Summary: Miss D complained on behalf of her sister who lives in supported living accommodation arranged by the Council. We upheld her complaint, finding the Council failed to take sufficient action to safeguard Miss D’s sister after she experienced aggressive behaviour from another resident. We considered its inattention caused unnecessary distress to both Miss D and her sister. The Council has accepted these findings and at the end of this statement, we set out action it has agreed to take to remedy their injustice and try to prevent a repeat.

The complaint

1. Miss D complained on behalf of her sister, Ms E, an adult with learning disabilities. Ms E lives in supported housing, with care and support from a registered care provider, St Annes Community Services (the ‘Care Provider’). Miss D complained the Council and Care Provider failed to adequately safeguard and support Ms E. This was after Ms E repeatedly became distressed because of the actions of Ms F, another resident in the supported housing scheme.
2. Miss D said as a result Ms E experienced unnecessary prolonged distress. Miss D said she also experienced distress, both because of her sister’s experience and because of frustration with the Council and Care Provider, after she repeatedly asked both to intervene.

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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, sections 24A(1)(A) and 25(7), as amended).
4. We investigate complaints about ‘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. 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(1), as amended)
7. Under an information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I considered evidence provided by Miss D and the Council as well as relevant law, policy and guidance.
9. I also gave Miss D, the Council and Care Provider an opportunity to comment on a draft version of this decision statement. I considered any comments they made and further evidence provided before finalising the decision statement.

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What I found

Relevant legal & administrative considerations

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. Only the CQC, as the care regulator, can decide if a care provider meets the standards or is in breach of them. However, we consider the standards relevant to our investigations when deciding if a care provider was at fault. So, we take them into account and any accompanying guidance published by the CQC.
11. I consider the following fundamental standards relevant to this complaint:

• Regulation 12, which covers ‘safe care and treatment’. Providers must be able to show they have taken all reasonable steps to ensure the health and safety of those in their care and can manage risks arising while providing care. Guidance says this includes reviewing incidents and sharing details, where relevant, with families.
• Regulation 13, which covers safeguarding. Providers must take action to safeguard users of their services from abuse. Guidance says providers should use incidents and complaints to identify potential abuse and take preventative actions where appropriate.
• Regulation 17, which covers ‘good governance’. Providers must keep accurate, complete and detailed records about each person using their service.
• Regulation 20, which refers to the ‘duty of candour’. Providers must act in an open and transparent way with people who receive care and treatment.

12. Councils must make adult safeguarding enquiries if they think a person may be at risk of abuse or neglect and they have care and support needs meaning they cannot protect themselves. (Section 42, Care Act 2014)
13. The term ‘enquiries’ covers any action taken by a council in response to a concern about abuse or neglect. So, it can encompass anything from a conversation with the person who is the subject of the concern, to a more formal multi-agency discussion and plan of action. The council must decide whether it or another person or agency, should act to protect the person from abuse or neglect.

Background

14. Ms E is an older adult with learning disabilities and autism. She has lived in her current supported living accommodation for several years. The accommodation has three bedrooms and provides for two residents, with sleep-in accommodation for one support worker.
15. The Council owns the property. The residents live in the property under individual licensing agreements with the Council. The terms of the licence require the occupiers to “keep to the rules in this agreement which are to do with how you live with other people at the property”. Those rules include “not being aggressive” to other occupiers, and to be: “well behaved, respectful and […] not [to] cause nuisance or annoyance to all the other people who live at the Property”.
16. When a resident moves into the property, they do so at first for a six-week trial. After that, if a resident does not keep to the licence, the Council has the power to end it, by giving four weeks’ notice.
17. The Council contracts with the Care Provider for it to provide support for the two residents. For each resident there is an individual service agreement that specifies how many hours of support each will receive.

Chronology of key events

18. In May 2023, Ms F moved into the accommodation with Ms E. Both knew each other from spending time at a day centre. Before moving in, Ms F visited the property several times, sometimes staying for meals with Ms E. The Council recorded in June and July 2023 Ms F had settled well at the property.
19. In November 2023 Miss D contacted the Council to say Ms E became upset with the behaviour of her housemate. Miss D reported Ms F regularly shouting. I noted around this time the Care Provider recorded an incident where this happened. The record said Ms F did not target her behaviour at Ms E, but that Ms E became upset because of it.
20. The Council recorded this as a safeguarding enquiry. It gave advice to the Care Provider that it should encourage Ms E to report her concerns to the Care Provider. It also said the Care Provider should contact Miss D to discuss and address her concerns.
21. In January 2024 the Care Provider recorded Ms F “shouting and screaming” at Ms E and banging on the door of her room. Staff recorded that attempts to intervene with Ms F appeared to only heighten her behaviour. They recorded Ms E feeling “scared”.
22. In March 2024 the Care Provider recorded an incident where Ms F started shouting at Ms E over an item of clothing. Another relative of Ms E, who visited her at the time, witnessed the incident. They took Ms E away and reported her being upset for several hours and that Ms F had made a threat of physical violence. Also, that Ms F resumed shouting at Ms E when she returned to the home, something the Care Provider recorded. The Care Provider’s notes said Ms F banged doors and shouted, causing Ms E to become further upset.
23. In a separate incident the same month, the Care Provider again recorded Ms F shouting and slamming doors over a prolonged period. It did not record if Ms E was present at the time, nor if this affected her.
24. In communication with the Council around this time, the Care Provider said conflict between Ms E and Ms F could “escalate quickly”. It said both had expressed a wish to move at times. The Council recommended the Care Provider contact an NHS service to work with them. It later transpired the NHS service said it could only work with Ms F, as Ms E did not meet its criteria for support.
25. A note made around the same time also said Ms F had experienced previous placement breakdowns because of their behaviours. It described her as “escalating conflict” with Ms E.
26. In April 2024 a day centre attended by both Ms E and Ms F reported “incidents of conflict” between them causing “agitation and distress”. The Council agreed Ms E and Ms F would now attend the centre on different days to reduce the number of incidents and provide some time apart.
27. Around the same time the Council also agreed to fund extra hours of support for Ms F. A note of a supervision with a social worker recorded that she caused “much distress” to Ms E.
28. Later that same month the Care Provider reported another “verbal incident” to the Council. It then contacted Miss D to offer reassurance the Care Provider had dealt with the incident.
29. In August, the Council recorded that: “things appear to have settled down in the home and going much better”. However, just a few days later the Care Provider recorded an incident where Ms F shouted at Ms E and was “really angry”.
30. Miss D then contacted the Council around two weeks later to express her concern that Ms E continued to suffer upset because of Ms F’s behaviour.
31. When the Council checked with the Care Provider it recorded being told that Ms E was “super sensitive” and this contributed to her upset. The Care Provider told me that it recognised Ms E was sensitive, but that it did not recognise using this phrase. The Council notes said the Care Provider faced a “difficult situation”. They also noted a lack of any physical aggression towards Ms E from Ms F.

Miss D’s complaint

32. In September 2024, Miss D complained in writing and met with representatives from the Care Provider to set out her concerns. She said Ms E telephoned her several times a week upset with the behaviour of Ms F. She said Ms E kept asking to leave the placement and move in with Miss D, being “unhappy, unsettled and anxious”.
33. The Care Provider kept minutes of the meeting, where it reported saying that usually Ms E and Ms F got along well. But there were times when the latter became emotionally dysregulated. The Care Provider said Ms F was “transitioning to her new environment” and “still adjusting”. She was in the “early stages” of receiving help from the NHS and it would not look to move her from the property. Its notes set out its view Ms E had become “fixated” on the tensions with Ms F.
34. Around a month later Miss D spoke to Ms E’s social worker where she expressed unhappiness at the outcome of the meeting. She explained Ms E continued to experience distress and gave a further recent example of this. The Council said it would not try and move either tenant until it had taken “all reasonable steps”.
35. The following day the Council contacted the Care Provider to say it was closing enquiries into Miss D’s concerns. It suggested Ms E might attend a “healthy relationship course”. During that call the Care Provider explained some personal circumstances which had “heightened” Ms F’s behaviour over the previous week.
36. In December 2024, in a written reply to Miss D’s complaint, the Council said:

• before Ms F moved in with Ms E, the Care Provider had undertaken a thorough assessment to check her suitability, and Ms F had made several introductory visits to the property;
• that it did not consider Ms F bullied Ms E in the home. It said there was “occasional conflict” which either Ms E or Ms F might start. It recognised there were times when Ms F became emotionally dysregulated, and this resulted in “verbal altercations”. But it also said Ms F did not always direct anger at Ms E;
• it noted differences in personality between Ms E and Ms F, with Ms E being “very sensitive” and “very emotional”. It noted an incident could leave Ms E upset for up to a week;
• it promised to “offer support to both tenants to lower tensions and provide support and reassurance”. It said it would review activity plans, their health needs and explore education opportunities.

37. In January 2025, Miss D escalated her complaint to this office and we decided to investigate. This coincided with the Council opening another safeguarding enquiry. It did this in response to an incident where staff became worried Ms F might physically assault Ms E who had reacted to Ms F being “in her face” and “taunting” her. Staff described difficulties in managing Ms F’s behaviour and de-escalating it.

Other relevant records

38. The Council told me the Care Provider had changed its record keeping in October 2024. It provided me records of incidents kept under the new record keeping system. While I could not investigate the Council or Care Provider’s specific response to incidents after January 2025, I noted some of their content.
39. These records showed that between early March 2025 and mid-April 2025 there were a further five incidents where Ms F became verbally abusive and / or shouted at Ms E. They also recorded multiple other incidents where Ms F shouted at staff, although it is not clear if Ms E was present or affected by these.
40. In April 2025 the Council and / or Care Provider produced a behaviour strategy document designed to aid staff when Ms F showed dysregulated behaviours.
41. From late April 2025 onwards, the records showed changes in Ms E’s behaviours. In particular that she reacted more to Ms F’s behaviours by shouting. And that Ms E went missing from, or tried to leave the property at night, including one incident which led the Care Provider to call the police.
42. The Care Provider recorded another four incidents in May and June 2025. Ms F became abusive towards and / or shouted at Ms E; or else became dysregulated about something else which led Ms E to become upset.
43. In September 2025 Ms F left the property.

My findings

44. I did not find any fault in the process followed by the Council when Ms F first entered the supported living accommodation. She knew Ms E before moving in and I saw no evidence of any signs of tension between them before the move took place. Further, Ms F visited the property several times before she moved in, and I accepted there was no indication from those visits of the incidents to follow.
45. I saw one reference in the case papers which suggested the Care Provider and Council might have predicted such incidents. This was the record which referred to Ms F having previous placement breakdowns. However, I found no evidence for this statement, which was incompatible with Ms F’s previous living arrangements. I concluded therefore the incidents that followed were not reasonably foreseeable.
46. I also did not find evidence suggesting disruptive behaviours by Ms F began immediately on moving into the property. The Council said it reviewed Ms F’s placement in the first two months and had no concerns. While the earliest records I saw of any disruptive behaviour dated from November 2023. I accepted Miss D’s recorded concerns in that month, did not necessarily reflect that this was the first time she had any concern about the impact of Ms F’s behaviour on her sister. But I lacked evidence to find either the Care Provider or Council should have acted before then, to consider Ms F’s behaviour and its impact.
47. I noted however that I had to work with records that appeared incomplete or inadequate. Above, I noted how the Care Provider recorded six incidents of disruptive behaviour by Ms F between November 2023 and August 2024. It noted Ms E present and upset by that behaviour on five occasions and her being the target of Ms F’s behaviour in four of those incidents.
48. But the evidence from multiple sources suggested this was not a full picture of the behaviours Ms F displayed between these dates. First, I took account of Miss D’s contacts and complaint. In these she explained how Ms E contacted her often over time, worried and upset by Ms F's behaviours. The frequency of those contacts suggested Ms F’s behaviour went beyond isolated incidents.
49. Second, I noted the report of the day centre, which said it witnessed multiple episodes of conflict between Ms E and Ms F. I thought it unlikely this pattern did not repeat itself when they were away from the day centre at home.
50. Third, the Care Provider’s own statements alluded to there being more incidents than it recorded. For example, in March 2024 it said both residents had reportedly asked to move more than once, suggesting more regular conflict. The note made by the Council’s social worker in May 2024 also suggested Ms F’s disruptive behaviour was more frequent than the notes of sporadic incidents suggested.
51. This led me to conclude the Provider had not kept satisfactory records of all incidents of disruptive behaviour by Ms F, impacting on Ms E. This was a fault. It also suggested a possible failure by the Care Provider to meet the relevant fundamental standard (Regulation 17). Without full disclosure of incidents, this also called into question if the Care Provider could meet the duty of candour (Regulation 20).
52. I considered an under-recording of incidents could have contributed to a failure by the Care Provider and the Council to act sooner to address Ms F’s disruptive behaviour. I noted that in reply to Miss D’s complaint, the Council said both Ms E and Ms F began conflict. But I saw no evidence for this during the time under investigation. I only saw reference to Ms E shouting at Ms F in incidents that happened from January 2025 onward, and mostly then in reaction to behaviours by Ms F. Before then, all records of specific incidents attributed any shouting or aggression just to Ms F. So, I considered the onus was on the Council and Care Provider to consider what it needed do to address Ms F’s behaviour with her.
53. It should have begun to do that as soon as a pattern emerged that Ms F’s disruptive behaviour was not an occasional one-off. Given the shortage of incident reports, pinpointing when this was with certainty was impossible. But I considered on balance that by early 2024 Ms F’s behaviour caused regular distress to Ms E. So, while the Council did attempt some intervention from April 2024, this was around three months later it should have done. That delay was a fault.
54. Turning to the details of that intervention the Council pointed to the change in Ms F and Ms E’s pattern of attendance at the day centre. It increased Ms F’s support hours and referred her for some specialist support. I recognised all of these were genuine efforts to help reduce tension in the house. But I found the Council and Care Provider did not address in any systematic way how effective these measures were, by reviewing regularly their impact.
55. So, while the Council went on to record in August 2024 that relations between Ms E and Ms F had settled, it cited no evidence for this statement. And the subsequent incident reported by the Care Provider, followed by Miss D’s contact with both it and the Council provided a different perspective. These suggested any improvement was negligible or only temporary.
56. Therefore, while I could not say the measures tried by the Council were inappropriate, they clearly did not change the overall picture. Ms F’s behaviour continued to be disruptive and the failure to keep that under review resulted in me making another finding of fault.
57. Not having measures in place to safeguard Ms E from Ms F’s behaviours and / or not reviewing the effectiveness of those measures also led me to question if the Care Provider met the relevant fundamental standards (Regulations 12 and 13). It also suggested the Council did not think about the distress caused to Ms E in a strategic way. I questioned why it did not open a further safeguarding investigation following the repeated reports of Ms F’s behaviour during 2024. Had it asked itself if Ms E was a victim of abuse, then this might have led it take a more thorough and comprehensive approach to the reports it received.
58. Both the Council and the Care Provider also had an opportunity to try and intervene effectively with Ms F after Miss D complained in September 2024. But they did not do so and instead became defensive in response to her understandable concern for her sister.
59. I found both sought to underplay the incidents in three ways. First, by implying any disruptive behaviour would soon pass. By September 2024, Ms F had lived in the property for 17 months, yet the Provider told Miss D she was still “settling in”. I could see no evidence in the case papers for any optimism Ms F’s behaviours would change. Especially given the evidence pointed to Ms F settling into the property well at first and the disruption only beginning later.
60. Second, by suggesting the behaviour was neither that serious nor significant. The Council noted Ms F’s disruptive behaviour did not involve acts of physical violence towards Ms E. But I considered this did not take account of the potential impact of other forms of aggressive behaviour Ms F engaged in, which included threats, verbal abuse and actions such as slamming doors. And while I also found it correct that Ms F did not direct all her aggressive behaviour at Ms E, this did not make it less distressing for her. And nor would Ms E be unique in this. It would be distressing for anyone to share a property with someone displaying the behaviours Ms F had when she became dysregulated.
61. Third, by suggesting the behaviour disproportionately affected Ms E because of her perceived sensitivity. I failed to see how this could lessen the need to take decisive action to address Ms F’s behaviour. Raising this implied Ms E had some responsibility for her own distress, as she became ‘fixated’ on Ms F’s disruptive behaviours. If both Council and Care Provider knew Ms E to be sensitive, or to become easily upset because of her needs (as indicated also in her care plan), that was more reason, not less, to intervene.
62. I considered both the Council and Care Provider failed to consider the complaint through the lens of the impact the disruptive behaviour had on Ms E. I considered this failing, rooted in the mistaken approaches set out above, meant they also replied to Miss D’s complaint with fault. It meant the Council did not take a holistic view of the incidents which had occurred at the property since at least November 2023, and the ineffectiveness of efforts made to address those.
63. I also noted that at no point during the events covered by this complaint, did the Council step back to consider the nature of the licence agreement that it had with Ms F. As I noted in the facts, Ms F often behaved aggressively towards Ms E. She caused nuisance and annoyance to her. The licence agreement, which I assume Ms F had capacity to understand when she signed it, sought to prevent such behaviour.
64. I could see why, in response to single or sporadic incidents, the Council would not want to take the step of ending a licence with a vulnerable adult. But there were many incidents here and they went on for months. And I reiterate the behaviour reported would cause anyone distress, not just Ms E who is herself vulnerable.
65. In those circumstances I could not understand why there was not discussion about ending Ms F’s licence to occupy the property between social care and housing staff. In its comments on the draft version of this decision statement, the Care Provider said it too would have welcomed such discussion but had no contact in the Council’s housing service.
66. It was a relevant for the Council to consider this option when deciding how it might help resolve the distress caused to Ms E by Ms F’s actions. Its failure to take account of this relevant consideration, led me to make another finding of fault.
67. I considered next the consequences the faults identified above.
68. I found Ms E suffered prolonged distress from Ms F’s actions. Neither the Council nor Care Provider were responsible directly for that behaviour. But both failed to act sooner to address it, failed to review the effectiveness of measures belatedly taken to do so and failed to consider further action including ending Ms F’s licence agreement. But for these failures I considered on balance the distress Ms E experienced from Ms F’s behaviour would have been less, either in its frequency, severity, duration or all three. The faults caused injustice to Ms E, therefore.
69. I also found Miss D experienced unnecessary distress. Her sister turned to her for support and her efforts to provide that support met a barrier beyond her control, that of Council and Care Provider failing to take her contacts seriously enough. And failing to take the actions set out above they should have taken. So, the faults caused injustice to Miss D also.

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Agreed Action

70. I welcomed that in response to my draft decision, the Council accepted the findings set out above. It agreed that to remedy Miss D and Ms E’s injustice, that it would, within 20 working days of this decision statement:
1. apologise separately to Miss D and Ms E accepting the findings of this investigation. Its apology to Ms E would take account of her needs and so in a format she could understand. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council agreed to consider this guidance in making the apologies agreed;
2. make a symbolic payment to Ms E of £1000. This is double the higher end distress payment recommended in the Ombudsman’s guidance on remedies. However, the guidance explains the recommended amount can be higher where someone has experienced significant and prolonged distress, as Ms E did;
3. make a symbolic payment to Miss D of £500;
71. The Council also agreed to try and learn wider lessons from this complaint. Within two months of a decision on this complaint it agreed to review how it can strengthen its response in circumstances where one of its users of care services, experiences distress as a result of the actions of another. It agreed that review would consider making recommendations for improving its policy, procedures or the awareness of relevant employees. The review would cover, but need not be limited to:
1. considering if the Council used its powers to safeguard adults from abuse sufficiently in such cases;
2. whether it sufficiently considered such cases through the perspective of the victim of any disruptive or aggressive behaviour;
3. whether it could do more to encourage social workers to draw up actions plans to tackle problem behaviour and monitor their effectiveness;
4. considering where applicable, if it should use its power to end licence agreements in cases where a user of services in supported living accommodation it provides, breaches a ‘good behaviour’ clause in its licence.
72. The Council agreed it would provide us with evidence when it had complied with the above actions.

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Final Decision

73. For reasons set out above I upheld this complaint finding fault by the Council caused injustice to Miss D and Ms E. The Council accepted these findings and agreed action to remedy their injustice and try to prevent a repeat of the fault. Consequently, I completed my investigation satisfied with its response.

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Investigator's decision on behalf of the Ombudsman