Summary: Mrs Y complains on behalf of her daughter, Miss Z, about the Council’s failure to ensure a timely transition when the provider of Miss Z’s residential setting terminated her placement. Mrs Y also complains about the Council’s failure to communicate and consult with her at key times. In our provisional view, we find significant delay by the Council caused injustice to Mrs Y and Miss Z which the Council should remedy with payments of £600 and £300 respectively.

The complaint

1. Mrs Y complains the Council failed to inform her that her daughter, Miss Z, had been evicted from her care home until the notice was due to expire in January 2020. The Council failed to communicate properly with the family or safeguard her daughter who was attacked by other residents in her unsuitable placement.
2. Mrs Y complains the Council appointed an Independent Mental Capacity Advocate (IMCA) even though her daughter already had a lifelong advocate. Mrs Y also says the Council failed to support her daughter when moving belongings into her new placement.
3. Mrs Y would like to ensure that officers stay in touch with families, allocate social workers promptly and address safeguarding issues when raised.

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What I have investigated

4. I have investigated all the concerns detailed above, except for Mrs Y’s complaint about safeguarding. I have explained my reasons for not investigating this part of the complaint at the end of this statement.

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The Ombudsman’s role and powers

5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
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)

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How I considered this complaint

7. I tried calling Mrs Y to discuss her complaint and then corresponded with her by email. I considered the information she submitted, including complaint correspondence.
8. I made enquiries of the Council and considered its response alongside the requirements of the Care Act 2014.
9. Mrs Y and the Council now have an opportunity to comment on my draft decision. I will consider their comments before making a final decision.

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What I found

10. Mrs Y represents a complaint on behalf of her adult daughter, Miss Z, who is non-verbal, has severe learning disabilities and lives in long-term residential care. In November 2019 the provider of Miss Z’s residential placement, which I will refer to as ‘accommodation one’, gave three months’ notice for Miss Z to leave. The usual notice period is 28 days.
11. Mrs Y says she was not informed of the notice served on Miss Z until January 2020. Her complaint concerns the Council’s handling of Miss Z’s transition and other general concerns about Miss Z’s time in accommodation one.

Termination of placement

12. The Council received a letter from accommodation one on 22 November 2019 outlining its intention to terminate Miss Z’s placement. The Council did not receive a formal eviction notice. The letter said the reason for terminating Miss Z’s placement was because of a breakdown in the relationship between Mrs Y and staff members at accommodation one, and a disagreement about funding.
13. The Council accepts that it did not tell Mrs Y about the letter. The Council assumed the accommodation one told Mrs Y directly as she was very involved and present in the care of Miss Z. The Council also acknowledges that Miss Z did not have an allocated social worker at the time. This likely added to the communication problems between the Council and Mrs Y. The Council allocated a social worker to Miss Z on 30 January 2020 and arranged a review of Miss Z’s support plan.
14. In the meantime, the records show the Council was trying to arrange funding for a new residential placement for Miss Z.
15. The review took place on 7 February 2020 along with Mrs Y and staff at accommodation one. At this point the provider acknowledged that it had not informed Mrs Y of its intention to end Miss Z’s placement.
16. In March 2020 accommodation one informed the Council that Miss Z would need to move by the end of the month. However, due to the COVID-19 pandemic and the resulting lockdown restrictions, it was not possible for the Council to progress with transitioning Miss Z to a new placement. Accommodation one agreed that Miss Z could remain there until the Council found a new placement.
17. The records show the Council’s legal services team wrote to accommodation one in July 2020 stating that Miss Z could not be evicted until the Council has undertaken the appropriate assessments. The Council said this was in part delayed by the pandemic and Miss Z’s requirement to ‘shield’ as an extremely clinically vulnerable person.
18. Mrs Y had identified a new placement, which I will call accommodation two. In September 2020 the IMCA noted that accommodation two had not received any confirmation of fees from the Council or a support plan for Miss Z. The records show that accommodation two had a room available, which it was decorating at the time.
19. A review of Miss Z’s support needs took place in November. This identified that Miss Z would benefit from being in a smaller, quieter setting such as accommodation two. This is echoed in the IMCA’s report of December 2020.
20. The Council requested funding for Miss Z’s placement at accommodation two. The records from December show that accommodation two had several residents ill with COVID-19.
21. The Council completed Miss Z’s updated support plan in March 2021 and received approval for funding in April 2021. Miss Z subsequently moved to accommodation two on 21 June 2021.
22. The Council accepts it is responsible for ‘unacceptable delay’ in supporting Miss Z to move to accommodation two. In my provisional view, this delay was due to several factors:
• The outbreak of COVID-19 and the requirement for Miss Z to shield. Outbreaks of COVID-19 within accommodation two also caused some delay.
• The initial delay in allocating a social worker to Miss Z in late 2019 and the subsequent high turnover of staff. The records show this social worker, who soon after left the employment of the Council, failed to begin important processes such as a mental capacity assessment and support planning.
• Difficulties in engaging Miss Z in reviews and assessments. These mostly took place virtually and it is understandable that Miss Z may have struggled to participate.
23. In my provisional view, and based on the information seen so far, the Council is at fault for not initially telling Mrs Y of the intention to terminate the placement. The Council is further at fault for the delays and drift in securing Miss Z’s new placement. Some of this was likely caused by the restrictions imposed by the COVID-19 lockdown, which the Council cannot be held accountable for. However, in my view most of the delay identified is due to Council fault. I consider this caused Mrs Y avoidable injustice in the form of distress, frustration and time and trouble
24. I have also considered the impact to Miss Z. I am mindful that she was permitted to remain in accommodation one until she moved to accommodation two in July 2021. There was no interruption in the provision of services to her. However, despite Miss Z's learning disabilities and lack of cognition, I consider it is likely she would have known that something was happening due to the assessments and meetings taking place over a prolonged period between November 2019 and July 2021. In my view, this likely caused Miss Z some avoidable anxiety.
25. The Council should remedy this injustice with the actions recommended at the end of this statement.

Independent advocacy

26. The ‘Care and Support Statutory Guidance’ says:

“If a person does have substantial difficulty, the local authority must find someone appropriate and independent to support and represent the person, for the purpose of facilitating their involvement. This should be done as early as possible in the assessment process so that the individual’s involvement can be supported throughout all stages of the process”

“Local authorities must arrange an independent advocate to facilitate the involvement of a person in their assessment, in the preparation of their care and support plan and in the review of their care plan, as well as in safeguarding enquiries and SARs if 2 conditions are met. That if an independent advocate were not provided then the person would have substantial difficulty in being fully involved in these processes and second, there is no appropriate individual available to support and represent the person’s wishes who is not paid or professionally engaged in providing care or treatment to the person or their carer”

27. In July 2020, and eight months after receiving notice of the terminated placement, the Council commissioned an IMCA for Miss Z. The purpose of the advocate was to ascertain Miss Z’s wishes and feelings and support any assessments about the change of placement.
28. The Council says it appointed a professional advocate because the relationship between Mrs Y and accommodation one had broken down. It was therefore anticipated there may be a difference in opinion about Miss Z’s support needs.
29. On 28 September 2020 Miss Z’s social worker advised Mrs Y about the appointment of an IMCA. The Council says the IMCA engaged with Mrs Y and included her views in the assessment.
30. The Council completed its assessment of Miss Z’s mental capacity on 17 May 2021. The Council acknowledges this took a long time to complete and cites various factors which contributed to the delay, such as difficulties in engaging with Miss Z and the departure of her allocated social worker. The latter also caused delays in approving and sharing the assessment report. The Council has already apologised for the delay here.
31. I have reviewed the IMCA’s report completed in December 2020. Records show the Council did not share the report with Mrs Y until August 2021 and after Miss Z’s move. The report contains the views of some key people in Miss Z’s care and support, but it does not include the views of Mrs Y or demonstrate that she was consulted as part of the assessment.
32. The Council is not at fault for appointing an IMCA. The guidance makes clear that a person lacking capacity must have the support of someone “appropriate and independent”. The Council did not consider that Mrs Y met that criteria because of the conflict between Mrs Y and accommodation one. The Council was entitled to come to this view; however I would expect it to have included the views of Mrs Y within the IMCA report as she is the person who knows Miss Z best. I also consider there was delay by the Council in commissioning an IMCA.
33. However, in my provisional view, the fault identified did not cause significant injustice to Mrs Y. Although I appreciate Mrs Y was frustrated by the lack of consultation with her, the IMCA shared Mrs Y’s views about the appropriateness of accommodation two. There is no conflict of opinion on this key issue. The delay in allocating an IMCA likely played a part in the wider delay in Miss Z’s transition, and this will be considered as part of my recommendations.

Reviewing Miss Z’s support needs

34. Mrs Y believes that Miss Z’s placement at accommodation one failed because the Council did not undertake annual reviews of her support needs, and therefore missed opportunities to identify and resolve problems.
35. I have considered the frequency of the Council’s reviews. The records show the Council reviewed Miss Z’s support plan every year from 2014, except for 2018. The Council accepts that it should review support plans on an annual basis, in line with the Care Act, but does not consider that the failure to complete a review in 2018 contributed to the breakdown of Miss Z’s placement.
36. In my provisional view, the decision to terminate Miss Z’s placement was not due to lack of reviews by the Council. Instead, the information shows the placement broke down due to differences between Mrs Y and some staff members, and a dispute with the Council about funding.

Supporting Miss Z to move

37. Mrs Y says she had continually asked the Council for help with organising the removal of Miss Z’s belongings. Mrs Y says the Council only confirmed six days before the move that it would not help. In response to our enquiries the Council explained it was not required to oversee arrangements due to both accommodation one and two being available and willing to help.
38. The Council acknowledges that there were “conversations throughout planning her transition (from December 2020) but not specifically in relation to moving her belongings”. The Council says its records show on 22 April 2021 that Mrs Y confirmed she would take Miss Z to her new placement. On 28 April 2021 the Council records a further case note to say Mrs Y had spoken with the accommodation providers to discuss which items of furniture would need to move with Miss Z. There is no record of who would take responsibility for the move.
39. The final case note which references Miss Z’s removals is on 15 June 2021; two days before Mrs Y planned to collect Miss Z. An email exchange between Mrs Y and the Council shows Mrs Y was frustrated with the lack of clarity and planning.
40. Based on the information seen so far, I propose to find fault with the Council for failing to have oversight of Miss Z’s move and for not documenting who was responsible for each aspect of the move. Although we cannot say the Council should have funded the removals, I would expect the Council to have oversight of the move and properly plan and document how it would take place. This did not happen. Furthermore, the Council did not make its position clear until 15 June 2021 which left Mrs Y with very short notice, during the COVID-19 pandemic, to oversee the removal of Miss Z’s remaining items.

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Recommended action

41. The Council confirms it has already undertaken the following remedial action:
• Apologised to Mrs Y for the delay identified and the failure to notify her in 2019 of the letter received from accommodation one.
• Secured additional funding since 2019 for the appointment of more social workers.
• Reviewed the duty social work system and implemented a set of standards, clarifying the roles and responsibilities of the duty team and their manager. The duty team now use a ‘risk screening’ tool for every incoming request. All urgent requests are reviewed by the duty manager within 24 hours. The team also have access to a ‘health team manager’ to help respond to requests in a timely manner.
• Monitor feedback from families via weekly carer surgeries and monthly carer forum meetings. Feedback from families has been positive.
42. I am satisfied the Council has already implemented a range of appropriate service improvements and I do not intend to recommend anything further in this respect. However, in addition to the apology already given, the Council should provide a personal remedy to Mrs Y and Miss Z within four weeks of my final decision:
• £600 payment to Mrs Y for the distress, frustration and time and trouble caused by the delays and a further £300 to Miss Z in recognition of the impact of the delay.

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Draft decision

43. Subject to further comments by Mrs Y and the Council, I intend to complete my investigation with a finding of fault causing injustice for the reasons explained in this statement. In my provisional view, the actions I have recommended are an appropriate remedy for the injustice experienced.
44. This is a draft decision which is subject to change.

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Parts of the complaint that I did not investigate

45. Mrs Y complains about how the Council responded to safeguarding concerns when Miss Z was attacked by other residents.
46. The Council says it is aware of several safeguarding concerns raised during Miss Z’s time at accommodation one. Any safeguarding concerns about incidents which happened in accommodation one were considered by another council area. This is because accommodation one is not situated within the borough of Haringey.
47. As this complaint is against the borough of Haringey Council, I have not considered any safeguarding investigations undertaken by different councils. Mrs Y should pursue those matters separately if she remains dissatisfied.

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Investigator's decision on behalf of the Ombudsman