of her move to Care Home B is fault. Mr X says Mrs Y was unable to shower without the shower seat, found using the toilet to be difficult, and was scared of falling out of bed because of the lack of side rails. I acknowledge Mr X’s comments and find the injustice to Mrs Y is the avoidable difficulty and distress she experienced as a result of not having the required adaptations.

The Council’s closure of Mrs Y’s case

34. The Council notified Mrs Y on 10 June 2025 that involvement from its social care practitioner would end. This was the day after Mrs Y moved into Care Home B. In its complaint response, the Council acknowledged that best practice would have been for the assessor to review Mrs Y’s progress prior to ending their involvement.
35. I agree with the Council’s comments. In addition, the Council’s care needs assessment dated 15 April 2025 stated a further assessment was likely to be needed should Mrs Y’s living situation change. Mrs Y’s living situation did change on 9 June 2025 as she moved from a care home setting (Care Home A) to an extra-care setting, Care Home B. As a result, the Council should have reviewed how Mrs Y was able to manage in her new accommodation, and potentially carried out a new care needs assessment, before ending its involvement. The failure to do so is fault.
36. I acknowledge the Council has subsequently carried out a further care needs assessment for Mrs Y since her move to Care Home B. Nevertheless, the injustice resulting from the fault identified is the avoidable distress caused to Mrs Y, as recorded in the Council’s case note dated 3 July 2025. This stated Mrs Y felt as though she had been dumped with little to no support.

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Action

37. To address the injustice identified, the Council has agreed to take the following action within one month of the final decision:
1. Provide an apology to Mrs Y for the fault identified. 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. Make a symbolic payment of £250 to Mrs Y in recognition of the distress caused by the fault identified, and
3. Produce guidance for relevant staff regarding instances where service users move to a new address, to review the service users’ progress and to ensure all necessary aids and adaptations are in place prior to ending the Council’s involvement.
38. The Council should provide us with evidence it has complied with the above actions.

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Decision

39. I have found fault causing injustice. The Council has agreed to take the above actions to remedy the injustice and I have therefore concluded my investigation.

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Investigator's decision on behalf of the Ombudsman