Summary: The Council is at fault for failing to properly assess, review and put in preventive measures to support a person with complex needs. To remedy the complaint the Council has agreed to apologise to Mr C and make a symbolic payment to reflect the service failure, distress and uncertainty caused by the Council’s faults. It will also work with Mr C to assess and plan future services for him, review procedures and remind staff about the importance of assessment and support planning.

The complaint

1. Mr C complains about services provided by Lifeways, a supported living provider at Grove Court. The Council arranged and funded Lifeways.
2. Mr C complains Lifeways failed to:
1. provide Mr C with an opportunity to choose his own support team;
2. provide consistent staff trained and knowledgeable in supporting people with Autism;
3. provide person centred care;
4. failed to analyse incidents and put in place preventative measures;
5. failed to prepare Mr C for appointments and meetings;
6. failed to provide a visual timetable, use a tracker, and listen to professional and family advice;
7. failed to act on the behaviour of other residents towards Mr C and treated other residents more favourably;
8. failed to support Mr C with his personal care;
9. failed to support Mr C with maintaining his flat and with meals;
10. failed to keep Mr C safe;
11. inappropriately served notice on Mr C.
3. Because of these failings Mr C says he had to leave independent living as Lifeways did not provide him with the care he needed. He now has no choice but to live with his parents which has caused his behaviour to decline and has also affected his family. Mr C says his mental health has worsened because of the way Lifeways treated him, and it has affected his confidence and what he is now able to do.

Back to top

The Ombudsman’s role and powers

4. 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)
5. 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. (Local Government Act 1974, section 25(7), 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(i), as amended)

Back to top

How I considered this complaint

7. I have read the complaint correspondence and Mr C’s comments about what the Council and Lifeways have said. I have spoken with Mr C’s advocate and gained a further insight from him about how the events have affected Mr C. I have considered the following:-
• relevant legislation including the Care Act 2014 and the associated Care and Support Statutory Guidance, (CSSG) and the Autism Act 2009;
• case notes,
• assessments and support plans for Mr C;
• Council contract with Lifeways.
8. Mr C, Lifeways, and the Council were invited to comment on two draft decisions. I considered any comments received before making a final decision.

Back to top

What I found

Background information

9. Mr C has complex health problems and is Autistic. Mr C needs support so he can manage day to day living. Over the past few years he has lived in supported accommodation. This means he has had his own tenancy with support staff to help him. Following eviction from his last supported living provider Mr C lives with his parents.

What should have happened

Autism Act 2009

10. The Autism Act underpins the adult autism strategy statutory guidance which says councils,
11. “should be providing general autism awareness to all frontline staff in contact with adults with autism, so that staff are able to identify potential signs of autism and understand how to make reasonable adjustments in their behaviour and communication. In addition to this, local authorities are expected to have made good progress on developing and providing specialist training for those in roles that have a direct impact on and make decisions about the lives of adults with autism, including those conducting needs assessments. This expectation remains central to this updated statutory guidance.”.

Adult social care

12. 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. 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.

Care planning

13. Once eligible needs have been identified through the assessment process the council must produce a care and support/support plan. Certain elements must always be incorporated in the final plan. The relevant elements to this complaint are:
• the needs identified in the assessment;
• whether, and to what extent, the needs meet the eligibility criteria;
• the needs the Council is going to meet & how it intends to do so;
• the person’s desired outcomes relevant to care and support;
• information and advice on reducing needs and preventing or delaying needs in the future;
14. Sign-off should occur when the person and LA have agreed on the factors within the plan including the final personal budget amount.

Review of care and support plans

15. Care and Support Statutory Guidance (CSSG) says reviews should be person-centred and outcome focussed. Care plans should be kept under regular review and there should be a light touch review within six to eight weeks of a care plan sign off. They should cover the following elements:
• have circumstances or needs changed?
• what is working in the plan, what is not working and what might need to change?
• have the outcomes identified in the plan been achieved?
• does the person have new outcomes they want to meet?
• could improvements be made to achieve better outcomes?

Lifeways Policies

16. Lifeways booklet “Choosing My Support Team” says,
17. “The Service Managers and Team Leaders will work with you to recruit and choose the right people to support you. We want to give you as much choice as possible. You can be involved as much as you would like to be.”
18. Open Framework Agreement with the Council
19. “31.2 The Approved Provider may terminate its obligations for any Call-Off Contract or Immediate Response Call-Off Contract by giving 12 weeks written notice to the Authority
20. 26.1.1 When the Council receives a request to terminate a service the Referrer will be responsible for reviewing the Customer’s care and/or support needs. This will involve deciding if a modification to a Customer’s Care and Support Plan would enable the existing service to continue. This should always be the first consideration before the Provider formally gives notice that it wishes to terminate the service.”

What happened

21. The Council completed a review of Mr C’s support plan in June 2019. At this time he had self-contained accommodation and received 70 hours one to one support and shared waking night staff per week. The review identified Mr C had several support needs which included disruptive behaviour, absconding, threatening behaviour towards himself and others, inappropriateness around women, and verbal aggression.
22. In December 2019 the Council record the relationship between the supported living provider and Mr C had broken down and it asked Mr C to leave. Mr C moved into Lifeways in March 2020. When considering alternative provision the Council completed an assessment of Mr C’s needs and shared it with providers as part of the Learning Disabilities framework. Lifeways responded saying it could meet Mr C’s needs and would compile a bespoke support plan and risk assessment for Mr C.

Staffing and support provided

23. Before moving into Lifeways Mr C met with staff. He explained it was important for him to choose his own support staff. Lifeways assured him this would occur and provided him with a booklet called “Choosing My Support Team”.
24. Lifeways accepts it did not involve Mr C in the recruitment process but says it had offered opportunities for Mr C to join in interviews and to provide interview questions. Mr C says this was the crux of the difficulties he had with Lifeways. He says at first male workers from an agency supported him, but this did not last for long. Mr C says the support workers identified were mainly female and a lot did not share his interests. Mr C says he did not know who was supporting him daily and because of his difficulties it increased his anxiety and triggered behaviour.
25. In April 2021 a Multidisciplinary (MDT) meeting identified Mr C had difficulties with female staff. Lifeways acknowledged its most significant challenge was having the right staff members working with Mr C. Lifeways said it would look at ways to introduce new staff members gradually so Mr C could develop relationships with a wider staff group. There had also been a decrease in Mr C’s care package by one and half hours per day, this was without any review of Mr C’s care needs.
26. Actions from this meeting included:-
• to create magnets with staff members and activities;
• to create a visual timetable;
• use of a tracker as Mr C had gone missing several times in the preceding months and got into a physical altercation with a member of public.
27. In May 2021 Lifeways produced the document, “Me at a Glance” followed in June by support plans, risk and needs assessments, communication plan an Escalation plan. A further MDT meeting also identified some of Mr C’s difficulties and developed a follow up action plan. Mr C says the Speech and Language service developed the communication plan and the risk assessments were inadequate as they did not reflect all the risks.
28. Lifeways says it could not provide magnets as female staff members were unwilling to have their pictures taken because of previous threats made by Mr C. It appears this decision was made without a risk assessment, or consideration of any alternatives. It also does not appear Lifeways told Mr C or his family about its decision. Lifeways says it did use a visual timetable, but this did not work as Mr C did not always wish to use the timetable. Lifeways says it sent copies of the timetable to Mr C’s family but Mr C disputes this.
29. Lifeways says it provided a stable group of five members of staff to support Mr C. However because of Mr C’s behaviour and his refusal of some staff to support this was at times difficult. Mr C says no-one ever asked why he refused certain staff and disputes that he received a stable staff group. He provides an example in September 2021 of seven different staff members used in seven days.
30. Mr C says Lifeways did not do enough to support him when he tried to abscond and to keep him safe. This includes installing a door alarm or providing him with a tracker. Lifeways says after gaining Mr C’s consent it provided a tracker, but he would disable them when he absconded. Mr C disputes this and says his family provided the tracker which Lifeways also used to protect its staff members.
31. Lifeways says staff members could not use their personal phones to download apps to track Mr C. It says Mr C’s family refused to buy a smart phone which it could use to track Mr C. Mr C disputes this and says he had told Lifeways he wanted to use a tracker and had asked a support worker for an alarm.
32. Mr C complains once when he absconded a staff member drove past and did not pick him up or contact his mother or the police. Mr C spent another four hours lost. On this occasion he did have a tracker, but it had no charge, and he could not be located. Lifeways says due to an incident earlier that week the staff member did not feel it was suitable for Mr C to go into her car but did contact Mr C’s mother. In another incident police found Mr C at a bus stop inappropriately dressed in the cold and rain. They raised concerns about his safety.
33. Mr C says Lifeways did not always support him with his personal care. The needs assessment says staff should provide verbal prompts daily to ensure Mr C remembers to have a wash and to keep personal care products within reach so they can be used. Lifeways says staff prompted Mr C to keep his flat clean, but he would refuse staff members to enter or for them to help him. It accepts however that it did not consider how to improve the situation.
34. Similarly Mr C complains staff also did not support him to prepare and cook nutritional meals. Lifeways accepts it did not always support Mr C to have regular cooked meals but says it supported Mr C with microwave meals.
35. Mr C says Lifeways did not prepare him for meetings and ignored professional and family advice. Lifeways says it did remind Mr C about appointments with support from Mr C’s mother. Professionals also contacted Mr C before meetings which was an extra prompt. There appears to be no clear plan about who was responsible for advising Mr C about appointments and monitoring whether Mr C kept appointments, and if there was a need for follow up action.

Events leading up to the eviction

36. In October 2021 building work started on the outside of Mr C’s flat which he says caused him distress. Lifeways says it told residents by letter about the works, but Mr C says he had no notice. Mr C’s support plan says care staff should support him with letters, there is no evidence Lifeways explained to Mr C about forthcoming work allaying any fears or anxieties he may have over the work.
37. At this time Mr C expressed his unhappiness at Lifeways. He was having nightmares about his family being murdered, he says this was because of a threat from another resident. He had broken door locks and another resident had entered his property uninvited. This was despite Mr C’s parents providing funds to change the locks. By this time all staff received Autism training.
38. Mr C says Lifeways failed to respond to the impact of the other residents’ actions on him. This includes verbally aggressive and threatening behaviour. Lifeways does not dispute this but says this was in response to behaviour Mr C had shown towards them.
39. There was an increase in Mr C’s agitation resulting in the assault of two members of staff, absconding and threats to take his own life. On one occasion a member of public found Mr C lying in the middle of the road. Following these incidents Lifeways gave 28 days’ notice from 29 October for Mr C to leave, by 28 November 2021. The basis of the notice was Lifeways inability to keep Mr C, other residents, and staff safe from Mr C’s behaviour. At the same time Lifeways completed a crisis plan. This involved an increased staffing ratio of two carers and not entering Mr C’s flat. Lifeways removed Mr C’s kettle so he could not make himself a hot drink. Staff had 20 minutes direct access per day to Mr C for essential tasks. During the notice period because of the lack of staff intervention Mr C also had to wait between 2 and 6 hours for support from his parents to clean him following an incident of soiling.
40. Lifeways did not share the crisis plan with Mr C or his family until after an incident on 18 November involving the police after Mr C physically assaulted a staff member. There was a further incident when Mr C says he was left unable to access his bathroom after he had accidentally jammed the lounge/kitchen door shut. Because Mr C could not get to his bathroom and staff’s inability to help, Mr C says he had to wait for his family and was forced to use his sink as a toilet.
41. On 26 November Mr C returned home where he has remained. It appears that some of Mr C’s behaviour were caused by issues Mr C had with another resident. Mr C’s mother raised these concerns during and after Mr C’s tenancy but there is no evidence staff took action to address the concerns. Lifeways says had the Council told it about Mr C’s history and behaviour it would not have accepted him.
42. Mr C says Lifeways did not properly complete incident reports or use debriefs to better understand him and to improve his support. Lifeways says it tried to engage with Mr C after incidents, but he would often not engage with staff. It does however accept that it should have completed formal debriefs so it could learn from incidents.

Is there fault causing injustice?

Fault

43. The Council provided Lifeways with an assessment and support plan. Lifeways agreed to complete its own assessment and support plan which it failed to do. The failure to do so is fault and not in line with its agreement to provide services on behalf of the Council.
44. Lifeways has accepted it did not properly support Mr C with making meals. I have considered daily records and there is not enough evidence care staff properly supported Mr C with cleaning his flat or with social activities. Neither is there evidence Lifeways supported Mr C with prompting for his personal care which was identified as a need. While Lifeways provides several reasons about why it could not provide support; it did not on a consistent basis record the efforts made and reasons for not completing tasks. Lifeways is at fault for failing to properly record and evaluate the reason for non-completion.
45. Lifeways also failed to provide a visual timetable, consistently use the tracker, and take on board family and professional advice which identified the benefits of these aids. There is evidence for example of Lifeways being unable to use the tracker as it was not charged. This is service failure.
46. The Council has provided limited incident reports. The Council says it expects care providers to complete and provide incident reports. The incident reports provided are inadequate and do not appear to cover all the incidents that occurred. Incident reports are an analytical tool to consider what happened, what could have been done to prevent the incident and future actions to prevent recurrence. There is no evidence either Lifeways or the Council did this in a meaningful way. Similarly Lifeways did not complete risk assessments until June 2021, this is fault. Measures taken appear reactive rather than preventative. As a result of these failures Lifeways failed to keep Mr C safe.
47. There is also no evidence Lifeways properly considered information Mr C provided about why he felt threatened. It failed to properly consider Mr C’s fears about other residents and how his autism may have contributed to his feelings of anxiety. This is fault.
48. While the Council was in regular contact with the family and Lifeways it failed to review Mr C’s care package initially and when issues arose. This is not in line with CSSG as described above. These were further missed opportunities to consider what actions Lifeways and others could take to minimise risks of recurrence.
49. Lifeways has accepted it could have involved Mr C more to recruit staff. It has not recorded the efforts it says it made to involve Mr C in the interview process. This is fault. There is also no evidence Lifeways considered other ways Mr C could engage in the interview process focusing on his anxiety rather than looking at the interview process itself.
50. There is also a lack of evidence to show staff employed by Lifeways to support Mr C had the necessary skills, knowledge, and personal interests to meet Mr C’s needs. There was also a lack of any planning about how to transition new members of staff.
51. Lifeways did provide basic autism training for staff members; however this was some time after Mr C moved in. The training was at a basic level and appears inadequate to gain an understanding of Mr C’s difficulties and how different strategies could benefit him. For example knowing which staff members and activities were planned was important to Mr C as uncertainty caused him anxiety. Similarly the lack of a formal process to ensure Mr C attended appointments was not in place. This is not in line with the Autism Act. The Council is at fault for failing to consider whether staff had the necessary skills to consider and meet Mr C’s autistic needs.
52. By the time Lifeways served notice to Mr C the relationship between both parties had broken down considerably putting both staff and Mr C at risk. There are different clauses which set out how much notice the Care Provider is supposed to provide to the Council with 12 weeks appearing to be the set amount. All the documents however say the Care Provider needs to liaise with the Council to look at ways to avoid an eviction. This did not occur in this case and is fault.

Injustice

53. Once Mr C went into Lifeways it had a contractual duty to provide suitable support. It failed to do this, and Mr C did not receive consistent support with cooked meals, prompting with personal care and help with cleaning his flat and engaging with social activities. It also failed to set out its concerns at an earlier point which would have either allowed for a 12 week notice period or allowed the Council to intervene to look at ways Mr C could remain in his tenancy.
54. As well as the effects of service failure Mr C has the outrage and distress that both the Council and Lifeways did not always listen and involve him in important decision making about his care. Mr C says the failure to involve him resulted in recruiting inappropriate staff which resulted in a poor service and eventually a decline in his health. While I am unable to say but for the faults identified Mr C’s placement would not have broken down; Mr C has the uncertainty that had Lifeways and the Council followed the right processes he could have maintained his place and remained living independent. Mr C has now lost confidence in his own abilities and trust in the Council that it will provide him with viable future independent living.
55. The case records also show that Mr C’s family have consistently stepped in to advocate and support Mr C which has also caused them time, trouble, and distress.

Back to top

Agreed action

56. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions and service of Lifeways, I have made recommendations to the Council.
57. I have found fault in the actions of the Council which caused Mr C significant injustice. The Council has agreed to take the following actions to remedy the complaint:
58. Within one month of the final decision the Council will;
1. apologise to Mr C and his family for the failures I have identified in this statement;
2. pay Mr C £3000 for the service failure, distress and uncertainty caused by the Council’s failures.
59. Within three months of the final decision the Council should:
1. hold a multidisciplinary meeting to properly consider Mr C’s housing and social care needs;
2. reassess Mr C’s social care needs and provide him with a copy of his personal budget, support plan and assessment. The assessment should be completed by an officer who is specially trained in autism;
3. make any appropriate referrals for specialist support if identified within that assessment.
60. Within three months of the final decision the Council will:
1. remind staff about the importance of providing all relevant information about a person’s needs when commissioning care and of providing an assessment and support plan;
2. remind staff about reviewing support packages within the statutory timescales and when a person’s circumstances change;
3. ensure staff supporting people with autism via commissioned services are appropriately trained in autism;
4. through contract monitoring with Lifeways ensure processes are in place so: -
1. assessments and support plans are in place for service users;
2. staff are aware and complete risk assessments when they are needed;
3. staff are aware of when to complete incident reports and the forms used are fit for purpose;
4. systems are in place so staff are aware and can use behavioural support tools effectively;
5. there are consistent contracts in place which outline the steps needed before someone is given notice.
5. review the Council’s contracting in general to ensure as far as possible contracts are in place and are routinely reviewed so they are consistent in how and when care providers can give notice. This may involve considering and reminding departments of their responsibilities towards contract compliance and the way they are interlinked. Once this is completed remind staff about the notice period required and the steps organisations need to take before they can evict someone.
61. The Council should provide us with evidence it has complied with the above actions.

Back to top

Final decision

62. I have found fault in the actions of the Council and Lifeways acting on behalf of the Council which has caused Mr C injustice. I consider the agreed are suitable to remedy the complaint and have completed my investigation and closed the complaint on this basis.
63. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

Investigator's decision on behalf of the Ombudsman