Summary: Miss B complained that the Council delayed in reaching a decision about her mother, Mrs C’s long term care needs, misrepresented Mrs C’s capacity to make decisions about her care and communicated poorly with Miss B. We found there was some delay in progressing Mrs C’s case between May and September 2025 which caused Miss B and Mrs C uncertainty. The Council has agreed to apologise to them and make a symbolic payment.

The complaint

1. Miss B complained on behalf of her mother, Mrs C, that the Council:
• wrongly said Mrs C could return to an unsafe home after a stay in a care home;
• misrepresented Mrs C’s capacity suggesting she could make decisions about her care;
• deflected responsibility for Mrs C’s care and wellbeing; and
• communicated poorly with Miss B.
2. Miss B said the failings put Mrs C at risk of harm and caused significant distress to Miss B.

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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. 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 recommend a remedy. (Local Government Act 1974, sections 26(1) and 26A(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. 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

6. I have investigated the period from May 2025 when Mrs C went into the care home until 7 December 2025 when we decided to investigate the complaint.

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How I considered this complaint

7. I considered evidence provided by Miss B and the Council as well as relevant law, policy and guidance.
8. Miss B 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

Intermediate Care and Reablement

9. Intermediate care and reablement support services are for people usually after they have left hospital or when they are at risk of having to go into hospital. They are time-limited and aim to help a person to preserve or regain the ability to live independently.

Mental capacity assessment

10. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:

• because they make an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

11. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
12. An assessment of someone’s capacity is specific to the decision to be made at a particular time. When assessing somebody’s capacity, the assessor needs to find out the following:

• Does the person have a general understanding of what decision they need to make and why they need to make it?
• Does the person have a general understanding of the likely effects of making, or not making, this decision?
• Is the person able to understand, retain, use, and weigh up the information relevant to this decision?
• Can the person communicate their decision?

13. The person assessing an individual’s capacity will usually be the person directly concerned with the individual when the decision needs to be made. More complex decisions are likely to need more formal assessments.
14. If there is a conflict about whether a person has capacity to make a decision, and all efforts to resolve this have failed, the Court of Protection might need to decide if a person has capacity to make the decision.

Best interest decision making

15. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
16. If there is a conflict about what is in a person’s best interests, and all efforts to resolve the dispute have failed, the Court of Protection might need to decide what is in the person’s best interests.

Deprivation of Liberty Safeguards (DoLS)

17. The Deprivation of Liberty Safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without the authorisation, the deprivation of liberty is unlawful.

What happened

18. Mrs C moved into a care home (the Home) at the end of May 2025 following a discharge from hospital, on a short-term basis to assess her long-term care needs. Miss B was told Ms C would be there for four weeks.
19. Miss B chased up the Council on 23 June. A social worker (SW) started the assessment on 7 July. SW noted Mrs C wanted to return home and was very distressed about being in the care home. SW had no concerns about Mrs C’s capacity and found that she was independent in all her daily living activities. They concluded that Mrs C’s care needs could be met in the community with a care package of two daily visits to her home. They referred her to an Occupational Therapist (OT) to carry out a visit before she could go home.
20. OT visited Mrs C and her home the following week. OT concluded that Mrs C could live in the downstairs of her property. She needed the toilet, bed and sofa raising and some grab rails.
21. At the end of July, a Council assessor (the Assessor) carried out a mental capacity assessment (MCA). Mrs C partially engaged but then declined to continue. The Assessor referred her to the GP as Mrs C had declined the offer of support. The GP referred her to mental health services for an assessment. The Assessor noted that when Miss B had taken Mrs C for a day out, Mrs C had tried to get out of a moving car. This raised concerns about her capacity to make decisions.
22. On 4 August the Assessor carried out a follow-up MCA. This time they concluded she needed 24-hour residential care. The Council arranged for an advocate to visit Mrs C to ascertain her wishes, but Mrs C did not wish to engage with them. On the 14 August Mrs C said she was ok at the Home.
23. On 12 September Miss B complained about the delay in moving Mrs C from the short-term placement bed. On 15 September a DoLS was granted on the basis that Mrs C lacked capacity and would not be returning home.
24. On 19 September the Council told Miss B that it was looking for a further short-term bed in a residential setting while it waited for the mental health services appointment and a best interests meeting. The Home agreed to extend the short-term placement.
25. On 22 September SW contacted Miss B to say they would look for a more suitable placement in the area and chase mental health services regarding the appointment which had been cancelled. The following day SW clarified that the appointment had actually been brought forward to 11 September and Mrs C had been prescribed some medication.
26. On 23 September the Council responded to Miss B’s complaint saying that it upheld the complaint as there had been significant delays in progressing Mrs C’s case and finding a long-term placement.
27. On 25 September Miss B said she wanted Mrs C to remain at the Home until somewhere more suitable (with more-like-minded residents with similar capacity) could be found for the long term.
28. In October the case was transferred to the community team and a new social worker allocated (SW2) to carry out a further assessment. On 31 October SW2 contacted Miss B to arrange a meeting with Mrs C. Miss B explained that Mrs C’s house had been on the market for some time and was being sold. She thought extra care housing may be a better option and said Mrs C had agreed to this.
29. On 5 November the Home said Mrs C was improving with the new medication: she was joining in with communal activities and not asking to go home. On 6 November Mrs C’s advocate said she strongly wished to return home but the DoLS was still in place.
30. Miss B asked for details of extra care housing if the house was sold. SW2 went through the options: going back home would be the quickest and most straightforward. Extra care housing would require a package of care. Mrs C would also have to pay a wellbeing charge and need a financial assessment to determine her contribution to the cost of the care. Mrs C would also have to go on the housing register and wait for a place.
31. On 21 November SW2 had a telephone call with Miss B and Mrs C to discuss Miss B’s concerns about Mrs C returning home. She also noted the DoLS was still in place which she considered would prevent a return home.
32. SW2 made enquiries about the DoLS. The Assessor replied saying that three different decisions had been made previously that Mrs C lacked capacity to make decisions about her longer-term care needs, hence the DoLS. SW2 agreed to get OT to assess the safety of the home and then SW2 would carry out a fresh MCA
33. On 25 November Miss B complained to us.
34. On 28 November SW2 visited Mrs C’s home with Miss B and other family members. On the 1 December SW2 and her supervisor carried out a MCA of Mrs C. They concluded Mrs C had the capacity to decide where she lived: she had articulated a clear wish to return home and demonstrated an understanding of the risks associated with this. The plan was to return Mrs C to a community setting with support. They also considered extra care- or sheltered housing. But at this stage they did not conclude that Mrs C needed long-term 24-hour care.
35. Mrs C’s family, including Miss B raised concerns about the long-term viability of Mrs C returning home due to fact it was being sold, it needed significant and ongoing maintenance and there were many safety issues.
36. On 2 December SW2 and her supervisor held a joint telephone call with the family and said that Mrs C did not meet the criteria for long-term 24-hour residential care.
37. We decided to investigate the complaint on 7 December.

Findings

38. The Council acknowledged that it took too long between May and September 2025 to progress Mrs C’s case. Miss B understood an assessment would be done within four weeks, but it actually took six weeks to make a start. This slight delay was fault.
39. The decision was initially for Mrs C to return home, but following the two MCAs over the next month, the decision changed to 24-hour care and a DoLS was authorised. I do not find fault here as capacity can fluctuate and vary depending on the decision in question. The Assessor spoke to Mrs C and family members as part of the decision-making process.
40. But the Council then took no action to find Mrs C a permanent placement until Miss B complained in mid-September, a delay of approximately a month. This was fault which caused uncertainty to Miss B and Mrs C as to the long-term plan for Mrs C’s care.
41. The Council was then planning to find a more suitable short-term placement while it waited for the outcome of a mental health assessment, but Miss B advised she would prefer Mrs C to stay in one place until a permanent decision was made. I do not find fault here.
42. Between October and December 2025, the Council was carrying out a further assessment before reaching a view on longer term care options. The Council reached a decision that Mrs C had capacity and could return home with a package of care. It spoke to family members, visited Mrs C’s property and gave reasons for that decision. Although the family strongly disagreed and the decision went against the previous decisions about Mrs C’s capacity, it is not for me to say which view is correct. Ultimately that is a matter for the Court of Protection. I also note that the Council has not had the opportunity to consider a complaint about the events from October onwards as Miss B complained to us. So I do not find fault during this period.

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Action

43. In recognition of the injustice caused by the delay of approximately one and a half months, I recommended the Council within one month of the date of the final decision:
• Apologises to Miss B and Mrs C and makes a symbolic payment of £200.
44. The Council should provide us with evidence it has complied with the above actions.

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Decision

45. 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