Summary: The Council was at fault for not meeting Mr Y’s assessed care and support needs when it housed him in unsuitable accommodation. The Council was also at fault for its poor communication and complaint handling. It will apologise and make a symbolic payment to Mr Y to acknowledge the distress caused by his unmet care needs and the avoidable frustration and uncertainty he was caused by its faults. It will also take action to prevent the recurrence of the same faults.

The complaint

1. Mr X complained on behalf of Mr Y that the Council:
1. Provided and left Mr Y in unsuitable accommodation (Property A) for eight months,
2. Failed to appropriately respond to safeguarding concerns he raised about Mr Y in early June 2024,
3. Did not communicate with transparency – it told Mr Y that his stay in Property A was temporary while it recorded that it may be permanent, and
4. Poorly investigated and handled the complaint.
2. Mr X said as a result Mr Y’s physical health and wellbeing worsened and he was caused distress and frustration. Mr X also said the Council’s handling of his safeguarding concerns related to Mr Y caused him frustration.

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The Ombudsman’s role and powers

3. 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)
4. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
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)

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How I considered this complaint

6. I spoke to Mr X about the complaint.
7. I considered evidence provided by the Council as well as relevant law, policy and guidance.
8. Mr 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 guidance

The Care Act 2014

9. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.

Housing

10. Part 6 of the Housing Act 1996 governs housing allocations. Councils are required to allocate housing in line with the provisions in this part of the Act. Part 7 of the Housing Act 1996 and the Homelessness Code of Guidance for Local Authorities set out councils’ powers and duties to people who are homeless or threatened with homelessness.
11. Our Principles of Good Administrative Practice guidance sets out the transparency, accountability and good administrative practice we expect to see from councils.

Safeguarding

12. A council must make enquiries if it thinks a person may be experiencing or is at risk of neglect and has care and support needs (whether or not it is meeting any of those needs) which mean that the person cannot protect themselves against the neglect or the risk of it.
13. The purpose of the adult safeguarding enquiry is to enable the council to decide whether any action is required in the adult’s case to protect them, and if so, what and by whom. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement (section 42, Care Act 2014).

The Council’s complaint policy

14. The Council publishes information about its two-stage complaints process on its website:

• Local resolution (stage one) – The service being complained about is notified of the complaint so that they can investigate and resolve complaint internally.
• Final review (stage two) – Final reviews are independent of the service being complained about and complaints at this stage are investigated by the Council’s complaints team.

What happened

15. This section sets out the key events in this case and is not intended to be a detailed chronology.
16. Mr Y is an adult with health conditions and physical disabilities who uses a wheelchair.
17. In May 2023, Mr Y was in temporary accommodation provided by the Council under its homelessness duties. An occupational therapist (OT) reviewed Mr Y’s case. The OT report showed that Mr Y had a large wheelchair, and he required a “standard” wheelchair property. The OT review also outlined further details such as the turning circle diameter of the wheelchair and width of door openings required to be 860mm at least, but ideally 900mm
18. Mr Y left the country for three months. He returned in August 2023 and submitted a new homeless application. The Council refused to accept this application. It said as Mr Y had left his previous temporary accommodation, he had made himself intentionally homeless. There had been no change in his circumstances, so it had no duty to house him under part 7 of the Housing Act 1996. The Council had previously assessed him as having eligible care and support needs (under the Care Act 2014).
19. Mr Y’s case was referred to the Council’s adult social care (ASC) team in August 2023. The Council notes showed that the Housing team agreed to find accommodation for Mr Y for a few days so that ASC could assess him. It was also noted that ASC would fund the cost of Mr Y’s accommodation.
20. The Council housed Mr Y in accessible rooms in hotels while it looked for accommodation. The Council notes showed that ASC contacted the Housing team to help source a suitable wheelchair accessible accommodation as Mr Y had a wider than usual wheelchair therefore wider access points and turning circle was needed in any accommodation.
21. In August 2023 the Council completed a care needs assessment and offered Mr Y a package of care which he declined. An OT also visited Mr Y to assess his functional ability. The Council record of this visit showed that “with time and maximum effort” Mr Y could transfer independently from his bed to his wheelchair. It was also noted that Mr Y was not able to use the toilet due to being in pain.
22. In early September 2023 ASC requested further support from Housing to find suitable accommodation for Mr Y and asked whether there was any sheltered accommodation which it could use. It said Mr Y needed wheelchair accessible accommodation and had a wider than usual wheelchair, so he required wider access points and turning circle. ASC responded that Mr Y needed a standard wheelchair property with door opening of a minimum of 870mm.
23. The Council notes showed that an OT visited a sheltered accommodation (Property A) in mid-October. Records showed that the OT contacted ASC following their visit to Property A and said “there was a high chance it could meet needs” and that a visit with Mr Y would be helpful. The OT also highlighted potential issues in particular with the door widths of the main bedroom and bathroom (770mm and 780mm respectively). They also added that the fire advice would be to remain in the property to await evacuation. They sought ASC’s thoughts.
24. The Council notes of a meeting held soon after recorded that Mr Y used a 20-inch-wide wheelchair which was 500mm and the widest point across push rims was 685mm. It added that if the bedroom in Property A was too narrow for Mr Y to self-propel then it could set up a microenvironment in the main living room.
25. In late October 2023 the Council moved Mr Y to Property A. Mr Y said he signed a one-month tenancy agreement for this property. There were no Council records/notes of an OT visit to assess the suitability of Property A in the Council case notes. ASC covered the cost of this accommodation including the utility and council tax costs.
26. The Council told us Mr Y’s social worker and an OT were present with him on the day of his move to Property A. The Council notes stated that Mr Y was asked if Property A “was suitable and if he would consider it as his permanent home if it was available, as current arrangement was temporary”, to which Mr Y said that “if offered on a permanent basis, he will be happy to stay.” The Council notes showed that “it hoped the current accommodation (Property A) becomes long term”, however, it “cannot confirm this arrangement at this stage.”
27. A few days after Mr Y moved to Property A, he contacted the Council to say that the accommodation was not suitable for him. The Council notes stated that Mr Y said he was not able to turn around in the accommodation and could only access the kitchen by going in backwards. Further, he struggled to get through the narrow doors. It also noted that Mr Y said the fire department had attended and stated that Property A was not suitable for Mr Y to stay in to await rescue, in case of a fire due to the narrowness of the doors.
28. In response, the Council noted that it had “assessed the property as suitable” and “we may need to consider if another OT visit is needed to support (Mr Y) with transfers/access.” It said it would consider a package of care to support Mr Y. It also noted that Property A had been agreed for four weeks but the Council understood that there was scope to extend this. The Council record of the fire department visit showed that it told Mr Y that property A would be “sufficient as a temporary measure”.
29. In early November 2023 Mr Y’s social worker contacted him and offered a package of care which he refused. Mr Y said he had meals delivered to the flat and he declined support with personal care. Mr Y’s representative Mr X also wrote to the Council to outline access issues in Property A and its impact on Mr Y’s independence and dignity.
30. In November 2023 a specialist NHS OT assessed Mr Y. The OT updated the Council that Mr Y was “self-propelling around the flat independently but getting through doorways and turning was effortful and tight.” Mr X said he did not think carers would be of any benefit for him at that point, but it was noted that he would like some support for going out.
31. Mr Y contacted the Council over the next weeks to ask for an update on his accommodation and to share his difficulties in accessing his accommodation and the premises. The Council told him it was looking for housing options for him. Mr Y also shared that his new wheelchair was being made but it would not fit in property A. The Council offered care and support around personal care and domestic tasks, but Mr Y declined this. It also offered an OT visit to support with transfers, but Mr Y declined saying OTs had already visited and said the flat was not suitable.
32. In late November 2023 Mr X contacted the Council again to say that it had not responded to their previous concerns and to highlight suitability issues with Property A. They added that Mr Y’s personal care was also impacted due to access issues to the shower, and that Mr Y’s tenancy period, as previously agreed, had also ended. In response the Council said it was in regular contact with Mr Y and was working to resolve the issues.
33. In early December 2023 the Council records showed that Mr Y agreed to some support with personal care and other household chores. The records also showed that the Council arranged for a shower chair to help Mr Y access the shower independently.
34. In mid-December 2023, an OT and social worker visited Mr Y to review possible equipment and support for personal care. The Council notes showed that the OT observed that the shower chair could not fit through the doorway, therefore could not be used in Property A. It agreed to provide Mr Y with weekly support around personal care, cleaning, laundry and access to the community.
35. In early January 2024 Mr Y’s new wheelchair arrived. The Council notes showed that the new wheelchair could not be used until Mr Y moved to a suitable property. An officer spoke with Mr Y who said the care provider reported it could not provide personal care unless there were two carers.
36. Mr X also contacted the Council again and said that they had provided medical evidence from Mr Y’s consultant which stated that Mr Y needed to be in a suitable accommodation for him to access support for his needs to be met. They added that property A was impacting Mr Y’s health, wellbeing and independence. They also asked the Council to arrange a professionals meeting to discuss a plan going forward.
37. In late January 2024 the Council telephoned Mr Y to discuss care and accommodation. The Council’s records showed that:

• Mr Y was involved with the support plan arrangements, but it was recorded that he did not feel that the care agency was helpful when they started providing support; he added that the carers said they would not be able to take on certain tasks in the support plan. The Council sought to arrange a joint visit with the care agency which Mr Y declined.
• Mr Y was told that the Council’s private rented housing team was continuing to look for properties for him and that he would be updated in due course.

38. In February 2024 the Council social worker visited Mr Y:

• Mr Y said he was not able to attend to his personal care but could do this when he was away, in a hotel. The social worker offered support from carers which Mr Y declined. He added that he was a “young man and would like his privacy and independence and will not let carers attend to his personal care.”
• Mr Y said he preferred support by a personal assistant rather than carers especially around his social needs.
• Mr Y also said that he wanted to be housed in a suitable property; he had been looking for private accommodations and had sent these to the Council but had not received a response. The social worker said that these were being considered and that the search for suitable accommodation was ongoing.

39. In late February 2024 Mr X contacted the Council regarding their request for a professionals meeting. They reiterated that they had provided medical evidence that Mr Y’s housing situation needed to be resolved urgently.
40. In early March 2024 the Council spoke to Mr X and stated that the traditional homelessness pathway was not available to Mr Y because the Council’s Housing team had discharged its duty. The Council’s private rented scheme was the only pathway, but no properties were currently available. It also noted that Mr Y did not wish to have support from carers but would like to be considered for direct payments.
41. In late March 2024 the Council contacted Mr Y about a potential property that it was considering for him. It noted that Mr Y said he was aware of this property but it was not suitable because it had no wheelchair access and was too far away.
42. In early May 2024 Mr Y contacted the Council to say that neither him nor Mr X had received any update from the Council. Mr X also contacted the Council to request a professionals meeting for all parties to identify the barriers, plan a way forward and for Mr Y to convey the impact on his life and independence. They added that Mr Y had been looking for rental properties with no success.
43. In late May 2024 the Council’s ASC team contacted its Housing team to query if it was willing to overlook its decision to discharge its duty towards Mr Y “due to the length of time his housing issues are taking to be safely resolved.” In response, the Housing team said it had asked its private sector solutions team to assist ASC in finding a suitable offer of private rented accommodation for Mr Y. But this was challenging due to Mr Y’s very specific housing needs.
44. In late May 2024 the Council social worker visited Mr Y in Property A:

• They noted that Mr Y was not attending to his personal care because he was unable to access the bathroom; he was also unable to get up from bed due to pain.
• Mr Y agreed to receive a care package for support with personal care, domestic tasks, shopping, laundry, meal preparation and community access.

45. The Council notes from late May 2024 showed that the care agency carried out an assessment and informed the Council that:

• Property A was not suitable for Mr Y as identified in his support plan – the kitchen was too small for him to access with his wheelchair to prepare himself food.
• The toilet was too small to access with wheelchair; Mr Y said he was able to transfer from his wheelchair to a toilet in a suitable setting. Mr Y reported he could not accept personal care in bed as turning him in bed caused severe pain.
• It could only support with meal preparation, shopping and housework and laundry.
• It would not be able to provide support with Mr Y’s personal care, continence and toileting needs as Mr Y would need the support of two carers to do so and it had no capacity to provide doubled up care.

46. In early June 2024, following a joint meeting with different parties involved in Mr Y’s case, Mr X wrote to the Council to say that he now had safeguarding concerns regarding Mr Y’s living arrangements. He outlined that Mr Y, who was previously able to undertake personal care tasks independently, was now unable to. They said the initial fire risk assessment was out of date as it was conducted on the basis that Mr Y would only stay in property A for a couple of weeks. They also added that the Council had been aware of these concerns since Mr Y moved into property A yet failed to appropriately address them.
47. The Council wrote to Mr X and said that it would continue to liaise with Mr Y directly around the issues raised. In response, Mr X said that the Council’s response was unacceptable as Mr X had raised serious safeguarding concerns in their capacity as a professional about their client’s (Mr Y) health and wellbeing. Mr Y also replied to the Council and said that he had wanted Mr X to be kept involved throughout.
48. In mid-June 2024 the Council wrote to Mr Y and said that it had approved an extra care setting for him and that it would contact him as soon as a space became available. It sent Mr Y a draft support plan with details of his care package. It also said that Housing was looking for a suitable options via the private rental sector but it had been challenging. It added that direct payments could be arranged in the future once Mr Y had transitioned over following his move.
49. Mr Y asked the Council to put the care support on hold while he arranged a meeting that involved him, Mr X and the Council.
50. In late June 2024 Mr Y contacted the Council to say that the lift in his accommodation had broken. The lift was temporarily fixed but Mr Y reported that it broke again the next day. Mr Y told the Council he was concerned about being stuck inside his accommodation and being unable to leave in an emergency. It was the only way to leave the premises.
51. Issues with the lift continued over the next couple of days. It was reported that Mr Y fell from his wheelchair and had to be evacuated from Property A to be taken to seek medical help as the lift was still broken. Mr Y was hospitalised and did not return to Property A.
52. The Council provided a permanent accommodation to Mr Y in July 2024. It told us Mr Y manages his tenancy at this property independently. The Council also completed another needs assessment in August 2024 - the outcome of this was that Mr Y did not require formal care and support for his needs.
53. In July 2024 Mr X complained to the Council on behalf of Mr Y. They complained the Council:

• Provided and left Mr Y in unsuitable accommodation despite clear communication about his needs and circumstances.
• Did not address safeguarding concerns they raised. Instead it attempted to stop contact with them.
• Did not take action despite being aware of the ongoing issue with the lift.

54. In August 2024 the Council issued a stage one response which said it did not move Mr Y back to Property A after he was evacuated in end of June 2024. Mr Y had visited Property A prior to his move and the accessibility was assessed by an OT manager. It also added that it would continue to liaise with Mr X on matters going forward.
55. Mr X was unhappy with the Council’s stage one response and asked the Council to escalate the complaint.
56. In November 2024 the Council issued a stage two complaint response. It was signed by the same Council employee who had signed the stage one response:

• It apologised for its delayed complaint response.
• It said when Mr Y was placed in Property A, the Council considered it as a long term option but it became clear that this would not have met Mr Y’s needs long term. Mr Y was now settled and living independently in permanent accommodation
• The Council had not assessed Mr Y as needing an advocate as he was able to advocate for himself.
• The safeguarding concern raised when Mr Y was evacuated from Property A was not investigated further as Mr Y was moved to a hospital and did not return to Property A.
• Regarding Mr X’s complaint that the Council had not outlined how services would be improved for vulnerable adults like Mr Y, the Council felt that Mr Y’s case was a positive example of departments (ASC and Housing) working together while keeping Mr Y actively involved in conversations and decisions about him.
• Regarding compensation, the Council said Mr X’s accommodation costs prior to his move to his current accommodation had been covered in full by ASC.

57. Mr X and Mr Y were unhappy with the Council’s final response. Mr X complained to us in April 2025.

Findings

Mr Y’s stay in property A

58. The Council records showed that it internally shared the May 2023 OT report when looking at housing options for him. This stated that Mr Y required a “standard” wheelchair property while it also noted that Mr Y’s wheelchair was wider than usual (therefore not standard) requiring wider access points (at least 860mm, ideally 900mm) and turning circle in any accommodation.
59. The OT visit to Property A raised concerns about the door widths to the main bedroom and bathroom. These were measured to be 770mm and 780mm, lower that the minimum requirement stated in the May 2023 OT assessment. The Council’s notes did not show how it took this into consideration in its decision to confirm Property A for Mr Y. This was fault.
60. Records also showed that the Council was aware (through an OT visit) that Mr Y could not access the shower because the shower chair it provided could not fit through the door, and that Mr Y and Mr X had both raised concerns about the suitability of the property after Mr Y moved in. However, the Council failed to develop a clear plan of action to address Mr Y’s needs and failed to clearly communicate how it intended to meet Mr Y’s needs in the long term.
61. The Council did not take enough proactive steps to find suitable and timely solutions to enable it to meet Mr Y’s assessed care needs. This was fault.
62. I cannot say, even on balance, what would have happened had the Council acted without fault. However it is clear that Mr Y’s assessed care needs were not met when he stayed in Property A and that was a significant injustice. The records showed that the Council regularly offered Mr Y a care package to meet his care needs and that Mr Y initially declined this offer. However, when he did accept this the records showed that the carers told the Council they could not deliver the care package because the property was not suitable and that they were unable to meet his personal care needs.

Safeguarding

63. Mr X raised safeguarding concerns in early June 2024 following a joint meeting with relevant parties involved with Mr Y regarding Mr Y’s inability to carry out personal care tasks and their concerns for Mr Y’s wellbeing. The Council’s complaints and enquiry responses addressed the safeguarding concern around Mr Y’s ability to be safely evacuated from the building raised by a third party. However, this did not address Mr X’s concerns about Mr Y's care needs not being met and the difficulties he had in the accommodation.
64. Although the Council did not address these issues as a safeguarding concern, the records showed that it was aware of the same concerns which it was trying to address through its offers of care, support and through its search for another accommodation.

Communication and complaint handling

65. Mr X said the Council’s communication around Mr Y’s stay in Property A was misleading. The Council explained that it did consider Property A as a long-term option when Mr Y moved in but it then became clear that this property would not meet Mr Y’s needs long term. There was no fault by the Council.
66. The Council stopped communicating with Mr X despite Mr Y repeatedly stating he wanted Mr X involved throughout the process. It said this was because it did not consider that Mr Y required an advocate. This was fault – there was no reason why Mr Y was not entitled to seek representation from Mr X who had also previously supported him. If the Council was concerned Mr X was not a suitable representative for Mr Y then it should have recorded its reasons for its decision to stop communication with them. This fault caused Mr Y significant frustration.
67. The Council’s stage two complaint response showed that it was completed by the same employee who completed the stage one investigation. This was not in line with its own published policy (requiring independent stage two investigation) and was fault that added to the frustration.

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Agreed action

68. Within one of this decision the Council will:
1. Apologise to Mr Y for the avoidable frustration and uncertainty caused by its faults. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council will consider this guidance in making the apology.
2. Pay Mr Y £1000 to acknowledge the avoidable distress and uncertainty caused by its lack of proper consideration of alternative solutions that would have enabled it to meet his assessed care needs.
69. Within two months of this decision the Council will share our decision with its Adult Social Care department and Housing team to identify areas of learning around effective communication and record keeping. It will set out the action it proposes to take to improve its services in future and prevent recurrence of the faults identified in this decision.
70. The Council will provide us with evidence it has complied with the above actions.

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Decision

71. I found fault causing injustice and the Council agreed actions to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman