Summary: The Council was at fault in delaying in allocating a social worker for Mr X. This caused a delay in the Council’s reassessment of Mr X’s eligible care needs, and the assessment of his family members’ support needs. The Council also delayed in finding a supported living placement for Mr X, in arranging increased day centre provision for him in the interim, and in considering whether Mr X’s mother could be employed as his personal assistant. To remedy the injustice caused, the Council will apologise and make payments to the people affected. It will also explain how it has implemented the recommendation of a safeguarding enquiry into Mr X’s care.

The complaint

1. Mr X is an adult with learning disabilities. The Council has assessed him as lacking mental capacity in key decision-making areas. Mr X’s sister, Miss X, complained about the care and support provided to him by the Council’s Adult Social Care Service. Her complaints included that the Council:
1. Did not allocate a social worker to Mr X until February 2025 and, when it did, that social worker left and the Council did not allocate another to Mr X for several months;
2. Delayed in carrying out an annual review of Mr X’s care and support needs and creating a care and support plan and, when it did, it included outdated information;
3. Did not carry out carer’s assessments for Mrs X (Mr X’s mother) and Miss X;
4. Did not deliver to Mr X the amount of care included in his care and support plans;
5. Did not involve Mr X’s family in the planning of his care and support;
6. Delayed in identifying a suitable supported living placement for Mr X;
7. Did not ensure that a respite placement it offered to Mr X in early 2025 was safe, suitable, and properly vetted. This resulted in Mr X being neglected and a safeguarding enquiry being carried out; and
8. Initially refused the family’s request to make Mr X a direct payment in order that he could employ his mother, Mrs X, as his Personal Assistant (PA) to provide his care.
2. Miss X said that the Council’s failings meant that:
1. Mr X’s needs were not met, his wellbeing was negatively affected, and he was put at risk of neglect;
2. Mrs X has suffered financial hardship; and
3. The whole family has suffered frustration and distress.

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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. 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)
4. 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)
5. We may investigate matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)
6. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
7. 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)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

9. 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)
10. In addition to the matters listed at paragraph one, Miss X also complained to the Ombudsman that the Council had not reviewed Mr X’s care for six years. This complaint is late. I have not seen good reasons why Miss X could not have brought this complaint to us sooner, and so I have not investigated it.
11. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6)
12. Miss X approached the Ombudsman in September 2025. Six months later, she contacted us with concerns about Mr X’s new supported living placement, and about the fact that he was, again, without an allocated social worker. I consider it would be reasonable for Miss X to notify the Council of these complaints and give it an opportunity to investigate and reply. If she is dissatisfied with the Council’s response, it will then be open to her to bring those complaints to us.
13. I have investigated the period between August 2024 and September 2025 – that is, the year before Miss X approached the Ombudsman.

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How I considered this complaint

14. I considered evidence provided by Miss X and the Council as well as relevant law, policy and guidance. I discussed Miss X’s complaint with her on the telephone.
15. Miss X 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

Law, policy and guidance

Assessment

16. 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.
17. 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.

Care and Support Plan

18. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan for a person with eligible needs. The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The care and support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.

Reviews

19. 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.

Direct payments

20. Direct payments are monetary payments made to individuals who ask for them to meet some or all of their eligible care and support needs. They enable people to arrange their own care and support to meet those needs. The council must ensure people have relevant and timely information about direct payments so they can decide whether to request them. If they do so, the council should support them to use and manage the payment properly.
21. The gateway to receiving a direct payment must always be through the request from the person. Councils must not force someone to take a direct payment against their will. They should not place someone in a situation where a direct payment is the only way they can get personalised care and support.
22. Councils must tell people during the care planning stage which of their needs direct payments could meet. However, councils must consider requests for direct payments made at any time and have clear and quick procedures in place to respond to them.
23. After considering the suitability of the person requesting direct payments against the conditions in the Care Act 2014, the council must decide whether to provide a direct payment. In all cases, the council should consider the request as quickly as possible.
24. Regulation 3(2) of the Care and Support (Direct Payments) Regulations 2014 allows an exception to the rule forbidding the person with eligible care needs from paying close family or household members to provide their care. It allows a council to approve these payments if it determines it is strictly necessary to meet the person’s needs.
25. The council must provide interim arrangements to meet care and support needs to cover the period in question. Where accepted, the council should record the decision in the care or support plan. Where refused, the council should explain its decision in writing to the person who made the request. It should also tell the person how to appeal against the decision through the local complaints procedure. (Care and Support Statutory Guidance 2014)

Carer’s Assessment

26. Where somebody provides or intends to provide care for another adult and it appears the carer may have any needs for support, the council must carry out a carer’s assessment. A carer’s assessment must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself. This includes the practical and emotional support the carer provides to the adult.
27. As part of the carer’s assessment, the council must consider the carer’s potential future needs for support. It must also consider whether the carer is, and will continue to be, able and willing to care for the adult needing care. (Care and Support Statutory Guidance 2014)

Carer’s Budgets and Respite

28. The Care Act 2014 says the council may meet the carer’s needs by providing a service directly to the adult needing care. The carer must still receive a support plan which covers their needs, and how the council will meet them. The carer’s personal budget must be an amount that enables the carer to meet their needs to continue to fulfil their caring role. It must also consider what the carer wishes to achieve in their day-to-day life. Part of the planning process should be to agree how the carer will use the personal budget to meet their needs. (Care and Support Statutory Guidance 2014)

Safeguarding

29. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

30. This section sets out the key events in this case and is not intended to be a detailed chronology.

2024

31. In late August 2024, Miss X emailed the Council to ask about alternatives to the day centre Mr X had been attending, three days a week for several years, “to further enhance [his] level of independence and development”. She felt Mr X was no longer making progress at the current centre.
32. In late September 2024, Miss X asked the Council to allocate a social worker to reassess Mr X’s care needs, including whether he would be eligible for a supported living placement. The Council was unable to allocate a social worker immediately and placed Mr X on a waiting list.
33. Miss X contacted the Council in early October, saying that Mr X’s behaviour had changed: he had assaulted her, Mrs X and his carer. She asked for an urgent review.
34. In mid-November, the Council reviewed Mr X’s case and decided that a social worker should be allocated urgently, given “the carers are at risk of breakdown”.
35. Also in November 2024, Miss X told the Council that she was unhappy with the service provided by the care agency (specifically, that the care worker took Mr X on six buses per day, to and from the day centre). She asked the Council to change the care agency or, if that would not resolve the transport issue, to consider whether she or Mrs X could become Mr X’s PA via direct payments. The Council told Miss X that family members living at the same address could not be considered as PAs. Miss X said that the Council had agreed such an arrangement for the family in the past, and that it should take account of their exceptional circumstances.

2025

36. The Council arranged for a new care agency to care for Mr X from early January 2025.
37. The first social worker was allocated to Mr X in late January 2025 and completed the reassessment. Because Mr X did not have capacity to engage in the reassessment, the social worker spoke to Mrs X and Miss X. The first social worker sent a summary of the reassessment to Miss X on the day it was carried out. The summary included that:
• A change of day centre, to one which helped Mr X to develop his skills of daily living, would be of benefit to him (the first social worker attached a leaflet about a suggested day centre);
• It had been discussed and agreed that it was “time to start looking for” a supported living placement for Mr X; and
• A carer’s assessment should be completed for Mrs X and Miss X.
38. The care and support plan that resulted from the reassessment (issued in February 2025) included that the Council should arrange a (permanent/full-time) supported living placement for Mr X.
39. The Council carried out a carer’s assessment for Mrs X in early February, and agreed to fund the cost of spa day for her.
40. The Council arranged for Mr X to be accommodated in a supported living service (the respite provider) in a second council area for one week in late February, to provide Mrs X and Miss X with respite.
41. Also in late February, the Council approved the request for a permanent supported living placement for Mr X.
42. The Council arranged a further week of respite care for Mr X in late March, with the same respite provider it had used in February. On his return home, Miss X raised a safeguarding concern of neglect. She said that Mr X had not been supported to shower or change his clothes during the week’s placement. The second council initiated a safeguarding enquiry, in which it involved the Council.
43. While discussing the safeguarding enquiry with the second council, Miss X identified that Mr X’s care and support plan included Mr X’s late father’s telephone number as the main contact. She reported this to the first social worker, who updated the information and apologised for the error.
44. In early May, the Council identified a permanent supported living placement for Mr X. Mrs X and Miss X visited the placement and confirmed they considered it to be suitable.
45. Also in early May, the first social worker contacted the second council to say that the Council remained concerned about why Mr X’s needs had not been “adequately and safely met” by the respite provider, and that it hoped the safeguarding enquiry would establish the reasons for this. As part of their own investigation, the first social worker noted that:
• The Council had sent Mr X’s care and support plan and risk assessment to the respite provider in early February. This included Mr X ‘s needs and how they could be met. The respite provider had not indicated it could not meet Mr X’s needs;
• The Council’s brokerage team was responsible for carrying out checks on placements before placing people there. The first social worker would check with the brokerage team what checks had been carried out and whether anyone else had reported issues with the respite provider;
• The second council did not use the respite provider for residents of its own council area;
• Mr X had been accommodated by the respite provider on a previous occasion (February 2025) without any issues being raised; and
• The respite provider had not been inspected by the CQC, and any existing rating applied solely to the service’s previous location.
46. A second social worker completed a carer’s assessment with Miss X in May 2025. This set out that Miss X’s support needs arose from having “had to put her own life on hold to care and advocate on behalf of her brother”. The support plan included that the main form of support the Council would provide to Miss X was respite care for Mr X. It also said Miss X “would benefit from having a self-care session to boost her energy in order for her to continue in her caring role”, and included a one-off direct payment for a spa day.
47. The first social worker left the Council in early June 2025. Mrs X and Miss X emailed the first social worker to thank them for the support they had provided in “progressing his care and future plans”, and for the “updates and attached documents”. The second social worker was allocated to Mr X in mid-June.
48. In mid-June, Miss X made a formal request for the Council to consider making a direct payment to Mr X in order for him to employ Mrs X as his PA.
49. In late June, the permanent supported living placement that the Council had identified for Mr X told the Council it no longer had a vacancy.
50. The second council completed the safeguarding enquiry in July and shared the outcome with the Council and the CQC in August. The enquiry’s recommendations included one for the Council to “review the suitability of [the respite provider] as a respite provider for adults with complex needs, particularly those who are non-verbal and require full support with personal care”.
51. The Council refused Miss X’s request for her mother to be employed as Mr X’s PA in late July. It told Miss X this decision was made considering “[Mrs X]’s current health status, the availability and involvement of external care provision, and the ongoing review of alternative long-term care solutions such as supported living”.
52. Miss X complained to the Council on the day she received that decision, about the matters set out at paragraph one.
53. Miss X discussed her complaint with a senior Council manager in early August. The Council agreed that Mrs X could be employed as Mr X’s PA via direct payments, for 29 hours per week. Payments started immediately and continued until Mr X moved into supported living in late February 2026.
54. The Council responded to Miss X’s complaint in early September. The response included:
• The Council had delayed significantly in reviewing Mr X’s care between 2019 and 2025. It offered a payment of £1000 in recognition of the injustice the delay caused to Mr X and his family. The Council said it would ensure it carried out reviews annually in future.
• When Miss X had discussed her complaint with the senior Council manager, she had explained that the care and support Mrs X provided to Mr X:
1. Was not impacted by Mrs X’s own health conditions, as it consisted primarily of verbal prompting (as well as practical help with tasks such as meal preparation);
2. Was vital to supporting Mr X’s “mood, behaviour, personal care, and accessing the community”; and
3. Could be provided by Mrs X alone, because of her unique relationship with Mr X. In her absence, Mr X had “been reported to exhibit challenging behaviours”.
• Following this conversation, the senior Council manager agreed that Mrs X should become Mr X’s PA via a direct payment.
• Based on the information available to the Council in November 2024, it had been correct in telling Miss X that “family members living at the same address could not be considered as PAs”.
• However, if the first social worker had obtained the relevant information about Mrs X’s unique role during the January 2025 reassessment, “the outcome of the care and support plan may have been different”, and “further delay may have been avoided”.
• The Council would arrange for all employees who complete Care Act assessments and reviews to “attend further assessment and strength-based discussions training in order to avoid this situation” in future.
55. The Council offered its apologies for these failings.
56. The Council arranged for Mr X to attend a new day centre, five days a week, from late September. This was the centre that had been suggested by the first social worker in January 2025.
57. Also in late September, Miss X escalated her complaint to the Ombudsman.
58. In its response to my enquiries about the respite provider that was the subject of the safeguarding enquiry, the Council said “the Council regularly monitors care quality via Care Quality Commission reports, feedback from people receiving care and support and family feedback and contracted compliance to ensure the safeguarding of vulnerable adults”.

My findings

Delay in allocating a social worker; delay in carrying out an annual review

59. Miss X complained that the Council did not allocate a social worker to Mr X until January 2025 and, when it did, that social worker left and the Council did not allocate another to Mr X for several months. She also complained of delay in the allocated social worker completing a Care Act review.
60. In August 2024, Miss X asked the Council to review the day centre Mr X attended. This should have prompted a reassessment of Mr X’s needs. And, in September 2024, Miss X specifically asked the Council to allocate a social worker to reassess Mr X’s care needs. The Council did not allocate a social worker until January 2025, despite Miss X informing the Council that the situation had become untenable, and the Council identifying that “the carers are at risk of breakdown”. This delay was fault, that caused Mr X and his family distress, frustration and uncertainty about whether Mr X’s care and support needs were being met.
61. Given reviews should be carried out as quickly as reasonably practicable, on the balance of probabilities, I find that, had the Council acted without fault, it would have allocated a social worker by October 2024, carried out a reassessment in November 2024, and produced an updated care and support plan by December 2024. I acknowledge that Mr X’s care needs had not been reviewed since 2019, but this period is outside the scope of my investigation as set out in “what I have and have not investigated” above. The Council offered the X family a payment of £1000 in recognition of the long delay in reviewing Mr X’s needs, which includes, but is not limited to, the period covered by my investigation. I consider this a suitable remedy for the injustice caused by this fault.
62. Once the Council had allocated a social worker to Mr X, they carried out a Care Act reassessment in January 2025 and produced a care and support plan for Mr X in February 2025. This was a reasonable timeframe, so the Council was not at fault for delay in this period.
63. When the first social worker left the Council in June 2025, the Council promptly allocated the second social worker to work with Mr X and his family. The Council was not at fault. Mr X may have been without an allocated social worker in more recent months, but that is outside the scope of my investigation.

Inclusion of outdated information

64. The first social worker produced a care and support plan for Mr X in February 2025 that included his late father’s telephone number. This was fault, that caused the family distress. I consider the first social worker adequately remedied this injustice by apologising and removing the information.

Carer’s assessments for Mrs X and Miss X

65. Miss X complained the Council did not assess her and Mrs X’s needs as carers. The Council carried out a carer’s assessment for Mrs X in February 2025, and for Miss X in May 2025. These assessments resulted in a support plan including a one-off direct payment for a spa day for Mrs X and Miss X. Mr X’s care and support plan also included an increase in respite care from 14 to 28 days per year to meet Miss X and Mrs X’s needs as carers. I set out above that “the council may meet the carer’s needs by providing a service directly to the adult needing care”, and so, the Council was not at fault in relation to the substance of this complaint. However, these assessments should, as in Mr X’s case, have been carried out in November 2024, and the delays beyond this are fault. The Council’s fault caused Miss X and Mrs X a delay in their support needs being met.

Did not deliver to Mr X the amount of care included in his care and support plan; delayed in identifying a suitable supported living placement for Mr X

66. In late August 2024, Miss X asked the Council to consider alternatives to the day centre Mr X had been attending for several years, “to further enhance [his] level of independence and development”. She asked the Council to consider a supported living placement for Mr X in September 2024.
67. These matters were considered during the Care Act reassessment of January 2025. The resulting care and support plan, completed in February 2025, included that the Council would seek a supported living placement for Mr X and that it would arrange a suitable day centre in the interim.
68. The first social worker suggested a suitable alternative day centre at the January 2025 reassessment, and Mr X’s care and support plan included that his attendance at a day centre should be increased from three days per week to five. The Council changed neither the location nor frequency of Mr X’s day centre attendance until the end of September 2025, when it arranged for him to attend the new day centre five days a week. The Council was at fault in delaying moving Mr X to a different day centre, and in delaying increasing his day centre provision. I found earlier that the Council should have issued an updated care and support plan for Mr X by December 2024. Had it done so, I consider that Mr X could have started at the new centre in January 2025.
69. Mr X moved into a supported living placement in February 2026, a year after the Council issued the February 2025 care and support plan. During my investigation, I asked the Council for evidence of searches it had carried out, and settings it had consulted, during the search for a suitable placement. It did not provide me with this evidence. In the absence of this evidence, on balance, I find that, although not all the delay was the Council’s fault (a chosen provider did not have a vacancy; the family wanted to visit placements before they would agree them, which took time), much of it was. Had matters progressed without fault, I find that the Council should have identified and contracted with a suitable care provider much sooner.
70. The Council’s delays caused Mrs X and Miss X uncertainty about whether Mr X’s needs would have been better met at a different day centre or in supported living. The delay in moving Mr X to supported living also meant they were left caring for him during a period of crisis (for them) for longer than they should have been.

Did not involve Mr X’s family in the planning of his care and support

71. Miss X contacted the Council to discuss Mr X’s care and support on a frequent (usually weekly, sometimes daily) basis throughout the period I have investigated. This contact was sometimes via email and sometimes in the form of telephone calls. I have seen evidence that the Council almost always responded promptly and helpfully to these contacts, even if not always to Miss X’s satisfaction.
72. Further, as Mr X did not have capacity to participate in the reassessment of his needs, Miss X and Mrs X did so on his behalf. The Council also consulted Miss X and Mrs X on the potential supported living placement it had identified for Mr X, which was appropriate. I note also that Miss X thanked the first social worker for updating the family. And so, I find the Council was not at fault in the way in which it involved Mr X’s family in the planning of his care and support.

Initially refused the family’s request to make Mr X a direct payment in order that he could employ his mother, Mrs X, as his Personal Assistant (PA) to provide his care.

73. The Council has accepted that, at the January 2025 reassessment, it should have established the unique role that only Mrs X could play in caring for Mr X, and considered making a direct payment to Mr X to employ Mrs X as his PA. The fact it did not do this was fault, that caused Mr X and his family uncertainty and frustration about whether the Council may have agreed direct payments at that time. The Council apologised for the injustice caused by this fault in its response to Miss X’s complaint, but I consider that leaves some injustice unremedied, for which I have recommended a symbolic payment.
74. I find further that the Council should have considered the matter even earlier, when Miss X raised it as possibility in November 2024. People can request direct payments at any time, and so the Council should have given the matter due consideration when Miss X asked it to do so in November 2024. It did not do so (it simply rejected the suggestion). This was fault, that caused Miss X and Mrs X uncertainty about whether Mrs X could have been employed as Mr X’s PA from November 2024.

Did not ensure that a respite placement it offered to Mr X in early 2025 was safe, suitable, and properly vetted, resulting in Mr X being neglected and a safeguarding enquiry being carried out

75. As the second council was the council area in which the respite provider was located, it was not fault that the Council did not lead the safeguarding enquiry, but only participated in it. The second council did not make a finding on whether Mr X was neglected by the respite provider. If Miss X is unhappy about this lack of a finding, it is open to her to complain to that council.
76. Nonetheless, the second council identified action for the Council to take, to prevent issues in future. I have seen no evidence that the Council has fulfilled the recommendation the safeguarding enquiry made to it, as set out at paragraph 50. Instead, it gave the Ombudsman only general assurances about the processes it usually follows to monitor the suitability of providers from whom it commissions care. This was fault, and causes Miss X uncertainty about whether the safeguarding enquiry’s recommendations have been fully implemented.
77. In addition, despite Miss X complaining about how the Council decided the respite placement was suitable before it placed Mr X there, the Council did not include this matter in its response to her complaint. This was fault, that caused Miss X uncertainty. I shall make recommendations to remedy the injustice caused.

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Action

78. We have the power to make recommendations to remedy the injustice experienced by complainants and members of the public affected by fault we identify. (Local Government Act 1974 s 31(2B)). I have set out below the actions the Council should take to remedy the injustice to Mr X and to Mrs X and Miss X, who are also caused an injustice by the Council’s fault.
79. Within one month of my final decision, the Council has agreed to:
1. Apologise to the X family for the injustice caused by the faults I have identified in my findings. 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;
2. Explain to Miss X, and to the Ombudsman, how it checked the suitability of the respite provider before it placed Mr X there, and the action it has taken in response to the outcome of the safeguarding enquiry;
3. Make a payment of £500 to Miss X, for the benefit of Mr X, in recognition of the injustice caused by the delays in assessing his needs and in arranging suitable provision to meet those needs;
4. Make a payment of £500 to Mrs X, and another of £500 to Miss X, in recognition of the distress, frustration and uncertainty caused by the Council’s faults.
80. These payments are recommended in addition to, not instead of, the payment of £1000 already offered by the Council.
81. The Council should provide us with evidence it has complied with the above actions.

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Decision

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

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Investigator's decision on behalf of the Ombudsman