The complaint

1. Ms X complains the Council failed to properly manage and respond to issues arising between her brother, Mr Y, and another resident at the supported living accommodation they shared.

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 an injustice, 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 have:

• considered the information provided by Ms X, including the Council’s response to her complaint;
• made enquiries of the Council and considered the responses;
• considered relevant legislation;
• offered Ms X and the Council an opportunity to comment on a draft of this document, and considered the comments made.

Back to top

What I found

Relevant legislation

5. Section 42 of the Care Act 2014 (the Act) defines an adult at risk as an adult who:

• has needs for care and support (whether or not the local authority is meeting any of those needs) and;
• is experiencing, or at risk of, abuse or neglect; and
• as a result of those needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect;
• the local authority retains the responsibility for overseeing a safeguarding enquiry and ensuring that any investigation satisfies its duty under Section 42 to decide what action (if any) is necessary to help and protect the adult, and to ensure that such action is taken when necessary.

6. The Act sets out a clear legal framework for how local authorities and other parts of the system should protect adults at risk of abuse or neglect. It must:

• lead a multi-agency local adult safeguarding system that seeks to prevent abuse and neglect and stop it quickly when it happens;
• make enquiries, or request others to make them, when it thinks an adult with care and support needs may be at risk of abuse or neglect and,
• determine what action may be needed.

7. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
8. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary.
9. When assessing if someone has capacity, the assessment must only examine a person’s capacity to make a particular decision when it needs to be made. This is particularly relevant to people with fluctuating capacity.
10. The test of capacity has two stages:

• does the person have an impairment of their brain or mind?
• does that impairment mean that the person is unable to make a specific decision when they need to?

11. Where there is disagreement between the Council and the family, the Council should appoint an Independent Mental Capacity Advocate (IMCA) when important decisions need to be made. The IMCA represents the person who is incapacitated.
12. A key principle of the MCA is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests. Section 4 of the Act provides a checklist of steps that decision-makers must follow to determine what is in a person’s best interests. This includes considering the person’s past and present wishes and feelings, the views of family and carers, whether the person is likely to recover capacity and the relevant medical and social circumstances.

Background

13. Mr Y is in his thirties and has complex physical and cognitive health needs requiring ongoing monitoring and input from professionals. He is registered blind and lives in shared, 24‑hour supported accommodation. Mr Y aims to live as independently as possible.
14. Mr Y moved to his current accommodation in 2015 and initially experienced positive relationships with staff and other residents.
15. I have reviewed a needs assessment completed by the Council in May 2025. This assessment is detailed and records that Mr Y can communicate verbally with support and usually requires assistance from staff or his mother. It notes Mr Y may need prompts or options to assist decision‑making. The assessment also records difficulties with short‑term memory and understanding complex or longer‑term decisions, requiring support to check his understanding and retention.
16. The assessment confirms the involvement of Mr Y’s parents, Mr and Mrs W, who both hold lasting powers of attorney for health and welfare and for property and financial affairs. It records that Mrs W works closely with the care provider to ensure Mr Y receives the support and assistance he needs.

The family’s concerns

17. Ms X complained on behalf of her brother, Mr Y. She says:

• Mr Y was subjected to bullying, false allegations, and threats from another resident over a prolonged period.
• The Council failed to provide appropriate safeguarding support or protection.
• The family were not informed about the situation for a significant time.
• The allocated social worker was dismissive and excluded the family from the safeguarding enquiry.
• The Council provided inaccurate and misleading information about whether a mental capacity assessment had been completed.
• The Council failed to share safeguarding and risk management documentation.
• Ms X says these failings caused Mr Y distress and caused the family significant anxiety, uncertainty, and loss of confidence in social services.

Key facts

18. The Council says it first became aware of concerns involving Mr Y and another resident on 3 June 2025. It describes this as a single verbal incident and says initial enquiries were made. The outcome was shared with Mrs W, and it was agreed the care provider would arrange a meeting. The care provider’s records indicate that a safeguarding referral was made to the Council in April 2025. Thereafter, the Council received a number of emails from the charity highlighting concerns about the relationship between Mr Y and another resident, and about the actions of the other resident
19. The Council says the care provider met with Mr Y’s parents, Mr & Mrs W, and Ms X on 13 June 2025. A social worker did not attend. At this meeting, the family were told for the first time that Mr Y had experienced bullying from another resident over approximately the preceding 12 months.
20. Following the meeting, Ms X raised a safeguarding concern with the Council on 17 June 2025. A social worker was allocated on 19 June 2025. Mrs W asked to be present during the social worker’s visit, explaining Mr Y did not always communicate effectively and that she had concerns about his capacity to understand and engage. Ms X says the social worker told her mother she could not attend, and that the family would have no role in the safeguarding investigation.
21. Ms X says she was so concerned about the conversation Mrs W relayed with the social worker she sent an email to the social worker setting out her concerns about the lack of the family’s understanding of the situation and the lack of involvement in the safeguarding investigation. She asked what support and assistance could be provided to Mr Y to support him to deal with the situation.
22. Following concerns raised by Ms X, the visit was delayed. It is not clear what action was taken to address the family’s concerns. The visit took place on 24 June 2025. No family members were present.
23. The social worker’s notes of the visit record that Mr Y was unable to provide detailed information but indicated something had occurred involving another resident and that more information emerged as the visit progressed. The record lacks further detail.
24. Mrs W requested the visit notes. The Council refused, stating Mr Y had capacity. The family say the social worker told them a capacity assessment had already been completed and was held on file. The family asked for a copy, the request was refused.
25. Council documents relating to an earlier matter refer to a historical, decision-specific Mental Capacity Act assessment concerning the installation of a camera in Mr Y’s room, which was in place for a short period. The family told this office they were not aware of the camera or the information recorded in relation to that matter.
26. A safeguarding strategy meeting took place on 30 June 2025. Attendees included Council officers, the care provider and Mr Y’s family. Concerns were raised about the timing of the safeguarding response and about Mr Y’s capacity. The social worker said Mr Y should be presumed to have capacity and confirmed no formal assessment had been completed. A protection plan was agreed to mitigate the risks to Mr Y. The Council’s records show that Mrs X and other family members were provided with a copy of the minutes of the meeting on 31 July 2025. The minutes included the agreed protection/action plan.
27. Ms X submitted a formal complaint to the Council on 11 July 2025.
28. The Council provided Ms X with a complaint response on 6 August 2025. It confirms that when Mr Y's mother asked for a copy of the safeguarding meeting transcript, she was told by the Chair that, because Mr Y was considered to have capacity, the request would need to come from Mr Y himself. It accepted there had been poor communication and misleading information about Mr Y’s capacity and agreed to undertake a formal mental capacity assessment. It also acknowledged concerns about the social worker’s conduct.
29. A further safeguarding strategy meeting was held on 7 August 2025. The family questioned why information had been withheld and raised concerns about threats to Mr Y and the adequacy of the protection plan. They again sought clarification about Mr Y’s capacity. The Council said it would “discuss the need” for a formal capacity assessment. The action plan was not shared with the family.
30. A new social worker was allocated on 13 August 2025. He visited Mr Y on 18 August 2025 and recorded an intention to commence a mental capacity assessment. The assessment commenced on 29 August 2025 but was not completed.
31. The Council refused to share assessments and all safeguarding documentation with the family, citing Mr Y’s capacity and third‑party confidentiality.
32.  
33. The Council held a further safeguarding strategy meeting in October 2025. It says the position regarding Mr Y’s capacity had “evolved” and that a formal Mental Capacity Act assessment was no longer needed as safeguarding measures and protection plans were in place and Mr Y was happy with the arrangements. However, Mr Y’s family continued to say that a formal Mental Capacity Act assessment was required. The records show there was still disagreement and a lack of clarity between the parties about whether an assessment was needed, and no clear agreement that it was no longer necessary.
34. The Council says that no further incidents involving Mr Y and the other resident were reported following the implementation of the protection plan. The family disagrees. Mrs W contacted the Council in early April 2026 to report further incidents and distress caused to Mr Y. She says she was told the case had been closed and that no further action would be taken.

Current situation

35. The other resident has moved to alternative accommodation within the last four weeks. This has now removed any ongoing risk to Mr Y.
36. Ms X says the family have lost confidence in social services and have concerns about the professional conduct of some social workers. She also says they are worried about their future relationship with social services and fear they may be excluded from, or not kept informed about, matters relating to Mr Y’s care and wellbeing.

Analysis

37. There was a delay in the care provider notifying the Council of the situation between Mr Y and the other resident. Once notified, the Council was at fault in how it responded, including poor communication with the family, inaccurate information about mental capacity, and failures to act in line with the Mental Capacity Act, which caused Mr Y distress and his family avoidable anxiety and uncertainty.
38. The Council recorded Mr Y’s parents as his attorneys and key supporters. Given this role and their previous involvement, the evidence does not show a clear or consistent reason for limiting their involvement in safeguarding enquiries and related decisions. While the evidence shows the family were provided with the minutes of the June 2025 safeguarding strategy meeting, there were other occasions where information was not shared with them or their involvement was restricted, with capacity or confidentiality cited as the reason. The Council’s complaint response also confirms that requests for information would need to come from Mr Y himself, showing that capacity was relied on to restrict access at the time. This indicates the Council did not involve them consistently in their role as key representatives, which contributed to the family’s uncertainty and sense of exclusion.
39. The Council provided contradictory and misleading information to the family about whether a mental capacity assessment had been completed. Capacity is decision-specific and may fluctuate. The records indicate that a Mental Capacity Act process was commenced but not completed. The Council’s position is that this was because Mr Y was considered to have capacity, and therefore a full assessment was not required to continue. However, the documentation does not clearly evidence how that conclusion of capacity was reached in relation to the relevant safeguarding decisions, nor does it set out a structured, decision-specific Mental Capacity Act assessment or recorded rationale supporting that determination. The family do not accept this conclusion and dispute that capacity was properly assessed. The records indicate a lack of clear and complete documentation demonstrating how the capacity decision was reached and why the MCA process was not taken to completion.
40. The family's concerns about assessing Mr Y’s capacity mainly arose from the difficulties between him and another resident. That resident has now moved on, and those issues have therefore been resolved. As things stand, there are no current issues requiring a specific decision about Mr Y’s care, support or living arrangements, so there is no clear decision at this time that require a Mental Capacity Act 2005 assessment.
41. The Council should ensure that any future significant decisions concerning Mr X's care, support, accommodation, restrictions, or other welfare matters are considered in accordance with the Mental Capacity Act 2005. Where there is reason to doubt Mr X's capacity to make a specific decision, the Council should complete a decision-specific capacity assessment.
42. Although the Council knew of the complaint submitted on 11 July 2025, the social worker remained actively involved in strategy meetings while the complaint about his conduct was unresolved. This was inappropriate
43. The above failings caused Mr Y distress and resulted in injustice to him and his family. His parents experienced significant anxiety, uncertainty and loss of confidence in the Council. Ms X was put to time and trouble pursuing the complaint on behalf of her brother and her parents.

Back to top

Agreed Action

44. The Council should, within four weeks of the final decision:

• Pay Mr Y £500 to acknowledge the distress caused by the failures identified in this investigation.
• Provide Mr and Mrs W with a written apology for the failures identified and pay them £250 for the distress, worry, and uncertainty caused.
• Pay Ms X £250 for the time and trouble spent pursuing the complaint with the Council and this office.

45. Within three months, the Council should:

• Circulate learning from this investigation and review its safeguarding procedures to ensure officers appropriately engage with family members and authorised representatives, and share information in a timely manner, with any decision to withhold or redact information properly justified and clearly recorded.
• Provide evidence of the above to this office.

Back to top

Final Decision

46. The Council was at fault for its handling of safeguarding concerns for Mr Y, including shortcomings in communication, record-keeping, and how it involved his family, as well as a lack of clear recording and application of Mental Capacity Act considerations. These failings led to avoidable uncertainty, distress and anxiety for Mr Y and his family, and a loss of confidence in the safeguarding process.
47. The above recommendations are a suitable way to remedy the injustice caused by the faults identified in this investigation.
48. It is on this basis; the complaint will be closed.

Back to top

Investigator's decision on behalf of the Ombudsman