Summary: Mrs X complained the Council has failed to adequately meet Miss Y’s care and support needs, and to safeguard her from neglect and abuse. We found the Council’s failure to hold a safeguarding planning meeting or complete comprehensive risk assessments was fault. As was the failure to ensure Miss Y received all of the support set out in her support plan. These faults have caused Miss Y and Mrs X an injustice. The Council will apologise and make payments to Miss Y and Mrs X to remedy this.

The complaint

1. Mrs X complained the Council has failed to adequately meet Miss Y’s care and support needs, and to safeguard her from neglect and abuse. This has caused Miss Y and Mrs X distress and affected their wellbeing.

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The Ombudsman’s role and powers

2. 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)
3. 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/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
4. 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, sections 24A(1)(A) and 25(7), as amended).
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

8. Mrs X has raised several concerns about Miss Y’s care and support since 2020, but I have not investigated this full period. As Mrs X contacted us in December 2024, my investigation has focussed on events since December 2023. It was open to Mrs X to raise her concerns about earlier events much sooner.

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How I considered this complaint

9. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
10. Mrs X 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

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 here

12. This is a summary of events outlining key facts and it does not cover everything that has happened in this case.
13. Miss Y has been living in a Voyage Care supported living placement since 2020. The Council reviewed Miss X’s care and support plan in late 2023 following two men moving into the property.
14. The reassessment noted the following needs which were the included in Miss Y’s support plan dated 16 January 2024:
• to be supported to prepare meals and encouraged to eat a healthy diet;
• to be prompted to refer to her personal care chart and shower and wash her hair, and keep her oral health routine;
• to be supported to keep a house rota of cleaning jobs and encouraged to complete them.
• to be supported to manage a budget with her finances;
• support in managing personal relationships and around her social media and phone use;
• to be supported to try new activities in the community and to build a routine.
15. The support plan provides for 72 hours 1:1 support and 49 hours of 1:3 support each week.
16. In March 2024 Miss Y made an allegation against Mr Z, one of the men she lives with. Voyage Care, the Care Provider made a safeguarding referral to the Council.
17. The records show the Care Provider implemented a risk management plan. This included that Miss Y and Mr Z were not to be left on their own; Miss Y could wake the sleep in member of staff if needed; and they had been advised to stay in their own bedroom. Miss Y told the Care Provider and Council that she did not feel safe living there and wanted to move out.
18. At the end of March 2024 Mr Z threatened Miss Y and was arrested by the police. The Care Provider again made a safeguarding referral to the Council. Mr Z returned to the property in April 2024 when the police decided to take no further action. The Council closed the safeguarding concern in June 2024.
19. The Council also allocated Miss Y a social worker in June 2024. The records show that over the following months Miss Y told her social worker she wanted to move out. The social worker confirmed they would explore this during her care review.
20. The social worker also encouraged Miss Y to think about the future and employment or work experience. As Miss X wanted to do nails at college the social worker suggested she to visit the college to discuss nail technician courses. Miss X also agreed the social worker could refer her to the Link Workers team to explore more options.
21. In October 2024 the Care Provider told Miss Y’s social worker that the property had £6000 in debt as the residents had not been paying their utility bills. As Miss Y had moved in first the bills were all in her name. The Care Provider was working out the amounts owed by each resident. It is unclear from the records whether the Care Provider or Council informed Mrs X of the debt at his stage.
22. At around the same time, Mrs X raised concerns with the Care Provider about Miss Y eating takeaway food most days whilst also buying food from the supermarket. She questioned whether the Care Provider was supporting Miss Y to cook balanced meals and asked to see receipts for her food shopping. The Care Provider provided copies of the receipts and confirmed support staff encouraged a healthy diet but Miss Y preferred junk food.
23. The social worker determined in November 2024 that Miss Y did not have capacity to consent to her care review. As Mrs X did not have Lasting Power of Attorney for Miss Y and lives abroad, the social worker made a referral for an advocate to support Miss Y.
24. The care review then took place in late November 2024. As Mrs X was unable to attend due to the time difference, the social worker updated Mrs X on the proposed changes. This included reducing Miss Y’s 1:1 support from 72 to 35 hours and increasing the 1:3 support to 2:3 support instead. The social worker said Miss Y had expressed that she wanted more independence and found the 1:1 support for all activities quite restrictive.
25. Mrs X was unhappy she had not been consulted on the changes and asked the Council to restore the level of 1:1 support. The Council arranged a further meeting to discuss Miss Y’s support plan in December 2024, which Mrs X attended and was able to give her views.

Complaints

26. In November 2024 Mrs X made a formal complaint to the Care Provider about its failure to support and safeguard Miss Y. Mrs X complained about:
• a lack of trained staff who understood Miss Y’s needs;
• an increased risk of abuse associated with living with two males;
• a failure to follow up on a meeting with the Council in March 2024;
• a failure to discuss prescribed medication with Mrs X;
• a failure to support Miss Y with a healthy eating plan;
• a failure to support Miss Y with a plan of becoming a teaching assistant;
• a failure to share risk assessments with Mrs X; and
• a failure to promote good working relationships with the family.
27. The Care provider responded in early December 2024 and addressed each concern in turn. It confirmed the staff were up to date with their training and were being monitored.
28. It also noted there had been a number of incidents in the previous 12 months referencing allegations of sexual abuse. The Care Provider confirmed adjustments had been implemented and Miss Y now had a lock on her bedroom door. In relation to allegations of verbal and physical abuse between Miss Y and the other residents it noted the police had been called twice and their investigations were resolved with no further action.
29. The Care Provider acknowledged Mrs X’s concerns but said there was no evidence to suggest Miss Y was at increased risk of abuse by living with males. It said Miss Y was supported by female staff for all her personal care needs and there were always enough females on duty to ensure Miss Y received support.
30. Miss Y’s support plan did not refer to Mrs X being involved in any of Miss Y’s medical appointments including medication or vaccines. The Care Provider suggested completing a mental capacity assessment for this area. If Miss Y was deemed to lack capacity her support plan could be updated to reflect Mrs X’s involvement.
31. The Care Provider also confirmed they had discussed Miss Y’s menu planner with her. Miss Y confirmed she did update this with support from her team and purchased ingredients from the supermarket, but she then chose to buy fast food instead. Miss X and the staff confirmed they reminded and encouraged Miss Y to follow her menu planner but she will decide to eat out instead. The Care Provider suggested completing a mental capacity assessment to confirm Miss Y’s capacity this area too.
32. In addition the Care Provider confirmed it was supporting Miss Y in line with her choices and preferences regarding a teaching assistant job, and her interest in being a nail technician. It also confirmed it had shared Miss X’s support plans which included risk ratings for all identified risks with Mrs X.
33. Mrs X was not satisfied with the Care Provider’s response. She maintained Miss X continued to reside in an unsafe and abusive environment and that the Care Provider had failed to meet Miss Y’s needs or communicate appropriately with Mrs X. She asked for her complaint to be escalated.
34. The Council responded to Mrs X’s complaint in early January 2025 and upheld a number of her concerns. It noted multiple concerns had been raised in relation to one of the housemates, the most recent of which on 1 November 2024. The adult safeguarding team and social worker had carried out a joint visit on 8 November 2024. The police were also present during this visit but did not take any further action.
35. The Council noted that despite the matter progressing to a safeguarding enquiry the efforts to address these concerns had not been formally structured through a Safeguarding Planning meeting. It said this had left gaps in the development of a coordinated plan and effective risk mitigation measures. The Council had now requested the concerns be logged and appropriately investigated.
36. In relation to Mrs X’s concerns about overnight supervision the Council confirmed this was based on the assessed needs of the individuals. However it acknowledged there should be a sufficient risk assessment and safety plan in place for the overnight period.
37. In addition the Council considered Mrs X’s concerns about failures to adhere to Miss Y’s support plan, particularly regarding the use of male support staff required further investigation. As did the Care Provider’s promotion of Miss Y’s mental and physical well-being, healthy eating habits and employment aspirations.
38. The Council set out the action it would take to address Mrs X’s concerns. These included:
• A safeguarding planning meeting;
• Miss Y’s social worker was already carrying out a review of her care and support. In addition the Council was carrying out a review of all the residents’ living conditions to ensure Miss Y’s safety and well-being.
• The Council would conduct risk assessments with Miss Y to develop a safety plan and mitigate identified risks.
• The Council’s commissioning and quality team would carry out a quality monitoring visit to ensure compliance and improvement where needed.
• The Council would carry out mental capacity assessment in relation to Miss Y’s ability to make decisions about her residence and care arrangements.
39. Mrs X has asked the Ombudsman to investigate her concerns. She wants the Council to take immediate action to ensure Miss Y’s safety and wellbeing by arranging new living accommodation. Mrs X also wants the Council carry out a thorough reassessment of Miss Y’s care plan, with input from Mrs X and Miss Y’s advocate too. And for the Council to develop and implement a comprehensive safeguarding plan, and to commit to transparent communication. Mrs X also wanted the Council to hold the Care Provider to account.
40. Since Mrs X complained to us the Council has completed a re-assessment of Miss Y’s needs and issued a new support plan. It has also held safeguarding meetings and implemented a safeguarding plan. And has carried out a monitoring visit to the Care Provider. More recently, the Council has identified and is arranging for Miss Y to move to a new property.
41. Mrs X has also raised additional concerns about the Care Provider not supporting Miss Y in paying utility bills. As a result Miss Y is now thousands of pounds in debt.

Analysis

42. The Council has accepted there was no cohesive safeguarding plan or comprehensive risk assessment in relation to both the verbal abuse and threats from Miss Y’s housemate, and the overnight period when there was no supervision. The delay in developing a safeguarding plan and in carrying out risk assessment and implementing a safety plan is fault. This has caused Mrs X and Miss Y frustration and upset.
43. The Council has apologised and taken appropriate action to address these shortcomings including reviewing Miss Y’s needs assessments and support plan; implementing a safeguarding plan; and carrying out quality monitoring of the Care Provider’s service. The situation has also moved on since Mrs X complained to the Ombudsman, with arrangements now in place for Miss Y to move to a new property. This is to be welcomed as it is clear the relationship between Mrs X and the Care Provider had broken down.
44. In relation to Miss Y’s daily care and support needs, the documentation provided shows the Care Provider routinely prompted and supported Miss Y with her personal care. The daily records show staff prompted and encouraged Miss Y to have a bath/ get washed and dressed and brush her teeth. Staff also supported Miss Y to wash and dry her hair.
45. The records also show that staff assisted Miss Y with a weekly meal planner and encouraged her to choose healthy options. Staff also supported Miss Y to prepare meals and encouraged her to eat she food she had in the fridge/ freezer. However it is also clear from the records that Miss Y often declined support and preferred to eat take away food, or to eat out. While I recognise this is both concerning and frustrating for Mrs X, the Care Provider is unable to compel Miss Y to eat in a certain way or to prevent her from eating her chosen foods.
46. The support plan refers to a house rota of cleaning jobs. While I have not been provided with a copy of a rota, there is reference in the daily records to staff encouraging and supporting Miss Y to complete chores. These include doing her laundry, tidying her bedroom, washing up and cleaning down the kitchen sides, mopping the kitchen floor and hoovering.
47. However, although also required by the support plan, there is no record of the Care Provider supporting Miss Y to budget or pay her bills. The Care Provider suggests there was a breakdown in communication when the supporting staff team changed. The Care Provider apologised to Mrs X as the new support team were not aware they needed to support Miss Y to make the payments. The failure to support Miss X in budgeting and paying her bills is fault. This fault has led to Miss Y accruing significant debts with utility providers.
48. The Care Provider’s failure to support Miss Y in building a routine or taking part in activities is also fault. There is no evidence of an activity plan for Miss Y or that Miss Y is routinely encouraged to take part in or explore different activities. Nor is there any evidence of the Care Provider supported Miss Y with a placement as a teaching assistant or in exploring becoming a nail technician.
49. I consider the Council should apologise and make symbolic payments to Miss Y and Mrs X to recognise the distress and frustration these faults have caused them.

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Action

50. The Council has agreed to:
• apologise to Mrs X and Miss Y for the faults identified and the distress and frustration caused. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology.
• pay Miss Y £300 to recognise the distress, worry and frustration caused by the faults identified above;
• pay Mrs X £300 to recognise the distress, worry and frustration caused by the faults identified above.
51. The Council should take this action within one month of the final decision on this complaint and provide us with evidence it has complied with the above actions.

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Decision

52. I find fault causing injustice. The Council has been asked to agree actions to remedy injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman