Summary. Mrs X complained about the failure of a Council funded provider to keep her daughter, Miss Y, safe when she moved to another room. We found fault with the provider’s risk assessment and some record keeping. This caused distress and uncertainty as to whether Y was safe and protected from harm. To remedy this injustice, the Council agreed to apologise, make a symbolic payment and work with the provider to improve its standards. We did not find fault with how the Council made its decision about the amount of night care for Miss Y.

The complaint

1. Mrs X complains about the Council’s failure:
1. to provide her daughter, Miss Y, with 1:1 overnight care, contrary to medical advice; and
2. to carry out a risk assessment when Miss Y was moved to another room within her supported living unit.
2. Mrs X says the Council’s actions have put her daughter at significant risk of harm and caused distress and frustration.

Back to top

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. 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(i), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. In this case the Council commissioned the care provider so we consider it was acting on behalf of the Council. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), 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. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)

8. 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)
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC). 

Back to top

How I considered this complaint

10. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
11. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Legal and administrative background

12. Our role is not to ask whether an organisation could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how it made its decisions. If we decide there was no fault in how it did so, we cannot ask whether it should have made a particular decision or say it should have reached a different outcome.

What happened

13. The following is a summary of key events. It is not intended to be a detailed chronology.
14. Miss Y is severely disabled and has lived for several years in a supported living unit (the Unit) with support funded by the Council by the Kent Autistic Trust (the Provider). She is registered blind and profoundly deaf.

The room move

15. In February 2025, the Provider told the Council Miss Y’s health was deteriorating. The Provider suggested Miss Y should move to a downstairs room due to a decline in her mobility. The Provider also consulted Mrs X about this proposal. Mrs X said she was agreeable in principle.
16. A care plan review was held in April 2025 attended by Mrs X. She agreement was contingent on a bath was being installed in the new room because this was enjoyed by Miss Y and helped her chronic skin conditions.
17. Following discussions between the Council and the Provider, it was decided it was not in Miss Y’s best interests to have a bath due to health and safety concerns.
18. Mrs X was notified of this decision and told the move would take place the next day. Mrs X felt she had been forced to accept the decision about the bath, otherwise the room move may be delayed or cancelled, putting her daughter at further risk of harm.
19. Mrs X was able to visit the Unit three days later. She said she was alarmed by obvious safety hazards in the new room. She was particularly concerns by the heaviness of the fire door and a raised edge on the door frame. The was also no toilet grab rail and the flooring was hard vinyl (as opposed to carpet in her other room).
20. A week later, Miss Y got out of bed in the night and attempted to leave her room. A member of staff signalled for her to go back to bed. She caught her foot on the raised door frame and fell over. She sustained no visible injuries. Later that day, when exiting her room, Miss Y’s fingers were caught when the fire door closed took quickly. Fortunately, a staff member stopped the door just in time to prevent a serious injury. This incident was not recorded until 9 July 2025.
21. The following day, Miss Y was admitted to hospital with respiratory and constipation issues.
22. Mrs X says both these incidents were both foreseeable and preventable. She says not enough was done to prepare Miss Y for such a significant change of environment. She is critical or “social story work” that was carried out because it did not consider Miss Y’s profound disabilities. She felt poorly managed room move contributed to a decline in Miss Y’s health that led to several hospital; admissions over the following months.
23. Approximately three weeks after the move the Provider requested an occupational therapy (OT) assessment, specifically about Miss Y’s mobility. He recommended a non-slip floor, clear walking routes, a small bed rail and close monitoring.
24. In Augst 2025, Mrs X made a formal complaint to the Provider about how it handled the room move. In response, the Provider:

• confirmed a risk assessment has been completed before the room move;
• the risk assessment was updated following the trip and, “the realisation of the heavy door”; and
• explained the height of the door lip was standard and not one that would “necessarily be expected to be included in the original risk assessment”.

Night time care

25. In early September 2025, Miss Y was admitted to hospital following a seizure. Three weeks letter, she was ready to be discharged back to the until. The Hospital discharge notes stated Miss Y, “needs 1:1 care even at night because she can be sleep deprived that can trigger epilepsy’s keeps walking/roaming which can lead to a fall/injury”.
26. Prior to her admission, the Council funded two night carers at the Unit, not dedicated to solely care for Miss Y.
27. The Council agreed to fund an additional 10 hours of night time support per week. This would be reviewed after three weeks.
28. Mrs X complained to the Council about this decision. She said the Council has no grounds to go against hospital advice and was putting Miss Y at grave risk of danger.
29. In response to the Council:
1. explained there was no clear clinical rationale for the discharge recommendation; and
2. feedback from the Provider reassured the Council that it was able to manage risk with 10 hours extra support.
30. Dissatisfied with this response, Mrs X brought her complaint to the Ombudsman in October 2025.

Analysis

31. My findings about Mrs X’s two areas of complaint are set out below.

The room move

32. In response to my enquiries, I have been provided with a copy of the Provider’s undated risk assessment. The Provider’s complaint response confirmed it was amended the after the two accidents to include the risks posed by the heavy door and raised door edge.
33. I am satisfied the assessment prior to the move only focussed on minimising risks to Miss Y’s mental health. I have found no fault in this area. Whist I accept this was an important matter, there is no evidence that practical safety issues posed by the new room were ever considered by the Provider. I note the OT was only consulted after the move, and the assessment was limited in its remit to Miss Y’s mobility and did not reference either to doorway or the firedoor.
34. Even with the benefit of hindsight, my assessment is that the risk assessment was inadequate because it was unable to evidence potential safety hazards in the room were considered. In my view, with the benefit of seeing photographs provided by Mrs X, the hazards were reasonably foreseeable. The purpose of a risk assessment is to mitigate the risk of harm to people. The reason the room move was deemed necessary because of a decline in Miss Y’s mobility. I consider a potential tripping hazard and a heavy self-closing fire door should have been risk assessed before the move. Mrs X says she was aware of them as soon as she walked into the room, and I have no reason to disbelieve her. The inadequacy of the risk assessment amounts to fault. There was additional fault in the recording practices, specifically, the undated risk assessment and late recording of the second incident.
35. To the Provider’s credit, it acted subsequently to address these issues, but only after, potentially serios incidents involving Miss Y.
36. Mrs X says Miss Y’s health deteriorated as a direct result of poor preparation before the room move. I cannot say, with any degree of certainty whether it did. Miss Y’s general heath was declining and so it is not possible for me to make a finding as to whether there was a causal link between the lack of planning and subsequent hospital admissions and cellulitis, as claimed by Mrs X. But I am satisfied both Mrs X and Miss Y suffered significant distress and frustration by the actions of the Provider
37. In cases such as this one, where the injustice is distress, the Ombudsman can offer a modest symbolic sum as a financial remedy and I recommend the Council pays both Miss Y and Mrs X £300.

The night time care

38. I understand Mrs X was of the strongly held belief that Miss Y’s could only be kept safe at night with a dedicated member of staff, awake through the night and assigned to focus on her needs only. The discharging hospital doctor shared the same view, as recorded on his discharge notes.
39. As the funding body, the amount of night care was a decision for the Council to make, not the doctor, nor Mrs X. The Council has provided an explanation as to why it considered Miss Y’s safety could be ensured by an extra 10 hours of support per week. Whilst the doctor’s opinion was considered as part of the Council’s decision making process, the Council was entitled to take into account the views of other with relevant knowledge and experience, such as the Provider.
40. Our role here is not to ask whether the Council could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how it made this decision. If we decide there was no fault in how it did so, we cannot ask whether it should have made a particular decision or say it should have reached a different outcome.
41. In this case, I am satisfied the Council considered the relevant evidence and followed the correct decision making process. The Council followed the appropriate procedures when making this decision and I cannot therefore criticise it.

Back to top

Agreed action

42. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care provider and make the following recommendations to the Council.
43. Within four weeks from the date of my final decision, the Council agreed to take the following action.
1. Apologise to Mrs X for the failure of its commissioned care provider to consider all reasonably foreseeable potential risks when Miss Y moved to another room 
2. Pay Mrs X and Miss Y £300 each as a symbolic payment in recognition of their distress caused by the Provider’s failure to carry out a proper risk assessment prior to the room move.
3. Arrange a meeting with Kent Autistic Trust to share our decision with it to ensure the Provider has policies and procedures in place to ensure comprehensive risk assessments are carried out when there is a change in circumstances. This meeting will also seek to ensure accident forms are completed at the time of incident and all forms and entries are date stamped.
44. The Council should provide us with evidence it has complied with the above actions.

Back to top

Final decision

45. I find fault causing injustice. The Council to has agreed to remedy the personal injustice and improve a commissioned service. On this basis, I have completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman