Summary: Mrs X complained the Council delayed in carrying out transition planning for Miss Y and failed to carry out adequate Care Act assessments. Mrs X also complained the Council delayed in providing a support plan for Miss Y’s which meant she was left without adequate care and support. We found the Council’s failings and delays in the transition process and in completing appropriate assessments and support plans are fault. These faults left Miss Y without appropriate care and support and caused significant uncertainty, distress and upset for Miss Y and her family. The Council will apologise and make payments to Mrs X and Miss Y and review its processes.

The complaint

1. Mrs X complained the Council delayed in carrying out transition planning for Miss Y and failed to carry out adequate Care Act assessments for Miss Y as part of the transition planning. The Council also delayed in providing a support plan for Miss Y’s which meant she was left without adequate care and support.
2. Mrs X also complains the Council failed to carry out a carer’s assessment which left Mrs X caring for Miss Y without support.
3. In addition, Mrs X complains the Council failed to respond appropriately to her safeguarding concerns about Miss Y, which again left her without support.

Back to top

The Ombudsman’s role and powers

4. 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)
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(1), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

7. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
8. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Relevant law and guidance

9. When a child reaches 18 years of age, they are legally an adult and responsibility for meeting their needs moves from the council’s children services to its adult services. The legal basis for assessing their needs changes from the Children Act 1989 to the Care Act 2014.
10. A transition assessment must give an indication of what care and support needs they are likely to be eligible for support once the child turns 18. If the council is going to meet needs under the Care Act after someone turns 18, it must create a care and support plan and produce a personal budget. This needs to be done early enough that the package of care and support is in place at the time of transition.
11. If transition assessment and planning is carried out as it should be there should be no gaps in the provision of care and support. However, if adult care and support is not in place when the young person turns 18, the council must continue providing the services under children’s legislation until it is in place or until it decides the young person does not have “eligible needs”.
12. The Council’s Independent Futures Team (IFT) supports young people to prepare for adulthood. This team is responsible for assessing eligibility and providing support plans for those with eligible needs. It will also provide advice and information to those who do not meet eligibility.

What happened here

13. This chronology gives an overview of key events in this case and does not detail everything that happened
14. Miss Y has complex mental health needs and was accommodated as a Looked After Child by the Council under s20 of the Children Act 1989 as Mr and Mrs X felt unable to keep her safe at home. Miss Y has an Education Health and Care (EHC) Plan and was also subject to a Child Protection Plan.
15. Children’s services referred Miss Y to the Council’s IFT in December 2023. The IFT allocated Miss Y a transition social worker, Officer 1 to complete a care needs assessment and ensure the smooth transition from Children’s services to Adult services.
16. Miss X was at that stage living in a residential placement in another part of the country. The placement gave notice and Miss X returned home while the Council looked for a new placement. While Miss X was at home she received support from an NHS intensive home treatment service and had a package of care to give her parents a break. Miss X then moved to another residential placement in April 2024.
17. Officer 1 visited Miss X at the placement in May 2024 and completed an assessment. The officer determined Miss Y did not have eligible care and support needs. They noted Miss Y had a care leaver Personal Advisor (PA) to support her post 18 who could help her look for alternative accommodation.
18. Mrs Y made a formal complaint disputing this decision. She said the assessment failed to address or acknowledge Miss Y’s vulnerabilities and the safeguarding issues associated with her significant mental health issues. Mrs X asserted the nature of Miss Y’s health, care and support needs combined with the current elevated level of support she received was evidence of a high level of care and support need.
19. In July 2024 the Council offered a re-assessment of Miss Y’s needs with another social worker, Officer 2. It said Officer 2 would endeavour to complete the assessment within four weeks to prevent any further delay in Miss Y’s support planning for adulthood.
20. Officer 2 visited Miss Y at the placement in August 2024 but had not completed the assessment when Miss Y’s accommodation placement ended in early September 2024. Mrs X was concerned about the delay in completing the assessment and asked for an update and for her complaint to be escalated.
21. Miss Y had returned to live with her parents on a temporary basis as the Council could not find an alternative placement. Mrs X was concerned Miss Y would be 18 the following month and Children’s services would close her case. Miss Y had no placement as no provider could meet her care and support needs and no access to education due to her care and support needs. She had also recently been admitted to hospital following of self-harming behaviour. Mrs X again questioned how the initial care assessment deemed Miss Y had no care and support needs when there was significant evidence to the contrary.
22. The Council sent Miss Y and Mrs X a copy of the care assessment on 24 September 2024. The assessment deemed Miss Y had care and support needs and was eligible for support from Adults’ Health and Care services.
23. Officer 2 subsequently confirmed they were looking for a suitable placement for Miss Y and had contacted a couple of providers.
24. Miss Y was 18 in October 2024. The following week the IFT informed Mrs X they were passing Miss Y’s case to the Adult services mental health team. They also confirmed that while the providers they had approached were not able to support Miss Y at home a supported living provider had agreed to assess Miss Y.
25. Mrs X questioned this as she had been told that the supported living provider had informed the Council the previous week that they were unable to assess Miss Y as there were no assessors available and there was a lengthy waiting list.
26. Officer 2’s closure summary notes there is no current support plan in place for Miss Y and that she would benefit from support Mondays and Fridays when she is not at college, for two to three hours. It also notes Miss Y’s parents support her at the weekend. The NHS intensive home treatment service were supporting Miss Y daily, but this would stop when Miss Y was 18 years and 2 weeks.
27. In late October 2024 Mrs X contacted her MP for assistance. She was concerned that Miss Y did not have a placement and that the Council was not actively searching for one. Miss Y was a Looked After Child, under a Child Protection Plan, with eligible care and support needs but had no support in place for her transition to adulthood. Mrs X felt isolated, disillusioned and failed by the system. The MP contacted the Council on Mrs X’s behalf.
28. Miss Y’s case was allocated to Officer 3, who arranged to meet with Miss Y in early November 2024. Officer 3 met with Mrs X instead as the evening prior to this visit Miss Y was admitted to hospital following incidents of self-harm. Officer 2 then met with Miss Y on 15 November 2024 in a joint visit with Miss Y’s Mental Health Nurse. They arranged to meet with Miss Y again the following week to complete a needs assessment.
29. The Council’s records say that at the next meeting Officer 3 told Miss Y that from the information they had gathered so far she may not meet the criteria for care and support or a referral to a support service. Following this meeting Miss Y was distressed and emotional and was admitted to hospital having self-harmed.
30. Mrs X raised concerns about the Council’s approach to Miss X’s needs and the impact of this on her. Mrs X says Miss Y’s version of her meeting with Officer 3 is different and questions the accuracy of the case recording. She say Miss Y was told in a direct, unprofessional way that she would not be offered a placement.
31. An officer met with Mr and Mrs X in early December 2024 to discuss the situation and the complaint submitted by Mrs X’s MP. When discussing a placement for Miss Y the officer noted this was not what Miss Y wanted, and suggested she remain at home with a support package. This could assist her to work on independence skills in preparation for a move on at some point from the family home. The support could also provide respite for the family.
32. The records of a Care Programme Approach (CPA) meeting a couple of days later acknowledged Miss Y was at risk of accidental death. The plan of action confirms the Council would:
• complete Miss Y’s care needs assessment;
• offer Mr and Mrs X carers assessments;
• source a domiciliary care package for Miss Y;
• complete risk assessments and refer Miss Y to the High Risk Dynamic Panel and the Risk Evaluation Panel.
33. The Council also made a referral for a support worker to support Miss Y with developing independence skills, for a three month period. The support worker began meeting with Miss Y once a week in mid- December 2024.
34. Officer 3 met with Mrs X to obtain her views as part of Miss Y’s care assessment. The records note Mrs X was devasted that Miss Y would not move to a supported living placement. She said Children’s services had promised this and the transition team had started looking for supported accommodation. Miss Y required a lot of support from her parents. The records also confirm a carers assessment would be completed.
35. Mrs X again questions the accuracy of the Council’s record keeping. She disputes presenting as devastated or saying that children’s services had promised a placement. Mrs X says that during the meeting she questioned why the Council was dismissing recommendations by children’s services and Miss Y’s psychiatrist that Miss Y would require a placement,
36. The Council completed Miss Y’s care needs assessment and sent this to Miss Y on 24 January 2025. The Council also allocated Miss Y a new social worker, Officer 4.
37. In February 2025 Mrs X raised a further complaint about failings in Miss Y’s transition into Adult Health and Care services. She reiterated her concerns about delays and errors by the IFT in completing care assessments which had left no time for purposeful planning before Miss Y’s 18th birthday. And meant there was no suitable placement for Miss Y to transition to.
38. Mrs X also complained that while the Council had now completed another care assessment for Miss Y, it has not completed carer assessments for Mr or Mrs X. She was also unaware of any proposed support plan for Miss Y. Mrs X said they were now at breaking point with carer stress and fatigue as they struggle to keep Miss Y safe. She noted the support worker’s involvement was due to end shortly and the support package agreed at the CPA meeting has not been put in place. Mrs X was disappointed Adult Health and Care services had dismissed the option of finding a suitable placement in specialised supported living accommodation. Particularly when this was contrary to the professional opinion of Miss Y’s psychiatrist and other professionals involved in her care.
39. The Council responded to Mrs X’s complaint in March 2025. It noted the initial assessment found Miss Y was not eligible for care and support under the Care Act. The second assessment reviewed the finding and collated additional evidence to support a different outcome. The Council said it used a strength based approach and worked in the least restrictive manner, with a focus on prioritising community based living over residential care. It said the IFT had little time to identify a new care provider to support Miss Y at home and despite their efforts were unsuccessful.
40. It apologised that a carer’s assessment had not been completed and noted a social worker had now contacted Mrs X to arrange this assessment. The Council also apologised Miss Y had not received a support plan. It said Officer 4 would contact Miss Y to complete the support plan and as part of this would discuss the role of the support worker.
41. Officer 4 and the support worker visited Miss Y together and discussed her goals and wishes moving forward. The notes record Miss Y wanted to move on from the family home and discussed shared and supported living. Officer 4 advised the next step was to speak with Mrs X and the professionals involved in Miss Y’s care as part of the support planning process.
42. In late March 2025 Mrs X contacted Officer 4 advising they were in the midst of a crisis due to Miss Y’s self-harming behaviour over the past 10 weeks. Mr and Mrs X were exhausted and overwhelmed and could not keep Miss Y safe. On 2 April 2025 Mrs X asked Officer 4 to arrange a package of care for twice weekly support. Officer 4 agreed to request funding for four hours weekly support.
43. In mid- April 2024 Miss Y was admitted to hospital and detained under the Mental Health Act.
44. Mrs X asked the Ombudsman to investigate her concerns about the failures and missed opportunities regarding Miss Y’s care. Miss Y was at risk of death and the family at crisis point but there was still no completed support plan, no package of care, no placement sourcing, no carers assessment and no risk escalation had been undertaken.
45. Mrs X asserts that had the IFT completed assessments in a timely manner a suitable placement might have been found that would have met Miss Y’s care and support needs and managed her complex mental health.
46. In response to our enquires the Council says Children’s services made a timely referral to the IFT when Miss Y was 17 years and 2 months old. The case was immediately allocated to Officer 1.
47. The Council says it is not necessarily uncommon for two social workers to hold differing views regarding a young person’s eligibility of need. It says establishing a strong rapport with young people can also be particularly difficult when they are placed far from home. As Mrs X contested the eligibility decision the Council says reallocating Miss Y’s case to another social worker within the IFT was an appropriate and justified course of action.
48. The Council is satisfied that overall the activity during Miss Y’s transition was suitable and aligned with expected practice. However it notes that several factors, including multiple relocations and hospital admissions contributed to a challenging period for Miss Y, her family and the professionals involved in her care.
49. It notes that when Miss Y turned 18 she was living at home. The Council says that although several supported living providers expressed interest in offering her a placement, none of these opportunities came to fruition.
50. At 18, Miss Y was allocated a new social worker from the adult mental health team, and a warm handover was completed by the IFT social worker. The Council says this handover highlighted the ongoing need to explore suitable support and accommodation options for Miss Y in her transition to adulthood.
51. Although a carers assessment was not completed by the IFT, the Council says Miss Y’s family were supported and kept informed throughout.
52. Mrs X disputes that the family was supported by IFT. She says officers only attended a handful of weekly meetings over the 10 month period IFT were involved. The family had no idea if a placement would be sourced, a package of care approved, how the transition would occur or when Miss Y would be allocated a new social worker.
53. Since Mrs X’s complaint to the Ombudsman matters have progressed.
54. Miss Y now has a support plan and when she was discharged from hospital in May 2025 the Council arranged a care package of 14 hours per week. Miss Y also continued to meet with the support worker once a week.
55. A social worker began a carers assessment in late April 2025 which was completed in September 2025. The Council has also completed risk assessments and held safeguarding meetings.

Analysis

56. The legislation and statutory guidance make it clear that transition planning and assessments must take place early enough to ensure that an adult care package is in place for when the young person turns 18.
57. In this case, although Miss Y was referred to the IFT in December 2023, the Council did not complete an assessment identifying Miss Y’s eligible needs until September 2024, one month before Miss Y’s 18th birthday. This did not allow sufficient time, especially given Miss Y's complex mental health needs, to ensure the smooth transition of provision to adult care services. This is fault.
58. There was no support plan in place for Miss Y when she transitioned to Adult Health and Care services. Although the IFT considered Miss Y would benefit from support for two to three hours twice a week when she is not at college, this was not arranged. Nor was there any ongoing attempts to identify a supported living provider.
59. It is unclear what regard the Adult Health and Care service had to IFT’s assessments or the views of professionals involved in Miss Y’s care whilst a child. It is similarly unclear what purpose the transition assessment and planning serves when rather than develop a support plan based on the care assessment completed only a month earlier, Adult services repeated the assessment. This extended the period Miss Y was without support rather than ensured a smooth transition.
60. The Council agreed in December 2024 to complete Miss Y’s care needs assessment and carry out carers assessments for Mr and Mrs X. It also agreed to source a domiciliary care package for Miss Y and complete risk assessments. However, at the time of Mrs X complaint to us in late April 2025 only Miss Y’s care assessment had been completed. The other actions remained outstanding and Miss Y still did not have a support plan. These delays in ensuring Miss Y and her family received appropriate care and support are fault
61. The Council has since completed a support plan and implemented a package of care. It has also completed risk assessments and a carer’s assessment for Mrs X. This is to be welcomed but should have happened much sooner.
62. Having identified fault I must consider whether this has caused Miss Y and her family a significant injustice. The documentation provided shows Miss Y’s self-harming behaviours were escalating and Mr and Mrs X were struggling to meet Miss Y’s mental health needs.
63. We cannot say that but for the Council’s failings and delay Miss Y would not have experienced difficulties or had as many hospital admissions due to self-harming behaviours. But it is likely, on the balance of probabilities that with an appropriate support plan in place sooner Miss Y could have been supported to manage situations differently.
64. An appropriate support plan also affords Mr and Mrs X some respite from their caring responsibilities. Had this been in place sooner it could have alleviated or prevented their exhaustion or carer burn out.
65. In addition to the uncertainty around what the outcome would have been if the Council had dealt Miss Y’s transition in a smooth and timely manner, the Council’s fault has also caused Mrs X and Miss Y significant distress and upset. The lack of support has had a significant impact on the wider family.

Back to top

Action

66. The Council has agreed to:
• Apologise to Miss Y and Mrs X for the significant uncertainty, distress and upset caused by the faults identified. 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.
• Pay Miss Y £1000 to recognise the injustice caused by the failings in the transition process and lack of support;
• Pay Mrs X £800 to recognise the distress, upset and uncertainty caused to her and the wider family;
• Review its procedures for transition planning for young people approaching 18. The review should focus on how staff will ensure assessments take place early enough so there are no gaps in provision, and an adult care package is in place for when the young person turns 18.
67. 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.

Back to top

Decision

68. I find fault causing injustice. The Council has agreed actions to remedy injustice.

Back to top

Investigator's decision on behalf of the Ombudsman