Summary: Mrs B complained in respect of her son Mr C, that the Council failed to provide an appropriate placement for him once he became an adult. The placement broke down within six weeks and he lived with Mrs B for seven months. Mr C was caused significant distress as a result of the unsuitable placement and Mrs B has also experienced significant stress. We find fault causing injustice and the Council has agreed to make payments to Mrs B and Mr C.

The complaint

1. Mrs B complains in respect of her son, Mr C, that Stoke-on-Trent City Council (the Council) failed to provide an appropriate placement for him when he turned 18. He spent six weeks in an unsuitable and harmful placement with inexperienced and uncaring staff, before she took him home to live with her. He moved into a new placement in July 2020: this was delayed due to the corona virus.
2. Mr C has experienced severe psychological damage as a result of the poor care and Mrs B has been unwell due to the stress, She also had to stop work for six months in order to look after him, which has affected her financially.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with a council’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)

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How I considered this complaint

5. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

6. Mr C is disabled and has complex needs. He has received support from the Council since he was a young child. In 2019 he was in a residential and educational placement living with three other young adults and receiving support on both a 1:1 and 2:1 basis. He was experiencing some problems with the residential element of the placement and was also due to turn 18, so the Council had started to look for an alternative placement. It identified a supported living placement and planned for him to move there in the autumn to coincide with his start at a new college. Mrs B says no alternative was offered and Mr C’s name was put on the waiting list without consultation.
7. The placement was a new facility (House D) to provide supported living in individual flats to adults with learning disabilities. The Council had put the project out to care providers to tender. Voyager Care was the successful bidder, scoring the highest on the tender process which considered a range of technical and commercial information.
8. The Council carried out a care needs assessment in August 2019 identifying that Mr C liked being outside, didn’t like busy or noisy environments and liked having activities to keep him occupied. It stressed that any transition to a new placement needed to be as seamless as possible and changes introduced at the right time to minimise the impact on Mr C’s wellbeing. It said the 1:1 support from staff was vital to ensure he was supported appropriately and that his safety was maintained. It suggested the new staff team visited Mr C in his current placement to get to know him and establish a rapport. The assessment provided a lot of detail about Mr C’s needs in terms of eating, dressing, night-time routine, toilet habits and his difficulties in communicating verbally to staff. It stressed consistency of staff was important for him to feel secure.
9. Mrs B visited House D and, aside from some minor issues which could be addressed, she was very happy with it. Voyage Care’s contract began on 14 October 2019 and the first tenancies started on 21 October 2019. Voyage Care received Mr C’s support plan on 1 October 2019 and started an assessment on 3 October 2019. It visited Mr C at college on 24 October 2019 and at his current placement on 26 October 2019. The case records show that Mr C visited House D at least once and moved in on 28 October 2019. Mrs B says she arranged all the visits to House D and implored the Council to carry out some transition work. The Council says it shared Mr C’s assessments with Voyage Care prior to him moving and it was confident it could meet Mr C’s needs. On 30 October 2019 Mrs B raised concerns with Mr C’s social worker (SW) about the staff, particularly during the night shift. SW spoke to her manager and agreed to review the situation in two weeks.
10. Mrs B raised further concerns about the ability of staff at House D to keep Mr C safe. She said the staff appeared to have no experience of working with adults with autism or learning difficulties and were unable to stop Mr C leaving the building. Door sensors and other safety measures had not yet been fitted. Mrs B said the transition to House D was too fast, with no chance for Mr C to get to know the staff. He was very unsettled, and the staff were not providing a structure or sufficient activities. SW spoke to the manager of House D who agreed to call Mrs B.
11. SW always made a safe-guarding referral. The Council decided not to carry out a full investigation but to involve the Intensive Support Team (IST -an NHS service) to offer additional support to Mr C and advice/training to the care staff. SW also said she agreed completely with Mrs B’s concerns and would visit House D weekly to monitor the situation.
12. Mrs B complained again on 9 November 2019 about the standard of care provided to Mr C. She said she did not believe Voyage Care had sufficiently trained, competent or confident staff to meet Mr C’s needs.
13. On 13 November 2019 Mr C assaulted staff and damaged a car while out in the community. SW arranged a safeguarding meeting to discuss the incident and the other issues. IST said it had huge concerns about House D’s ability to meet Mr C’s needs and keep him safe. It had been unable to provide 2:1 support as set out in Mr C’s care plan and none of the staff had been suitably trained. They had no routine or structure in place and no visual aids or communication tools.
14. The Council met with Voyage Care managers, who said they could still support Mr C with additional staffing. They also agreed to produce proposals within a week to improve the staffing issues. The Council reported that Mrs B wanted Mr C to remain at House D as long as appropriate staffing was in place.
15. On 19 November 2019 Mrs B complained again about the staff and said she had stayed with Mr C the previous night to ensure his safety. IST provided some training to Voyage Care staff, but Mrs B said things did not improve. She was staying most nights. A second safeguarding referral was made at the beginning of December following further concerns raised by Mrs B and another incident in the community where Mr C hit out at staff and a member of the public. Mrs B says Voyage care served notice on Mr C as they could not meet his needs.
16. On 23 December 2019 Mrs B took Mr C back home with her. She said she had no confidence that Voyage Care could keep Mr C safe and he was not happy there. SW agreed that Mr C needed a new placement for those reasons. She said the Council would hold a meeting on 2 January 2020 to discuss a way forward.
17. On 27 December 2019 Mrs B asked for support to help her and the rest of the family care for Mr C at home and to allow her to go back to work (she had not worked since Mr C had moved into House D). The Council cancelled the meeting on 2 January 2020 due to staff absence. Mrs B was very unhappy with the last-minute cancellation, given the urgency of the situation: she was single-handedly caring for Mr C with no support from the Council. She requested immediate agency support to prevent deterioration of her own and Mr C’s health.
18. Having heard nothing further Mrs B made a formal complaint on 7 January 2020. She said the Council was not providing any care or support to meet Mr C’s assessed needs. She wanted to give notice on his tenancy and House D and asked for compensation for the wasted furnishings and fittings, along with immediate care and respite at home.
19. The senior member of staff responded the next day apologising for the delay in contact, but they had been on leave since 26 December 2019. The Council said it was going to arrange a Best Interests meeting to decide the best options for Mr C in terms of housing, care and support. It also said it would take steps to find agency support now and store Mr C’s furniture.
20. Mrs B then complained to the Ombudsman.
21. From 3 February 2020 the Council arranged support for C on three evenings in the week to follow on from college and for five hours on Saturdays and Sundays. Mrs B says Mr C did not respond well to this arrangement, refusing to attend over the weekends. The Council also provided a direct payment to Mrs B to employ a cleaner. The Council also identified a possible residential placement with individual flats. The provider carried out an assessment in February 2020 and offered a place. But the transition was then put on hold due to the pandemic. The Council helped Mrs B rearrange Mr C’s support hours as activities and travel were restricted during lockdown and the Council arranged for Mr C’s belongings from House D to go into storage.
22. Transition meetings were held in June 2020. Mrs B visited several times to ensure the facilities were suitable. Mr C also visited on several occasions before moving in on 15 July 2020.
23. We decided to investigate the complaint in February 2020, but due to the pandemic casework pause we did not start the investigation until July 2020.
24. The Council has said in response to my enquiries that it recognises that Mr C’s experience at House D was not a positive one and it has caused stress to both Mr C and Mrs B, affecting their lives. It says it is committed to learning from Mr C’s experience and improve how we design, develop, commission, assess, match and provide support to its residents. It has enrolled an independent expert, to complete a ‘lessons learned’ report and presentation, having listened to the views of Mrs B and the professionals involved. This has been shared with senior officers who are developing an action plan which is currently in draft. It will then share a summary of the recommendations and action with Mrs B.
25. In respect of the furniture and furnishings, the Council has paid the storage costs since 27 April 2020. It has said it will give Mr C the proceeds from the sale of the items. Mrs B has submitted an inventory requesting £2138.

Analysis

26. It was apparent from the very start of Mr C’s tenancy at House D that the staff lacked the experience and training to meet Mr C’s needs. Few of the detailed requirements relating to his daily routine and outlined in the assessment documents were met causing distress to Mr C and Mrs B, as she had to repeatedly intervene to ensure Mr C was safe. The Council agrees that the transition period was inadequate. It was rushed and brief and not in accordance with Mr C’s needs. This was fault which caused injustice.
27. The Council responded promptly to try and address the situation following increasing and escalating concerns form both Mrs B and SW. It involved the IST to try and prevent the placement breaking down and carried out weekly meetings with Voyage Care. However, it is clear that the staffing problems were too fundamental and following a further serious incident, Mrs B felt she had no other option but to take Mr C home with her. This situation may not have arisen if the transition period had been longer and more thorough and if the staff employed by Voyage Care had been properly trained and experienced.
28. I consider the Council then took too long to provide Mr C with an interim support package and start the process of finding him an alternative placement. Given the proximity to Christmas I would not expect the Council to have been able to source support until the new year but it took a further month and chasing by Mrs B to get an interim package in place. I consider it should have got some emergency support in place by the beginning of January 2020. This was fault which caused significant stress and frustration to Mrs B. It was exacerbated by the very last minute cancellation of the meeting on 2 January 2020 with no alternative put in place for several weeks. She was also unable to work for about six months.
29. The Council sourced an alternative placement within a reasonable period of time and the delay in moving in has been due to the pandemic restrictions.
30. Mr C has incurred wasted costs in respect of the furniture. The Council has paid for the storage costs and offered the proceeds of the sale to him. Mrs B has requested a specific amount based on the unusable items.

Agreed action

31. I welcome the steps taken by the Council to learn lessons from these events, but I consider there is also individual injustice caused to Mrs B and Mr C which warrants further remedy.
32. I asked the Council (within one month of my final decision) to:
• pay Mrs B £1000 for the distress she experienced along with her time and trouble;
• pay Mr C £1500 for the distress he was caused and the risk of harm he experienced;
• continue to pay the storage costs for Mr C’s furniture until it is sold, pay the proceeds to Mr C plus £500 to Mrs B for the removal costs and Mrs B’s time and trouble; and
• ensure the report is shared promptly with Mrs B when it is finalised and any recommendations implemented within a reasonable period of time.
33. The Council has agreed to my recommendations.

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Final decision

34. I consider this is a proportionate way of putting right the injustice caused to Mrs B and Mr C and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman