Summary: Ms X complained the Council failed to implement her daughter’s, Miss Y’s, care assessment and provide her with a suitable commissioned placement. She also complained the Council based its decisions on unfounded allegations that Miss Y was a threat to others. We find the Council was at fault for its delays in securing a suitable placement for Miss Y. This caused distress and upset. The Council has agreed to apologise and make a payment to reflect the injustice caused.

The complaint

1. Ms X complained the Council failed to implement her daughter’s (Miss Y) care assessment and provide her with a suitable commissioned placement. She also complained the Council based its decisions on unfounded allegations that Miss Y was a threat to others. Finally, she says it wrongly changed Miss Y’s care assessment and forced her down the homeless route during a meeting where she did not have any representation.
2. Ms X says the Council’s faults led to a delay in Miss Y receiving specialist support for her mental health and she lived in unsuitable accommodation. Miss Y is now also behind in her academic studies.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by an organisation to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
4. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
6. 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

7. Ms X is unhappy the Council referred her and Miss Y to the police. The law that governs our work says the authority which the complaint relates must be afforded a reasonable opportunity to investigate it first. Ms X did not raise this issue when she complained to the Council. Therefore, it is premature and we cannot investigate it. Ms X can make a complaint to the Council if she remains unhappy.

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How I considered this complaint

8. I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance.
9. Ms 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

Assessment

10. 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.

What happened

11. This chronology provides an overview of key events in this case and does not detail everything that happened.
12. Miss Y has complex needs. The Council completed a care assessment for Miss Y in July 2024. It decided she had eligible care and support needs. It recommended a supported living placement/shared lives placement to meet her needs. In a shared lives placement, the person who needs support lives with a family. The family provides support.
13. Miss Y was a victim of sexual assault. She went into hospital in August.
14. The Council visited Miss Y in hospital. Ms X was also present for the visit. The Council asked Miss Y what support she wanted when she was discharged. Miss Y said she wanted a shared lives placement that met her needs. She said she needed a female only placement with no male carers. The Council explained there was limited availability of shared lives and supported living placements. It asked Miss Y what her thoughts her were on returning home. Ms X said Miss Y would need significant support if she returned home. Ms X said she worked away from home and so would not be able to provide support when Miss Y returned home.
15. The Council held a multi-risk agency meeting in late August to discuss Miss Y’s case. Officers discussed Miss Y’s discharge from hospital and what services could support Miss Y when she was in the community. They said they were waiting for feedback from an occupational therapy (OT) to determine what support Miss Y needed when she was discharged.
16. The Council contacted a supported living provider (Provider B) in late August to discuss Miss Y and whether it could accommodate her.
17. The occupational therapist completed their assessment. Miss Y went home from hospital in early September.
18. The Council spoke to Miss Y the following day after she was discharged. Miss Y said she was struggling. The Council said it would refer Miss Y to the reablement service for support at home. Reablement is short-term support designed to help people regain their independence.
19. The reablement service responded to the referral and said Miss Y needs were too complex and therefore it could not provide support.
20. Ms X contacted the Council and said Miss Y urgently needed supported accommodation. She said the home treatment team had visited but it was not working and it was causing distress.
21. Provider B assessed Miss Y in September and decided it could meet Miss Y’s needs, but there were no local placements available. The Council said Provider B had proposed a potential placement in a different area. Miss Y said she would be happy to move further away. The Council said it would consider whether a placement further away would be financially viable.
22. A few days later, Miss Y returned to hospital due to her mental health.
23. The Council went to visit Miss Y in hospital in October. The doctor and nursing staff said the plan was for Miss Y to be discharged on that day. The Council said it would need to consider a discharge plan.
24. The Council spoke to Ms X and explained the issue with Miss Y’s discharge. Ms X said her house was not a safe place for Miss Y to be discharged to.
25. The Council contacted a short stay residential service to see if it could accommodate Miss Y. The service responded and said it could not meet Miss Y’s needs.
26. The Council spoke to the ward manager at the hospital. It asked whether Miss Y could stay for a few days so it could find suitable accommodation. The manager said this was not possible and Miss Y was ready for discharge.
27. The Council told Miss Y to visit the town hall and present as homeless. The homeless team assessed Miss Y and decided her needs were too complex for its service. It told Miss Y to return to accident and emergency due to her mental health.
28. Miss Y returned to hospital. The Council then found her a hotel to stay in as a short-term measure until it could find long-term accommodation.
29. The Council continued to search for accommodation for Miss Y. It visited Miss Y regularly and provided her with support. Shared lives carers also provided Miss Y with support.
30. Miss Y had an assessment at a supported living provider (Provider C) at the end of October. Miss Y said she did not want a placement there as she did not want to live in Bury.
31. The Council spoke to Miss Y in early November. Miss Y said she wanted to live in female only accommodation. The Council managed Miss Y’s expectations and said it did not have any female only placements. It said it had a duty to provide her with suitable accommodation that met her needs.
32. The organisation that runs Provider C spoke to the Council in mid-November. It said had concerns a placement at Provider C would breakdown and therefore it was not suitable for Miss Y.
33. The Council visited Miss Y at the end of November. It explained it could no longer fund the hotel. It said she had to consider mixed placements, and it did not have any female only placements. It said she was on the waiting list for a shared lives placement but there was no availability. Miss Y said she would consider Provider C again.
34. Miss Y visited Provider C in early December. She said she would accept a placement there.
35. Provider C contacted the Council and said it did not consider it could meet Miss Y’s expectations. Therefore, it would not offer her a place.
36. The Council had a meeting to discuss Miss Y’s case. Officers discussed how Miss Y had shared information about their private lives. They expressed concerns how Miss Y had got this information.
37. Miss Y experienced a mental health crisis in late December and early January 2025. The Council made urgent referrals to supported living providers.
38. Another provider (Provider D) assessed Miss Y in mid-January. Miss Y said she was happy to accept Provider D.
39. Miss Y’s shared lives carer expressed concerns to the Council about some of Miss Y’s comments during the last session. The shared lives manager discussed the comments with Miss Y. Miss Y denied the comments.
40. The Council decided Provider D was not appropriate to meet Miss Y’s needs because it was a short-term provider and Miss Y could end up in the hotel again when the placement finished. This would have a negative impact on Miss Y’s wellbeing.
41. The Council emailed Ms X in February and said Miss Y’s mental wellbeing had improved and she was starting to access the community independently. It said it wanted to promote her independence further by exploring whether she could have her own tenancy (with support workers visiting her regularly). Ms X responded and said she thought an intervention from specialists at Provider D, rather than an independent tenancy, would be more appropriate for Miss Y.
42. The Council arranged a meeting to discuss Miss Y’s support. It invited Ms X to attend. Ms X said she could not attend and she asked it to re-arrange to the following day. The Council said it did not have availability for a meeting on Friday, and so the meeting on Thursday would go ahead.
43. During the meeting, the Council told Miss Y it would not tolerate some of her behaviours, including harassment of staff and stalking on social media. It also said 24-hour care was not appropriate for her, and it wanted to promote her independence. Therefore, it recommended she have her own tenancy. It asked Miss Y to complete a homeless assessment form. Miss Y signed the form.
44. Ms X sent a detailed complaint to the Council in mid-February. She said it had failed to provide Miss Y with a commissioned placement in line with the care assessment. She said it forced Miss Y down the homeless route. She also said it was trying to change the initial care assessment by recommending an independent tenancy. However, this did not meet Miss Y’s complex needs. She also said its focus had been on Miss Y being a threat. However, there was no evidence to support this allegation.
45. The Council found Miss Y a self-contained flat. It visited her in late February to go through her care assessment. Miss Y said she never wanted a tenancy. The Council explained it was suitable for her and would meet her needs. It also explained the consequences of her not accepting it. Miss Y decided to accept the flat. The Council commissioned five hours of daily support for Miss Y from a care agency.
46. The Council responded to Ms X’s complaint in April. It said the hotel accommodation was not a suitable environment for Miss Y and was not good for her emotional wellbeing. However, it had made significant efforts to find a suitable placement for Miss Y. This was made more difficult due to Miss Y’s engagement with the available placements. It said it had completed a new care assessment, and Miss Y’s needs had changed.
47. The Council reviewed Miss Y’s care and support in mid-April. Miss Y said she did not need any help from the support workers. She said she was meeting her personal care needs and was making meals independently. The Council said it would end the support from the care agency. Ms X said she was happy with the progress Miss Y had made.
48. The Council organised a safeguarding review meeting at the end of April. Ms X and Miss Y attended. Officers discussed how Miss Y’s mood had improved. Ms X said the Council’s perceptions of Miss Y’s risk to others had driven its decisions about her care. The Council explained Miss Y had previously made inappropriate comments to staff and it had to consider the risk to staff when finding a placement for Miss Y.
49. Ms X remained unhappy and referred her complaint to stage two of the Council’s complaints procedure. She said the Council’s actions were motivated by money. She also said the Council changed Miss Y’s needs to a lower level so it could force her into having her own tenancy.
50. The Council issued its final response to Ms X’s complaint in early June. It said Miss Y’s needs had changed since its previous assessment. It said it had met Miss Y’s eligible needs in line with its duties.

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Analysis

51. The Council decided in the care assessment from July 2024 that a supported living placement/shared lives placement would meet Miss Y’s needs. Shortly after it completed its assessment Miss Y went into hospital. During discharge planning in August 2024, the Council contacted Provider B. Provider B did not have any local vacancies, but it did suggest a placement further away. Miss Y said she was happy with this, and the Council said it would consider whether this was possible. However, shortly after this, Miss Y returned to hospital.
52. Hospital staff decided Miss Y was ready for discharge in October 2024 without pre-informing the Council in advance. This left the Council in a difficult position. It had to act quickly to find accommodation for Miss Y as Ms X made it clear her house was not a suitable place for Miss Y to stay. However, I have not seen any evidence the Council was actively making referrals to other providers during the time Miss Y was in hospital for the second time. This is fault.
53. I recognise the Council went to significant efforts to try and find Miss Y a placement when she was living at the hotel. However, providers either did not have vacancies, or they could not meet Miss Y’s needs. Miss Y’s request for a female only placement did limit the choices available to the Council, and Miss Y was sometimes reluctant to engage in what the Council proposed. However, I also recognise Miss Y was more willing to engage with the Council’s proposals after it met with her and explained it did not have any female only placements in the area.
54. To its credit, the Council visited Miss Y regularly when she was in the hotel, and she had support from shared lives carers. I welcome this. However, Miss Y remained in an environment that was unsuitable for her needs. This is service failure by the Council.
55. The faults outlined above caused Miss Y a significant injustice. She was caused distress and her mental wellbeing suffered. It also caused Ms X upset that Miss Y was not living in a suitable environment.
56. Ms X says the Council wrongly changed Miss Y’s care assessment and forced her down the homeless route during a meeting where she did not have any representation. The Council has a duty to review care and support needs over time. Adult social care promotes independence. The Council recognised Miss Y had become more independent, and her mental health had improved. It decided she could manage her own tenancy, with adult social care support. That was a decision it was entitled to take, even if Ms X and Miss Y strongly disagree. By April 2025, Miss Y was progressing and she did not need help from the care agency.
57. Ms X asked the Council to re-arrange the meeting in mid-February 2025 to the next day. The Council said this was not possible and the meeting went ahead. I consider the Council should have done more to try and arrange the meeting for another day that Ms X could attend. Its failure to do so caused Ms X some upset.
58. Officers decided Miss Y had mental capacity to make decisions about her own care and support needs. I have seen no evidence the Council forced Miss Y down the homeless route. However, it did explain to her the consequences of not accepting was it was proposing.
59. Finally, Ms X says the Council based its decisions on Miss Y being a threat, when this was an unfounded allegation. Miss Y had made comments about the personal lives of officers. Carers had also made complaints about Miss Y. The Council was not at fault for sharing this information among other professionals as it was a cause for concern. However, there is no evidence it only based its decisions on Miss Y being a threat. It considered Miss Y’s needs, her presentation and her strengths. I do not find fault.

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Action

60. By 21 May 2026 the Council has agreed to:

• Apologise to Miss Y and Ms X for the injustice caused by fault in this statement.
• Pay Miss Y £300 for her distress and the impact on her wellbeing.

61. The Council should provide us with evidence it has complied with the above actions.

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Decision

62. There was fault by the Council, which caused Ms X and Miss Y an injustice. The Council has agreed to my recommendations and so I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman