Summary: Ms Y, on behalf of Mr X, complained about the Council’s handling of his care and support needs, as well as its failure to oversee the completion of a housing adaptation, leaving the work unfinished. We find the Council at fault for failing to respond to contact, properly consider safeguarding referrals, carry out required assessments, take reasonable steps to arrange appropriate care support, and ensure the housing adaptation was completed. These failings caused Mr X distress and uncertainty. The Council has agreed to apologise, make a payment to Mr X, and improve its services.

The complaint

1. Ms Y, on behalf of Mr X, complained about the Council’s handling of his care and support needs, as well as its failure to oversee the completion of a housing adaptation, leaving the work unfinished. Specifically, she said that:
1. Mr X did not receive any care support between November 2022 and April 2023;
2. since November 2023, he has not received any care support;
3. he has had multiple different social workers allocated to him;
4. concerns about his hoarding have not been addressed;
5. home adaptations that began in December 2023 remain incomplete; and
6. the Council provided poor communication to both Mr X and Ms Y.
2. Ms Y says these issues have negatively affected Mr X’s physical and mental health. He is unable to leave his home to attend medical appointments due to a lack of necessary support, and the Council’s poor communication has caused distress and uncertainty.

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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 suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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)
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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What I have and have not investigated

6. I have not investigated part a) of Ms Y’s complaint. This is because Ms Y and Mr X were aware of these issues for more than 12 months before Ms Y brought her complaint to us. This is therefore a late complaint and there are no good reasons to investigate this now.

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How I considered this complaint

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

Relevant law and guidance

Community care assessment: duty to assess, eligibility criteria and care plan

9. 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. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. 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.
10. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.
11. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.
12. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

Direct payments

13. Direct payments are monetary payments made to individuals who ask for them to meet some or all of their eligible care and support needs. They enable people to arrange their own care and support to meet those needs. The council must ensure people have relevant and timely information about direct payments so they can decide whether to request them. If they do so, the council should support them to use and manage the payment properly.

Safeguarding

14. 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

Background information

15. In 2023, Mr X was awarded a disabled facilities grant (DFG) to install a level-access shower in his bathroom.
16. Following the withdrawal of support from a care agency (provider 1) due to Mr X’s behaviour, the Council reviewed his needs. It found him eligible for support under the Care Act, including help with food shopping, managing correspondence, and contacting and engaging with health services.
17. In June 2023, following what the Council described as extensive attempts to find a provider, a second care agency (provider 2) began supporting Mr X.

Ms Y’s complaint

18. In September, Ms Y raised concerns with the Council about fire hazards and blocked exits in the property in the context of hoarding.
19. In November, provider 2 withdrew its services due to Mr X’s behaviour towards staff and a member of the public. The Council visited Mr X to discuss the withdrawal. It agreed Ms Y would provide weekly support on a temporary basis, including help with food deliveries and written correspondence. The Council also discussed a potential care package but noted sourcing support would be difficult due to Mr X’s needs and previous behaviour.
20. In December, contractors started the works to Mr X’s bathroom. However, later that day, Ms Y told the Council that contractors had left the property due to Mr X’s aggression. Mr X was left with the use of a sink and toilet, but no washing facilities. It was agreed contractors would return in January, with Mr X to stay elsewhere whilst the work was completed.
21. Later that month, a new care agency assessed Mr X but declined to take on his care. Other professionals also raised a safeguarding concern about Mr X’s inability to shower.
22. In January 2024, a multi-disciplinary team meeting was held to plan the bathroom works. The Council agreed to support Mr X’s temporary move and would arrange a mid-week visit home to see the progress. Mr X was advised of the plans.
23. Throughout the month, the allocated case officer supported Mr X to manage his anxieties about the works. Mr X ultimately refused to leave his home, leading the contractors to suspend works. A multi-disciplinary meeting followed, where it was agreed to await feedback from the contractors and continue searching for a care agency.
24. In February, Ms Y raised a safeguarding referral with the Council, highlighting the lack of care support, hoarding-related fire risks, and the stalled bathroom works. She also advised that Mr X was being supported by a local food bank with food deliveries.
25. Mr X contacted the Council for an update on the bathroom works but received no response.
26. Later that month, Mr X’s allocated case officer ended their involvement due to a breakdown in their relationship. Their manager agreed to transfer Mr X to a social worker.
27. In March, Ms Y raised a second safeguarding referral due to the lack of response to her previous referral. She also repeatedly contacted the Council requesting care support, highlighting that Mr X had been without care since November, was unable to leave his house, and was struggling to get food but received no response.
28. In April:
• The Council again encouraged Mr X to move out temporarily so bathroom works could proceed.
• The Council reviewed and closed the February safeguarding referral.
• Mr X called the Council to complain about the lack of support; a complaint (complaint 1), was raised. He later called requesting to speak to someone but received no response.
• Ms Y submitted a complaint (complaint 2), saying Mr X had not received adequate support for years, the Council had not responded to his contacts, and his name had been misspelt in records.
• Another council made three safeguarding referrals after Mr X’s contacts with it raised concerns.
• Ms Y followed up on the safeguarding referrals she had previously made. The Council said there were no safeguarding cases open, and someone would contact her urgently.
• A new social worker was allocated. Mr X continued to request contact. The new social worker later discussed the bathroom works with Mr X and Ms Y.
29. In May, Ms Y submitted a complaint to the Council (complaint 3) raising concerns about the:
• failure to provide appropriate and consistent care to meet all of Mr X’s needs;
• inadequate communication and coordination between all involved parties;
• failure to respond to concerns about Mr X’s hoarding;
• delays responding to safeguarding concerns; and
• avoidable delays in completing bathroom adaptations.
30. Ms Y said these failings had contributed to a deterioration in Mr X’s physical and mental health, and the bathroom remained unfinished.
31. The Council responded to complaint 1, stating there had been regular contact between Mr X and any allocated workers and a review of his needs would be arranged.
32. In June, the Council responded to complaint 3. It did not address past events but said the new social worker would update Mr X’s assessment, follow up on the hoarding concerns, and liaise with other agencies. It acknowledged delays in handling safeguarding concerns but said no active safeguarding issues remained.
33. Later that month, the Community Mental Health Team decided there was no role for them in relation to his mental health, however it contacted the Council recommending an assessment of Mr X’s needs, and for a safeguarding referral to be considered.
34. In July, Ms Y escalated complaint 3, dissatisfied with the response. She added concerns including the delay in complaint handling, failure to explore alternative support for Mr X, and failure to consider one of Mr X’s relatives as a potential carer.
35. Mr X called the Council five times in July requesting contact. Messages were taken but not followed up.
36. In August, the Council issued its final response to complaint 3. It acknowledged Mr X had received no formal care since November 2023, explained why it had difficulties sourcing support and offered to explore direct payments with him. It also accepted there had been delays in handling safeguarding referrals but stood by the outcomes.
37. In September, another council raised a further safeguarding referral after a visit to Mr X. Mr X told it a recent fall had left him housebound, and during the visit he made suicidal threats. The other council requested contact be made with it by the allocated social worker.
38. In October, Mr X contacted the Council twice and no response was received.
39. Later that month, Ms Y brought the complaint to the Ombudsman.
40. In response to my enquiries the Council has confirmed:
• since December 2023, no efforts have been made to source a new care agency for Mr X;
• in August 2024, Mr X’s allocated social worker identified a number of assessments and referrals that needed to be completed to support Mr X, however these were never completed;
• no action was taken following the hoarding and/or safeguarding referrals made about Mr X;
• there has been no progression on the bathroom works; and
• a new social worker has now been allocated to complete the required assessments, referrals, and considerations.

My findings

Care support since November 2023

41. Mr X has been without a formal care package since November 2023. The Council has acknowledged that since December 2023, it did not take appropriate steps to meet his assessed needs, or to explore alternative support options. This is fault.
42. I cannot say, even on the balance of probabilities, whether the Council would have successfully secured another care agency, whether Mr X would have been eligible for alternative support, or whether he would have accepted this support. However, the Council’s failure to act has created uncertainty about whether Mr X could have been receiving the support he was assessed as needing.
43. The Council also failed to review or reassess Mr X’s care needs since early 2023. This is fault. While I cannot say, even on the balance of probabilities whether a review or assessment would have resulted in additional support, this failure again leaves uncertainty about whether Mr X’s needs were being properly identified and addressed.
44. It is concerning that, although the need for further assessments and referrals was identified in August 2024, these were not acted upon. During my investigation, a new social worker was allocated and will be completing the required assessments and planning support going forward.

Changes in social worker

45. The worker allocated to Mr X was changed in early 2024 at the request of the original worker. I do not find fault in the decision to change the allocated worker.
46. There was a gap between the original worker stepping back and the new worker being assigned. However, the Council arranged for alternative social workers to maintain contact with Mr X during this period. I do not find fault in how this was managed.

Hoarding concerns and safeguarding referrals

47. Between September 2023 and September 2024, the Council received ten safeguarding referrals from a range of sources, many of which were from other professionals. No action was taken in response to any of these referrals. This is fault and potentially left Mr X at risk of harm. It also directly contradicts the Council’s response to complaint 1 in August 2024, where it stated appropriate action had been taken. This inconsistency is further fault.
48. It is particularly concerning that despite these failures, the Council’s final response to complaint 3 found no fault in how the safeguarding referrals were handled. This response failed to recognise or address the clear failings in how these concerns were dealt with.

Home adaptation

49. There has been no progress on Mr X’s bathroom adaptation since April 2024. This is fault and has left Mr X without proper washing facilities, only a sink and toilet, since December 2023.
50. The Council has stated it intends to address the situation as part of the reassessment taking place. I cannot say, even on the balance of probabilities whether further action would have resulted in Mr X’s bathroom adaptation being completed sooner. I acknowledge that Mr X’s past behaviour has complicated the process, but the Council should have done more. The delays have caused distress and uncertainty for Mr X.

Poor communication

51. Between February 2023 and October 2023, Mr X and Ms Y contacted the Council 21 times. On only one occasion did Mr X’s allocated worker return his contact. This is fault. It caused Mr X distress, uncertainty and contributed to the escalation of concerns.
52. The Council failed to acknowledge or respond to Ms Y’s April complaint and delayed acknowledging her May complaint. Its June complaint response also failed to fully address the issues raised. This is fault.
53. While I am satisfied there are no outstanding complaint points, it is concerning that the Council’s complaint responses showed no evidence of learning or service improvement. It appears that only through this investigation has the Council begun to reflect on its failings.

Summary

54. This investigation found serious and prolonged failings by the Council in its support of Mr X. These included a failure to try and provide or arrange care since November 2023 despite his assessed eligibility, a failure to carry out timely reassessments of his needs, and a failure to act on multiple safeguarding and hoarding concerns raised by various professionals. There were also unacceptable delays in completing essential bathroom adaptations, leaving Mr X without suitable washing facilities for over twelve months. In addition, the Council’s communication was persistently poor, with numerous unreturned calls and unanswered correspondence, and its complaint handling was inadequate, failing to acknowledge the full extent of its shortcomings. These failings caused Mr X significant distress, uncertainty, and placed him at potential risk of harm. They also placed an undue burden on Ms Y, who repeatedly raised concerns on Mr X’s behalf without receiving appropriate support from the Council.
55. In recognition of these faults, the Council has offered to issue formal apologies to both Mr X and Ms Y, pay Mr X £1,000 to acknowledge the distress and uncertainty caused, and implement a number of service improvements. I have considered this proposed remedy and find it is in line with our Guidance on remedies. While we typically recommend up to £500 to recognise distress and uncertainty, I consider a higher payment to be appropriate in this case given the severity and duration of the failings and their impact on Mr X’s wellbeing.

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Action

56. To remedy the injustice caused by the above faults, within four weeks of the date of my final decision, the Council has agreed to:
• apologise to Mr X in line with our guidance on Making an effective apology;
• pay Mr X £1000 to recognise the distress and uncertainty caused; and
• complete a care needs assessment for Mr X and consider any further assessments or referrals as appropriate.
57. Within three months of my final decision, the Council has agreed to issue a briefing(s) note to all relevant staff using this case as a case study. The briefing(s) should reinforce the following expectations:
• Safeguarding telephone calls must be handled appropriately, with staff responding proportionately to each concern, regardless of whether the individual is a frequent caller.
• Staff must apply the correct criteria when responding to safeguarding concerns, including proper consideration of Section 42 of the Care Act 2014 where appropriate.
• All communications and decisions related to safeguarding concerns must be accurately recorded.
• Referrers should be included in the information-gathering process when responding to safeguarding referrals.
• Each case should be assessed individually. The allocation or pending allocation of a social worker must not prevent appropriate escalation of concerns.
• Assessment visits must be documented promptly, with any agreed actions carried out without delay.
• Contacts from individuals must be responded to by the allocated worker promptly.
• Where difficulties arise in sourcing an appropriate care provider, staff must continue efforts to meet the individual’s assessed needs. If all options are exhausted, the matter should be escalated appropriately.
• When care cannot be provided, a risk assessment must be completed and the matter escalated. This should include consideration of alternative legal frameworks and care solutions.
• Multi-disciplinary team meetings must be formally minuted, with clear action plans recorded.
• Where difficulties arise impacting the progression of DFG works. If all options are exhausted, the matter should be escalated appropriately.
58. The Council should provide us with evidence it has complied with the above actions.

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Decision

59. 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