Summary: Mr D complained about the support provided to his daughter who lives in supported living accommodation. We found some fault in the Council’s service provision and communications. This resulted in some avoidable distress and frustration for Mr D and his daughter. The Council has accepted these findings and at the end of this statement, we set out action it has agreed to remedy this injustice.

The complaint

1. I have called the complainant, ‘Mr D’. He complained on behalf of his daughter ‘Miss E’ who lives in supported living accommodation, with a care package arranged by the Council and provided by a care provider on site. He complained the Council:

• had not ensured Miss E received one-to-one care to help her to access the community;
• had not always ensured Miss E’s safety; in particular, he said Ms E reported threats, harassment and assaults while living in the accommodation;
• had more failed to adequately supervise the care Miss E received; for example, by ensuring the care provider had enough staff and they had completed all necessary employment checks;
• had not properly investigated his complaints about Miss E’s care.

2. Mr D said as a result Miss E experienced social isolation and avoidable distress. While he had unnecessary and avoidable frustration in making service requests and complaints on her behalf.

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The Ombudsman’s role and powers

3. 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)
4. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. 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. 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 suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a Council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
7. 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

8. Before issuing this decision statement I considered the following:

• Mr D’s complaint to the Ombudsman and any supporting information provided;
• correspondence exchanged between Mr D and the Council and / or Care Provider about the matters covered by the complaint;
• information provided by the Council in reply to my written enquiries;
• any relevant law, Government guidance or Council policy or procedure referred to below;
• any relevant guidance published by the Ombudsman.

9. I also gave Mr D and the Council chance to comment on a draft version of this decision statement and / or provide any further evidence they consider relevant to the complaint. I took account of their responses before finalising the decision statement.

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What I found

Key law and guidance

10. 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.
11. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan detailing:

• what needs the person has;
• what they want to achieve;
• what they can do by themselves;
• what additional care and support will meet their needs.

12. A council must make safeguarding enquiries if it thinks a person with care and support needs may be at risk of abuse or neglect. An enquiry is the action taken by a council in response to a concern about abuse or neglect. It can range from a conversation with the person who is the subject of the concern to a multi-agency meeting to discuss the concerns. 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).
13. Councils should have clear procedures to deal with social care complaints. Regulations and guidance say they should investigate and resolve complaints quickly and efficiently. A single stage procedure should be enough. The council should include in its complaint response:

• how it considered the complaint;
• the conclusions reached about the complaint, including any required remedy; and
• whether it is satisfied all necessary action has been or will be taken by the organisations involved; and
• details of the complainant’s right to complain to the Local Government and Social Care Ombudsman (see Local Authority Social Services and National Health Service Complaints (England) Regulations 2009).

Chronology of key events

14. The following paragraphs summarise the most relevant events forming the complaint.
15. Miss E is autistic and has mental health needs. She has lived in supported living accommodation for several years.
16. In June 2021 a care needs assessment noted Miss E misused alcohol. It also noted concerns about the impact of her relationship with another tenant, I will call ‘Mr X’. It noted Miss E experienced high levels of anxiety which made it hard for her to attend appointments or carry on activities outside the accommodation. It said she would “benefit from support” attending appointments. The assessment said Miss E rarely used the seven hours one-to-one support hours in her care plan because of her anxiety. An attached care and support plan said the Care Provider should support Miss E with a weekly timetable to access activity outside her accommodation. Also, that it should be “pro-active” in doing so; for example, helping her with tasks such as shopping and using public transport.
17. Miss E’s next care needs assessment was in April 2022. This noted an alcohol support service had been in touch with her, but she had declined its services. There were continuing concerns about alcohol misuse, social isolation, levels of anxiety, issues with other residents and potential vulnerability. In the assessment the Council recorded Miss E wanted to move, saying she did not consider she had made any positive progress and did not engage with staff. The assessment recorded the Council would explore other placements with Miss E. It was critical of the care provider saying: “I do not feel they are engaging with solutions to rectify issues in order to improve their ability to work with [Miss E]”. The attached support plan gave more specific advice to the care provider on helping to keep Miss E safe and on helping her budget and prepare meals.
18. The Council next undertook a needs assessment in February 2024. In between the Council took the following measures to try and support Miss E:

• It made repeated attempts to encourage Miss E to engage with the alcohol support service. Miss E did not consent to this until February 2023. By May 2023 Miss E had cancelled several appointments and so the Council arranged for the alcohol support service to visit her. In summer 2023 Miss E engaged to some extent with the service but then cancelled further appointments. The service therefore ended its involvement with her at the beginning of this year;
• at the same time, the Council liaised with local mental health services;
• in October 2023 the Council arranged for an autism support worker to visit Miss E weekly to help her access the community. The support worker met with Miss E, but Miss E then cancelled later visits. I found no record of further attempts by this service to contact Miss E after November 2023.

19. The February 2024 assessment noted the above. It provided updated medical advice on why Miss E struggled to keep appointments and consistently engage with services. It noted Miss E could sometimes be hostile to staff and other tenants. The assessment no longer referred to looking for alternative accommodation for Miss E, saying this had been discussed with her. However, it still recorded Miss E wanting to move.

Mr D’s complaint

20. I found before April 2022 Mr D had clearly raised concerns about some of the service Miss E received. The Care Provider sent a communication to the Council then, which went through a list of concerns from Mr D. It later shared this with him. That response:

• highlighted concerns about Miss E’s alcohol misuse and impact on her medication. The Care Provider said it had raised this with her GP, pharmacist and social worker;
• said attempts to support Miss E with meal preparation faltered because of her alcohol misuse;
• that this also impacted on her relations with staff and other residents; Miss E often cancelled her one-to-one support;
• listed measures taken to support Miss E including providing her with a named support worker, varying the time of her one-to-one support, referring her to an alcohol support service and seeking other specialist advice.

21. After this time Mr D continued to send messages he received from Miss E, often also expressing his own concern. Issues he raised, included:

• instances where Miss E did not receive support or where Miss E complained about staff;
• that Miss E was not accessing the community;
• that the Care Provider did not support Miss E when she bought a new bed;
• that staff did not call an ambulance for Miss E when needed;
• that a tenant ‘Ms Z’ disturbed Miss E with noise.

22. In November 2022 a manager from the Care Provider acknowledged Mr D had raised concerns. In December 2022 the Council also acknowledged correspondence from Mr D and said it would liaise with the Care Provider.
23. In February 2023 the Care Provider wrote to Mr D. Its response:

• explained difficulties it said it had providing one-to-one support for Miss E. She continued to refuse support or ask for it at times outside that arranged. She sometimes wanted different support workers. She often did not want to leave the building;
• provided an account for what happened when Miss E bought a new bed;
• provided an account for what happened when Miss E called an ambulance;
• that it did not have any record of disturbance caused by Ms Z.

24. From May 2023 onward, Mr D, following contacts from Miss E, began reporting concerns about the behaviour of Mr Y, another resident in the building. The Council investigated these via its adult safeguarding procedure. I saw evidence it put specific allegations made from Miss E to the Care Provider for its response. It recorded inviting Mr D to a meeting in July 2023 where there was discussion about Miss E’s care and Mr Y’s behaviour. It has said that it did not consider the actions of Mr Y justified a finding that Miss E was suffering, or at risk of, abuse.
25. In October 2023, the Council also wrote to Mr D. Among the points it made were the following:

• that it continued to have concerns for Miss E’s alcohol misuse. It considered she needed more specialist health support and it had made referrals for this;
• that it had investigated allegations about Mr Y’s behaviour, as a safeguarding matter. It recognised he had caused disturbance and explained the reasons;
• that it accepted Miss E’s current accommodation did not best meet her needs. It said she would benefit from a move to another supported living placement. It explained efforts made so far to identify an alternative.

26. After receiving this letter Mr D continued to report incidents involving Mr Y. In November 2023 the Council told him it was investigating his concerns via its adult safeguarding procedures. This included concerns he had that Miss E received inadequate support including with managing her medication and that staff used inappropriate language with her.
27. During safeguarding investigations in 2023, the Council twice arranged for Miss E to meet with an advocate and go through her concerns.
28. With his complaint to this office Mr D has sent footage of various incidents recorded by Miss E on her phone.

My investigation

29. I asked the Council about how it decided which service should support Miss E. It told me it provided a social work service through its mental health team. But that its autism team could support the mental health team, as it had done in Miss E’s case.
30. I asked the Council about its commissioning arrangements for supported living placements like Miss E’s, which are not regulated by the Care Quality Commission. It said all providers were subject to due diligence tests. It also expected them to provide services in line with an individual’s care and support plan. It said social workers oversee the care individuals receive and can alert the Quality Monitoring Team if they have any wider concerns about a service. That team also carries out its own monitoring and receives any adult safeguarding alerts.
31. Individual contracts also require contractors to ensure they provide “adequate” staffing and to carry out checks of employees with the Disclosure and Barring Service (DBS).
32. I asked the Council about how it dealt with complaints made about services it commissions but provided by third parties such as care providers. The Council said those using such services (or their representatives) could use either the care provider’s own complaint procedure or the Council’s. The Council complaint policy says it is “accountable for any service failure” by those delivering a service for the Council.
33. The Council also gave me a copy of its standard contract with care providers which says they can signpost complainants to the Ombudsman without referring complainants to the Council.
34. As part of my investigation, I also read through Miss E’s social work notes and a sample of the notes kept by the Care Provider.

My findings

Scope of findings

35. I decided my investigation should consider events from June 2021 onward. I decided there were special reasons that justified investigating complaints from that date, even though this meant some of the events took place more than 12 months before Mr D complained. First, Mr D had consistently raised concerns about Miss E’s care throughout this time. Second, I also found the way the Council and Care Provider responded, meant Mr D’s concerns had not all passed through either organisation’s complaint procedure. This made it much harder for Mr D to come to this office sooner.
36. I also chose this date because the care needs assessment completed then highlighted concerns for Miss E which remained current at the time of the investigation. In particular around her alcohol misuse, lack of social activity and contact with others. I wanted to consider how the Council and Care Provider had tried to address these matters.

The complaint Miss E did not receive one-to-one care to help her to access the community

37. I found the records showed Miss E had not regularly received the hours of support set out in her care and support plans. However, I found the primary reason for this was a lack of regular engagement by her. The Care Provider recorded multiple instances of Miss E declining support.
38. I also did not find any evidence of general failings by the Care Provider in how it interacted with Miss E. I watched film clips where Miss E was clearly unhappy with how staff spoke to her, or what they said. But I did not see any evidence in those of unprofessionalism, rudeness, or other poor service. Nor did this come across in any notes.
39. I did find it recorded that part of the support Miss E should have received was to access the community. I noted the frustration the Council expressed in 2022 that the Care Provider could be doing more to support in that. And I noted how, during 2023, it had tried providing an extra service to Miss E, employing an autism support worker specifically to have weekly sessions with her. But this service stopped because Miss E failed to engage with the support worker over several weeks.
40. I considered the main barrier to Miss E not accessing support centred on her consistently struggling to engage with services. As well as the Care Provider and Autism Support Worker, this was also illustrated in her difficulty engaging with the alcohol support service, even when it came to her.
41. This did not imply any blame on Miss E. She clearly had complex needs and experienced high levels of anxiety. She had also begun to misuse alcohol over recent years. These were all issues I considered probably contributed to her non-engagement but were not issues the Council or Care Provider could readily overcome. However, I noted in the last 12 months the Council had clearly made efforts to try and do so.
42. But all that said, I still had some concerns about the Council’s service, especially before 2023. First, it recorded from 2021 onward concerns around Miss E’s anxiety levels, alcohol misuse and social isolation all of which appeared inter-related. Yet it did little to look at ways these could be overcome before 2023. For example, before then it had referred Miss E to the alcohol support service but did not offer support to take her there or ask the service to visit Miss E in her home.
43. Second, I found some inconsistency in how the Council approached the question of whether Miss E’s accommodation may have contributed to her overall presentation and anxiety. In 2022 the Council said Miss E needed a change of accommodation. But by 2024 its support for this had changed, adopting a neutral tone in its care assessment.
44. However, despite some inconsistency on this point, I found the Council had looked for a change of accommodation for Miss E, in line with her wishes, and those efforts continued. Its records showed attempts to find alternative supported living were proving unsuccessful for reasons including that Miss E did not fit the client profile of some providers. In other cases, supported living providers reported having no availability or the location was unsuitable.
45. Third, allied to these points, I found there was not always clear communication with Mr D when he raised concerns. I return to this point below when considering the Council’s complaint handling.
46. For the reasons above I therefore upheld this part of the complaint, finding the Council at fault.

The complaint the Care Provider did not always keep Miss E safe

47. I did not find the evidence showed the Council or Care Provider had failed to keep Miss E safe when tensions arose with Mr X. I was satisfied with the investigation of Miss E’s allegations made about Mr X. She had either gone on to withdraw allegations or else investigation did not find evidence for what she said.
48. Turning to issues with Mr Y, I noted here some of Miss E’s film clips recorded loud shouting, including one instance where it seemed directed at her. I could understand why Miss E experienced distress.
49. However, I considered on balance the Council and Care Provider had responded appropriately. While I could not see there was a detailed fact-finding investigation into each incident, the Council recognised Mr Y’s behaviour had impacted on Miss E. But there was no evidence suggesting the Care Provider did not manage the situation properly or failed to keep Miss E safe. Although in saying this I noted Mr F brought to my attention a more recent incident (April 2024) which this investigation did not include.
50. Turning to other concerns raised, I found over the last twelve months the Council had made greater efforts to ensure a consistent investigation of these via safeguarding procedures. It had arranged for Miss E to have an advocate to support her which was best practice. It had properly put allegations to the Care Provider. I did not see any record which indicated to me the Council had failed to explore any incident which might point towards the Care Provider or another resident putting Miss E at risk of harm. It had also involved Mr D at times, showing good practice in inviting him to the meeting in July 2023.
51. However, I considered at times the Council could have communicated more consistently and clearly with Mr D. Again, I considered there was some fault here and I l return to this in the section below which considers the Council’s complaint handling.

The complaint the Council failed to adequately supervise the care Miss E received

52. I was satisfied with the systems the Council had in place to ensure that users of its services in supported living placements, received appropriate care. I did not consider there was anything we could fault in the Council’s contract nor in it having a dedicated quality monitoring team. Nor its expectation that individual social workers monitor the service individual users receive.
53. I would have liked the Council to comment further on how it checked staffing levels at individual placements and to ensure staff have appropriate employment checks. But I saw no evidence suggesting Miss E experienced any poor service because of poor levels of staffing, or this had been a contributory factor to any fault. Similarly, I saw no grounds that would justify me exploring further staff records, training and so on.
54. As I commented above, I considered the Council could have responded more robustly and sooner after 2021 to review the services in place for Miss E. But I considered the focus of the investigation must remain on the service she received and not any wider concerns about the Care Provider. So, I did not uphold this part of the complaint.

The complaint the Council had not properly investigated Mr D’s concerns

55. I did not find any fault in the policy or procedure the Council had for ensuring investigation of complaints about services delivered on its behalf. However, I found it difficult to follow how it had considered all the concerns raised by Mr D and communicated with him in response.
56. I recognised it was not always easy to categorise Mr D’s concerns. For example, a complaint about an individual instance where Miss E reported not receiving one-to-one support was an individual allegation of a service failing. But sometimes Mr D’s communications could also be read as forming part of a pattern of wider concerns or potentially raising safeguarding concerns.
57. In all events Mr D should have known what was happening. His contacts followed reports made to him by Miss E, which he understandably felt he must raise. I saw nothing raised by Mr D that did not merit a reply. So, I looked for evidence the Council and / or Care Provider had acknowledged the correspondence and explained how it would answer and under what process.
58. I found clear standards of communication were not always followed. Which is not to say Mr D, or Miss E, were ignored or the Council and Care Provider did not make efforts to engage. But their communications were sometimes confusing and this added frustration for Mr D, in his attempts to raise matters with both. I considered this was an injustice to him and Miss E, given she alerted Mr D to these matters in the first place wanting his help.

Considerations on injustice

59. Having identified the faults set out above, I went on to consider the impact of these on Mr D and Miss E. I considered it regrettable that Miss E remained in accommodation not best suited to her. I considered this may have contributed to the lack of progress in her being able to enjoy activity outside her accommodation. In my draft findings, I expressed the hope the Council would continue to do its best in both areas. As I noted above it could have offered more support sooner to Ms E in both these areas, as it had done so over the past twelve months. However, given the limited engagement achieved I could not say that if it had it done so, Miss E’s circumstances would be materially different. I could not say the injustice caused to Miss E was therefore measurable or significant. Although I still considered the Council should apologise to her.
60. However, I considered the failures in communications had resulted in a significant injustice to Mr D. These caused him some avoidable frustration and distress, not knowing the extent to which the Council or Care Provider took his concerns seriously or how it intended to investigate and respond.

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Agreed action

61. The Council has accepted the findings above. To remedy the injustice identified it has agreed that within 20 working days of this decision, it will:
1. apologise to Mr D and Miss E, accepting the findings of this investigation and taking account of Section 3.2 of our published guidance on remedies -Guidance on remedies - Local Government and Social Care Ombudsman;
2. make a symbolic payment to Mr D of £400 in recognition of his distress;
3. write to Mr D with proposals to manage communications with him and Miss E moving forward. As a minimum, the Council will provide Mr D with a named point of contact who will ensure that any future communications about Miss E’s case are responded to and replied to appropriately in line with the guidance at paragraph 56 and 57 above. The Council will also update Mr D on any communications it understands remain outstanding and offer clarity about how its search for new accommodation for Miss E will progress moving forward.
62. The Council will provide us with evidence it has complied with the above actions.

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Final decision

63. For reasons set out above I upheld this complaint finding fault by the Council causing injustice to Miss E and Mr D. The Council agreed action that I considered would remedy that injustice. Consequently, I could complete my investigation satisfied with its response.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman