Summary: Mrs W complains on behalf of her sister, Miss Z, about the risk she has experienced since moving into a supported living placement last year. We find the Council failed to properly consider and assess both the possible and known risks before placing the residents together. We also find the Council has failed to take action to remove the risk despite agreeing to move the other resident, Mr Y. The Council will remedy the injustice caused by fault with the actions listed at the end of this statement.

The complaint

1. Mrs W complains on behalf of Miss Z that the Council failed to properly assess the suitability of a male tenant before placing him in supported living accommodation with Miss Z and another female resident.
2. Mrs W says the Council gave them incorrect information about the tenant and then failed to relocate the tenant once Mrs W raised concerns about their inappropriate and unsafe behaviour.

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The Ombudsman’s role and powers

3. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
4. 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)
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(i), as amended)

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How I considered this complaint

6. During my investigation I considered the information provided by Mrs W, including the complaint correspondence.
7. I made enquiries of the Council and considered its response.
8. Mrs W and the Council had an opportunity to comment on my draft decision before I made a final decision.

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What I found

Supported living

9. When a person moves into supported living accommodation, they usually sign a tenancy agreement for their own house or flat, paid for by housing benefit if eligibility is met. Accommodation could be part of an independent living community, or a standalone property owned and managed by the council or an independent provider.
10. The council has a duty to assess whether someone in independent living accommodation has eligible social care needs. People with a range of needs are provided with independent living accommodation. Community care services and support are provided by either an agency, a live in carer/personal assistant or by a floating support worker (who does not live with the person). This could mean the service user is supported for a few hours a week, every day, overnight or 24 hours a day. The support should be carefully planned to meet their needs.

Safeguarding

11. 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

12. Mrs W complains on behalf of her sister, Miss Z, who lives in a supported living placement with two other residents: a male and female. I will refer to the male resident as Mr Y.
13. On 27 April 2022, and before moving into the placement, all three residents met. The Council said the meeting went well.
14. The Council completed a Care Act assessment for Miss Z on 20 May. This said that Miss Z had met with Mr Y and the other female tenant and would soon move from her family’s home to the supported living accommodation. The assessment said that Miss Z needs a stable and calm environment as she can become easily overwhelmed and agitated.
15. Miss Z visited the house four times as part of a transition period before moving.
16. The Council arranged 24-hour support with “experienced and skilled workers” to be divided between the three residents. The residents also received care from a waking night carer.
17. All three tenants moved into the house on 11 June.
18. Soon after moving, Mrs W raised concerns about Mr Y’s behaviour. She submitted a safeguarding alert to the Council on 12 July due to Mr Y’s physical aggression, which included spitting, hitting and grabbing.
19. Immediately after receiving the alert, the Council increased the support allocated to Mr Y and from 13 July he received dedicated 1:1 support during the day.
20. On 18 July, the Council further increased Mr Y’s support to 2:1.
21. The Council held a professionals meeting on 20 July to discuss the safeguarding alert. It decided not to progress the matter further because it felt that action had been taken to manage Mr Y’s behaviour and reduce the risk to the other residents. The Council agreed to undertake ongoing monitoring.
22. On 27 July the Council recorded its decision and noted that, “alternative accommodation is actively being sought for the other resident”.
23. On this date there is also a note recorded following a conversation with the care agency, which said “…the property is the home of all three of the residents in theory but in practice it is only [Mr Y’s] place because the girls are moved out of his way all the time”.
24. Following a reported improvement in Mr Y’s behaviour, the Council decided to reduce Mr Y's level of support from 2:1 to 1:1 from 10 October.
25. After the reduction in Mr Y’s support, Mrs W raised concerns with the Council. She said Mr Y screamed all night, dragged furniture around and screamed all morning. Mrs W said Mr Y’s behaviours were severely disrupting Miss Z’s enjoyment of her home.
26. Dissatisfied with the lack of action, Mrs W made a complaint to the Council in January 2023. Mrs W provided details of recent police involvement following alleged attacks on both female residents. Mrs W also said that Mr Y sometimes “paraded” in the nude and refused to get dressed.
27. The officer dealing with Mrs W’s complaint raised a safeguarding alert in March. The Council decided not to take any further action because it felt that measures were already in place to mitigate the risk. The Council again reiterated that “alternative accommodation is actively being sought for the other resident”.
28. The Council responded to Mrs W’s complaint in April. It apologised for the delay in the complaint handling. The Council reassured Mrs W that safeguarding measures were in place to maintain Miss Z’s safety and that Mr Y was appropriately supported to minimise any risk. The Council agreed to review Miss Z’s support needs.
29. On 16 June the Council did an ‘Adult Risk Assessment’. In summary, this concluded:
• The care agency reports that Miss Z is calmer following a prescription of anti-anxiety medication.
• Miss Z receives either 1:1 or 1:2 care during the day. Mr Y has his own dedicated 1:1 support.
• Carers ensure that residents are kept apart as much as possible.
• Mr Y spends most of his time in his bedroom.
• The Council is actively sourcing a new placement for Mr Y.
30. Dissatisfied with the Council’s responses, Mrs W approached the LGSCO.

Was there fault by the Council causing injustice to Mrs W and Miss Z?

31. Although I have reviewed all relevant files, I am not able to disclose information about Mr Y to Mrs W. However, from the records I have seen, I can say the Council should have done more to consider the both the known and possible risks before agreeing to place Mr Y with Miss Z. This was important given the Council knew that Miss Z needed a stable and calm environment and could easily become agitated.
32. There is no evidence of any risk assessments undertaken prior to Miss Z’s move to supported living in June 2022. Although the residents met on one occasion, and each received individual social care assessments, there is nothing to show how the Council considered the risks and the compatibility of the three people living together. This has caused uncertainty because we cannot know, with certainty, whether the Council would have allowed Mr Y to share a placement with Miss Z if it had assessed the risks. Miss Z has therefore suffered injustice.
33. Although the Council did not progress any of the safeguarding alerts in relation to the risk posed by Mr Y, it has acknowledged on more than one occasion that Mr Y needs to move to an alternative placement. The first time the Council decided this was in July 2022 when it began to “actively” seek a new placement. Despite this, 14 months have now passed, and Mr Y remains in the same household. The Council has not given any indication of an imminent move.
34. The LGSCO cannot make professional judgements. We cannot therefore decide whether a person poses a risk and needs a review or change of placement. Such decisions are outside of our remit. However, the Council has itself decided that Mr Y needs to move and so in our view this should be actively pursued to avoid any further risk or disruption.
35. It is my view that both Mrs W and Miss Z have experienced avoidable distress since July 2022 when the Council committed to moving Mr Y. Despite the Council’s ‘active’ pursuit of a new placement, nothing has changed, and Miss Z continues to live in an unstable and sometimes risky environment.
36. The Council has agreed to provide the remedy below.

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Agreed action

37. Within four weeks of my final decision, the Council will:
• Pay £750 to Miss Z for the uncertainty caused by the failure to assess the possible risk before placing Mr Y in a supported living setting with her, and for the avoidable distress she has experienced since July 2022;
• Pay £200 to Mrs W for the time and trouble caused by the delay in the handling of her complaint and for the general time and trouble she has endured when raising concerns on behalf of Miss Z;
• Complete up to date risk assessments for all three residents; and
• Make an ongoing payment to Miss Z of £150 per month. This payment should continue until Mr Y and Miss Z are separated.
38. Within eight weeks of my decision, the Council should also:
• Complete an action plan outlining the steps to be taken to resolve the known issues at the placement and to ensure Miss Z’s ongoing safety. The Council should share a copy of this with the LGSCO and provide an update to Mrs W (whilst maintaining Mr Y’s confidentiality).
39. The Council will provide us with evidence it has complied with the above actions.

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Final decision

40. I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. The agreed actions will provide an appropriate remedy for the injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman