Summary: Miss X complained the care home failed to properly communicate with her about Mr X’s care and failed to meet her agreed reasonable adjustments. The Council was at fault, causing distress and upset. The Council has agreed to apologise to Miss X, make a payment to recognise the injustice and agree new reasonable adjustments.

The complaint

1. Miss X complains the care home failed to understand and accommodate for reasonable adjustments she requires to the way it communicates with her about the care of her father, Mr X. Miss X says this caused her anxiety and means she feels excluded from Mr X’s care.
2. Specifically, Miss X says the care home failed to inform her Mr X was receiving hospital treatment for nine months and was only alerted to this on receipt of a text message from the hospital.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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)

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What I have and have not investigated

7. I have investigated Miss X’s complaint as set out above between January 2025 and December 2025. Any mention below to events that took place before January 2025 or after December 2025 are for reference only.

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How I considered this complaint

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

Relevant law and policy

10. The Equality Act 2010 provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. It offers protection, in employment, education, the provision of goods and services, housing, transport and the carrying out of public functions.
11. The Equality Act makes it unlawful for organisations carrying out public functions to discriminate on any of the nine protected characteristics listed in the Equality Act 2010. They must also have regard to the general duties aimed at eliminating discrimination under the Public Sector Equality Duty.
12. The ‘protected characteristics’ referred to in the Act are:
• age;
• disability;
• gender reassignment;
• marriage and civil partnership;
• pregnancy and maternity;
• race;
• religion or belief;
• sex; and
• sexual orientation.
13. We cannot decide if an organisation has breached the Equality Act as this can only be done by the courts. But we can make decisions about whether or not an organisation has properly taken account of an individual’s rights in its treatment of them.
14. Organisations will often be able to show they have properly taken account of the Equality Act if they have considered the impact their decisions will have on the individuals affected and these decisions can be challenged, reviewed or appealed.
15. Direct discrimination occurs when a person treats another less favourably than they treat or would treat others because of a protected characteristic.
16. Direct discrimination is generally unlawful. However, it may be lawful in the following circumstances.
17. In relation to the protected characteristic of disability, where a disabled person is treated more favourably than a non-disabled person.
18. Where the Act provides an express exception which permits directly discriminatory treatment that would otherwise be unlawful (for example, a faith-school admissions policy may lawfully discriminate on grounds of applicants’ faith).
19. Indirect discrimination may occur when a service provider applies an apparently neutral provision, criterion or practice which puts persons sharing a protected characteristic at a particular disadvantage.
20. The reasonable adjustment duty is set out in the Equality Act 2010 and applies to any body which carries out a public function. It aims to make sure that a disabled person can use a service as close as it is reasonably possible to get to the standard usually offered to non-disabled people.
21. Service providers are under a positive and proactive duty to take steps to remove or prevent obstacles to accessing their service. If the adjustments are reasonable, they must make them.
22. The duty is ‘anticipatory’. This means service providers cannot wait until a disabled person wants to use their services, but must think in advance about what disabled people with a range of impairments might reasonably need.
23. The Public Sector Equality Duty requires all local authorities (and bodies acting on their behalf) to have due regard to the need to:
• eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Equality Act 2010;
• advance equality of opportunity between people who share a protected characteristic and those who do not; and
• foster good relations between people who share a protected characteristic and those who do not.
24. The broad purpose of the Public Sector Equality Duty is to consider equality and good relations into the day-to-day business and decision making of public authorities. It requires equality considerations to be reflected into the design of policies and the delivery of services, including internal policies, and for these issues to be kept under review.

What happened

25. I have summarised below some key events leading to Miss X’s complaint. While I have considered everything submitted, this is not intended to be a detailed account of what took place.
26. Mr X requires 24/7 care and is resident at the care home which is arranged and funded by the Council.
27. In February 2023 Miss X complained to the care home about poor communication and interruptions during her visits to Mr X. Responding to this, the care home agreed to implement reasonable adjustments for Miss X which included ensuring visits were uninterrupted, agreeing not to contact her by phone unless in an emergency, and confirming written communication was the preferred and primary method of contact.
28. Miss X then brought her complaint to the Ombudsman. We found the care home at fault for poor communication and for failing to only communicate with Miss X in writing unless it is an emergency. The care home agreed to apologise to Miss X, make a payment to recognise the injustice, and consider what improvements it could make to how it recorded her reasonable adjustment requests to ensure all relevant staff were aware of this.
29. In February 2025, Miss X wrote to the new interim manager of the care home. Miss X introduced herself and explained she has high-functioning autism which meant she required reasonable adjustments. Miss X explained these included only being contacted by phone in an emergency and that she is able to visit Mr X uninterrupted. Miss X explained staff at the home were beginning to not uphold the uninterrupted visits again recently. Miss X said when this happens, she does not feel able to stay and it cuts visits short.
30. The care home treated Miss X’s communication as a complaint and responded in April 2025. The care home explained that a number of staff changes meant some of the previous protocols and agreements may not have been communicated to the incoming team, but it was working to ensure these were reinstated as quickly as possible. The care home encouraged Miss X to speak to the new manager when she felt comfortable to do so, so they could ensure all key areas of support were covered and there was a clear channel of communication for her to raise any future concerns. The care home apologised for the recent incidents where visits were interrupted and said it had addressed this with the relevant members of staff.
31. On 21 October Miss X emailed the care home to explain she had received a text message from the facture clinic to confirm an appointment for Mr X that she had not been informed of.
32. The following day, after finding out this related to treatment that had been ongoing since January 2025, Miss X raised a safeguarding concern with adult social care. Miss X also emailed the care home again to complain that she was not told of important information relating to Mr X’s care.
33. The care home responded to Miss X’s complaint in November 2025. It acknowledged it had failed to communicate with her about Mr X’s appointment and apologised for this and the distress it would have caused. The care home explained this was a procedural oversight rather than an intentional attempt to exclude Miss X. The care home said the absence of a robust communication protocol led to this issue and said to prevent a recurrence it had:
• Reinforced internal communication procedures to ensure families are promptly informed of all hospital appointments;
• Shared her email address with the nursing staff to direct communication regarding clinical matters;
• Agreed for the home manager to review staff training on family engagement protocols;
• Agreed the manager and clinical lead would oversee appointment notifications to ensure timely updates via email;
• Introduced annual care review meetings to give families the opportunity to contribute to care planning and stay informed about clinical matters, with optional participation.
34. Miss X asked the care home to reconsider her complaint as she did not feel the actions described would resolve the issues. Miss X said she believed the care home had acted in Mr X’s best interests when it came to treatment, but his family should not have been excluded from being told what was happening. Miss X also said one recent visit had been interrupted.
35. The care home responded further to Miss X’s complaint in December 2025. The care home said it recognised the importance of clear communication and transparency throughout Mr X’s care. The care home said it was important to establish the best way forward to ensure Mr X’s best interests remained central to all decisions and so had requested a care review with the Council who fund his place. The care home also offered Miss X the opportunity to meet face to face should she wish to discuss matters directly.
36. In response to our enquiries, the care home has confirmed it is undertaking the following actions to prevent a recurrence of the issues Miss X experienced:
• The deputy manager and clinical lead have been assigned responsibility for overseeing notification of hospital appointments and significant updates, as well as ensuring Miss X is informed of appointments in advance, and monitoring that agreed communication arrangements are adhered to;
• Clear guidance has been provided to staff regarding what information should be escalated to senior staff for onward communication;
• It has recruited and appointed permanent staff to bring greater continuity, accountability, oversight and strengthen communication;
• It will review and reinforce staff guidance and training relating to family engagement and communication, implementing reasonable adjustments, handling difficult conversations, and communicating appropriately.
37. The care home has said it recognises the importance of making reasonable adjustments to remove or prevent obstacles to Miss X accessing its service. However, it has said it needs to balance this against the need to ensure Mr X’s safety and wellbeing. This being the case the care home said there may be occasions when Miss X’s visits are interrupted unintentionally by staff or routine activity within the home.

Analysis

38. Across the timeline I have investigated there have been communication failings with the care home. The care home has already accepted it was at fault for not informing Miss X about Mr X’s appointments and for inconsistencies with how it met the previously agreed reasonable adjustments. As the care home has already accepted fault here, there is no need for me to reinvestigate whether this occurred. The fault caused significant distress and upset for Miss X, compounded as this is now a repeated issue, which is injustice. The care home has already apologised for the injustice, but I find it ought to also make a symbolic payment to recognise this.
39. The care home has set out the action it has taken and will take to prevent a recurrence of the issues, and I find this to be a suitable remedy to ensure consistent communication going forward.
40. The care home has said its overriding duty to meet Mr X’s care needs means it may not always be able to meet Miss X’s requested reasonable adjustments. For example, the care home has said there may be times when it is unavoidable that Miss X’s visits are interrupted. It is not for us to say whether requested reasonable adjustments are suitable. The care home should only agree to make adjustments where it is reasonable to do so. If the delivery of a requested reasonable adjustment would likely interfere with the delivery of care, it would not be reasonable and should not be agreed. As the care home feels it cannot meet all the requested reasonable adjustments, I find it should review these with Miss X to ensure it is only agreeing to reasonable adjustments it believes to be suitable.

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Action

41. To remedy the injustice caused by the faults identified above, the Council should take the following actions with the care home:
42. Within one month of the date of this decision:
• Provide Miss X with a written apology for the injustice caused by the communication failures and the failure to meet her agreed reasonable adjustments. 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 I have recommended in my findings.
• Make a symbolic payment of £200 to recognise the distress and upset caused to Miss X by the communication failures and the failure to meet her agreed reasonable adjustments.
43. Within three months of the date of this decision:
• Review Miss X’s reasonable adjustments to ensure it is only agreeing to adjustments it considers suitable and reasonable, and do not interfere with the delivery of care. The care home should provide Miss X with its reasoning where it does not agree to requested reasonable adjustments.
44. The Council should provide us with evidence it has complied with the above actions.

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Decision

45. 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