Summary: Ms Y complained about the Council’s support for her late son, Z, and the standard of support by the service provider the Council commissioned to deliver Z’s support. We have found fault causing injustice by the Council in failing to: properly monitor the service provider’s support for Z and take effective action to address this; and ensure there was an appropriate plan in place to respond to concerns about Z’s safety. We have also found fault with the service provider in the way it delivered Z’s support. The Council has agreed to remedy this injustice by apologising to Ms Y for the extreme distress caused, making a payment to recognise this distress, and a service improvement.

The complaint

1. Ms Y complains about the Council’s support for her late son, Z, as a young person leaving care. The Council commissioned a service provider, Jordan Xavier (JX), to deliver Z’s support.
2. Ms Y says:
1. JX failed to deliver all the support they were commissioned by the Council to provide to Z; and
2. the Council failed to:

• respond to the concerns she raised about the standard of JX’s support for Z;
• properly monitor the support JX delivered to Z; and
• provide her with details of Z’s support plan and package.

3. Ms Y says, because of these failures, Z did not receive all the support he needed or support of an adequate standard. The Council’s failure to respond to her concerns caused her extreme distress. And its failures to listen to concerns or properly monitor JX, as the service provider, may cause injustice to other service users and their families.

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The Ombudsman’s role and powers

4. 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).
5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these.
6. 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)
7. 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)
8. Under our information sharing agreement, we will share this decision with the Ofsted.

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How I considered this complaint

9. I considered evidence provided by Ms Y, JX and the Council, as well as relevant law, policy and guidance.
10. Ms Y, JX 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

What should have happened

Leaving care

11. The Children (Leaving Care) Act 2000 made changes to The Children Act 1989 by placing duties on councils to provide ongoing support for children leaving care. These duties continue until they reach age 21. If the council is helping them with education and training, the duty continues until age 25 or to the end of the agreed training (which can take them beyond their 25th birthday). 
12. Councils should appoint each care leaver with a personal adviser, and each care leaver should have a pathway plan. The personal adviser will act as a focal point to ensure the care leaver is provided with the right kind of support. The pathway plan should be based on a thorough assessment of the person’s needs. Plans should include specific actions and deadlines detailing who will take what action and when. They should be reviewed at least every six months by a social worker. 
13. Pathway plans should continue for all care leavers continuing in education or training. The plan should include details of the practical and financial support the council will provide. 
14. The guidance accompanying the Act says that when young people leave their care placement the council must ensure their new home is suitable for their needs and linked to their wider plans and aspirations. Moving directly from a care placement to living independently is often too big a step for young people. It is therefore good practice for councils to commission semi-independent and independent living options with appropriate support.  

Safeguarding Adults Review

15. A Safeguarding Adults Review must be undertaken where an adult with care and support needs has died or suffered serious harm and it is suspected or known the cause was neglect or abuse, including self-neglect, and there is concern agencies could have worked better to protect the adult from harm. (Care Act 2014 section 44)
16. The purpose of a Review is not to not to hold any individual or organisation to account, but, as set out in the statutory guidance, to “promote effective learning and improvement action to prevent future deaths or serious harm occurring again”.

What happened

Background

17. Z was placed in the Council’s care in 2017, following conflict at home. Ms Y remained in continuous contact with Z, and with the Council about his care and living arrangements.
18. Z was 18 at the end of 2017. The Council’s Young Adult Service (YAS) provided ongoing support for Z as a young person leaving care. It arranged his move to a semi-independent placement and commissioned JX to provide him with key worker support to develop independent living skills.
19. In 2019 Z moved to a new placement in another borough because of concerns about safety at his existing placement. The Council commissioned JX to continue providing key worker support for Z at the new placement.
20. On 5 January 2021 Z was found dead at home at his placement after a fatal drug overdose.
21. The Safeguarding Adults Board for the council in whose area Z’s placement was located commissioned a Safeguarding Adults Review
22. Ms Y complained to the Council it had failed to respond to her concerns about JX’s support for Z. It told her it would not respond to her complaint until the completion of the Safeguarding Adults Review.
23. The Review was not completed until May 2024. Ms Y then asked the Council for its response to her complaint.
24. The Council declined to respond so Ms Y brought her complaint to us.

Summary of events from 2019 to January 2021

25. I have focussed my investigation on what happened after Z’s move in July 2019, in the period leading up to 5 January 2021.
26. I have set out a summary of the key events below. It is not meant to show everything that happened. It is based on my review of all the evidence provided about this complaint.

September 2019: Ms Y’s contact with the Council about her concerns

27. Ms Y raised concerns with the Council about JX’s support for Z. She said this was not as robust as she had expected.
28. The Council held a meeting of professionals working with Z to consider safeguarding and risk concerns. The meeting notes record:
1. concerns about Z’s involvement with county lines;
2. JX had shared they had not had contact with Z for six weeks as he had not been engaging. They had a key to his flat but had not entered to carry out a welfare check; and
3. agreed actions included:

• a comprehensive risk and adult safeguarding assessment;
• referral to vulnerability, exploitation and risk panels;
• enquiries about autism support services;
• a request for a care act assessment; and
• announced and unannounced home visits.

29. Ms Y then raised further concerns with the Council. These included:

• she had not been given any information about the level of JX’s support and how often they would visit. She felt JX were not providing sufficient support and were not properly monitoring Z;
• Z needed a supported living placement;
• there should be a plan for vulnerable clients like Z who found it difficult to engage with support workers; and
• she wanted to see Z’s care plan.

Action following the professionals’ meeting

30. In its response to Ms Y the Council said:

• other young people and professionals had raised similar concerns about JX’s service. This had been addressed by its brokerage team;
• it was sorry Z was not receiving an appropriate level of support. JX had not always told it about difficulties unless there was a crisis;
• it agreed Z would benefit from supported accommodation. He was resistant to this, but it was exploring the option; and
• it was happy to meet with Ms Y to discuss the position further.

31. The Council then:

• referred concerns about JX’s service to its brokerage team;
• discussed a supported living placement with Z. He declined this because he was unhappy about its location. The Council said it would continue to look for another placement; and
• referred Z to its exploitation and risk panel.

32. JX sent the Council a monthly report of its contact with Z during September.

October 2019: Z’s Pathway Plan

33. The Council completed a Pathway Plan for Z on 4 October. This said:
1. Z lived independently in a standalone property with 10 hours a week of support from JX;
2. Z was engaging with and currently being supported by YAS on a weekly basis, due to safeguarding concerns. Once Z had settled the visits would go back to an eight-week basis;
3. YAS’s assessment was Z was engaging well but there were concerns about JX’s support of 10 hours and his placement. Safeguarding approaches were being considered;
4. JX shared that Z’s engagement with it was sporadic. They had not seen him for several weeks although they had a key to his flat;
5. Z often went missing from his placement. Ms Y reported these to the police. Z’s understanding of risk was limited; and
6. there were concerns the mental health team were not properly monitoring and supporting Z with his mental health issues.
34. The actions agreed in the plan were:

• provide Z with a copy of the plan;
• YAS to continue to attempt contact with Z and liaise with his parents;
• a referral for Z to Adult Social Care for a care act assessment; and
• follow up of Z’s referral to a specialist support service (service H).

October 2019: further action

35. JX sent the Council a monthly report of its contact with Z during October.
36. Z was referred to service H. The Council arranged for another specialist support service (service J) to work with Z.
37. Ms Y reported Z as missing from his placement a number of times.

Ms Y’s contact with JX

38. On 31 October Ms Y sent an email to JX setting out her concerns about its support for Z. She sent a copy of this email to the Council. Ms Y said JX should:

• be checking inside Z’s flat to make sure he was coping and providing support for his GP visits. She asked; for details of Z’s care plan; how much and what type of support he was receiving; and who was supporting him while JX staff were on leave; and
• tell her and the Council when they hadn’t seen Z for extended periods. This was not happening.

November to December 2019: Council’s contact with and about JX

39. The Council spoke to JX staff on 12 November about their recent contact with him. It told them to notify the Council and JX’s management about any concerns and if Z failed to be available for placement visits.
40. YAS noted a concern about Z’s risk management. A probation officer working with Z shared a concern with YAS as to whether he was actually receiving 10 hours of support from JX.
41. On 19 December the Council asked JX to carry out an urgent check on Z. A manager replied on 23 December. They said the relevant staff were away on leave but had advised they were finding it difficult to meet with Z because he cancelled meetings and was not at home when placement visits were carried out.

January 2020: concerns about Mr Z’s wellbeing and safety

42. The Council held a meeting with Z at his placement on 8 January. This was attended by YAS, service J’s support worker and Ms Y. They discussed Ms Y’s concern Z needed a supported living placement and the previous offer of a supported placement which Z had declined.
43. Ms Y also told the Council about her concerns J’s flat was being used by others. She said JX had told her they had not seen Z for five weeks and did not have a spare key to his flat. And service J’s support worker raised with the Council their concern Z’s flat had been taken over by others and that Z should be moved to supported accommodation.
44. The Council referred Z to a specialist housing support service (service K). It told this service Z received 10 hours of support a week.
45. The Council discussed with Z the supported housing available with service K. But Z said he would not move to this accommodation because of its location.

January 2020: Contact with JX

46. JX told the Council on 20 January Z had not been available. They said they had been to his flat but were unable to gain access as they did not have keys.
47. The Council asked JX to check Z’s flat urgently. JX said they were waiting for a new key to be cut.
48. On 22 January JX management told the Council:

• JX staff would attend Z’s flat tomorrow to gain access with the keys now obtained;
• they could not find Ms Y’s email from the previous year. If they had known how concerned she was about the current JX staff they would have arranged for someone else to work with Z; and
• they had spoken to Ms Y several times and she had not raised any concerns.

49. In her reply to the Council and JX, Ms Y said:

• she had contacted JX by email on 31 October 2019 and chased on 2 January 2020 but not had any response;
• her first conversation with JX’s management was on 7 January 2020; and
• it had been two weeks since the professionals’ meeting on 8 January and still no-one had entered Z’s flat to check it.

50. She also told JX it was not properly checking on Z. She said:

• She and JX went together following the meeting on 8 January to get a spare set of keys cut;
• when she asked JX to check on Z on Friday 10 January, she was told they could not go unaccompanied, and then that they would go on Monday 13 January; and
• on 13 January, JX told her they could not visit as they did not have the key to the communal door.

51. On 23 January JX reported they had visited Z’s flat that morning. He was not present, and they let themselves in with the keys. They contacted Z who said he was away and due to return in a few days. They had arranged to meet him the day he was due to return.

February to March 2020: further actions

52. The Council:

• referred Z to a specialist substance misuse service (service M) in February;
• noted, on 17 March, in the record of its contact that day with Z, JX should be visiting him weekly to ensure he was supported; and
• noted Z was now engaging with service J’s support worker.

May 2020: Pathway Plan

53. The Council reviewed Z’s Pathway Plan on 7 May. This noted:

• those involved in preparing the plan were Z, Ms Y, service J and K support workers, and YAS;
• the Council would continue to support Z through its leaving care service. This would include personal adviser support, six-monthly Pathway Plan reviews. two monthly contact, support with accommodation, education, training and employment;
• Z’s engagement with JX was poor. He missed contact and failed to communicate;
• lack of utensils in the kitchen showed Z had not been cooking although he had been supported to get equipment and started cooking during the Covid-19 lockdown period. He needed support with preparing meals. Ms Y reported times when he had not managed his money and asked her for food;
• Z had not used his placement appropriately. There were suspicions he had allowed friends to stay while he was away. But he was currently spending more time in his flat and reported to be keeping it tidy; and
• Z should continue to work with JX staff to develop independent skills.

54. The Council said Z would be provided with a copy of the plan, and the next review was due on 9 October 2020.

May to August 2020: Z’s support during this period

55. The records I have seen show that on:

• 29 May: YAS completed a virtual visit to Z by phone. JX was with him at his flat. JX reported the flat was clean and tidy but there was no food. It was agreed JX would take Z food shopping later. YAS noted an action JX should visit Z weekly;
• 6 June: JX sent the Council a contact report for the period 20 March to 14 May. This recorded JX staff had carried out 12 home visits with Z at regular intervals between 20 March (start of lockdown) and 14 May; and
• 7 July: YAS carried out a virtual visit with Z. It was noted he reported things were going well with JX staff, whom he had been seeing every week. He also now had a service K support worker. They discussed Z’s thoughts about education and employment, housing and budgeting.

56. YAS met with Z outside of his home. Z reported JX staff were supportive, he hadn’t seen his service K support worker much, but they spoke on the phone. YAS noted Z wasn’t getting the agreed support from service K.

September to December 2020: Z’s support during this period

57. The Council’s records show it received progress reports from service K’s support worker about their engagement with Z during this period.
58. Service K’s weekly report for 1 to 4 September said:

• Z’s case had been discussed at a recent panel meeting;
• Z was prone to cancelling appointments at the last minute. They were working with him on this; and
• They were supporting Z with education, employment and training opportunities. They proposed completing welfare checks, continuing to offer face-to-face meetings and conversations about the negative effects of substance misuse.

59. YAS completed virtual visits with Z, including on:

• 6 October: They discussed Z’s proposed work with his service J support worker on education, employment and training options; and
• 9 December: JX was with him at his flat. They discussed the delivery of a TV and sofa. Z confirmed he had met his service K support worker.

60. In their report of 18 December, service K’s support worker said they had:

• met Z and JX staff at the flat on 16 December. They and JX had compared diaries to ensure Z had as much contact as possible over the Christmas period. JX was setting up Z’s TV. They discussed education, employment and training opportunities with Z who had shut down in response to questions about housing and substance misuse. Z became frustrated about issues with the TV and asked them both to leave. Z phoned later that day, apologised and confirmed their meeting on Friday;
• discussed with service J concerns about Z’s substance misuse, safe areas and housing options;
• been due to meet again with Z on 18 December. But Z said he would not be at his flat and declined the suggested alternative of a meeting at Ms Y’s home. It was agreed the meeting arranged for 21 December would go ahead; and
• sent a message to Ms Y to introduce themselves, having been given her number by Z.

61. In their report of 24 December, service K’s support worker said they had:

• visited Z at his flat on 21 December for a support session. They discussed education, employment and training options and completed a referral for an outreach service;
• spoken to Ms Y to introduce themselves and the plan for support over the Christmas and New Year period;
• texted Z on 22 December but received no reply;
• texted Z on 23 December to remind them of their appointment that day. Z said not to come over as he was on his way to see Ms Y; and
• called Mr Z by phone on Thursday 24 December. Z said he was seeing Ms Y and JX staff that day and again on Saturday.

The period leading up to 5 January 2021

62. The following is based on service K’s report of 31 December; JX’s account to the Council in January 2021 of its contact with Z; and Ms Y’s contact with JX in February 2021 about what happened on 4/5 January.
63. Contact with Z in the period from 29 December to 2 January:

• 29 December: service K’s support worker called Z. He said he had been with Ms Y over Christmas. They confirmed their meeting for 30 December;
• 29 December: JX staff saw Z on a home visit;
• 30 December: service K’s support worker called Z to confirm their appointment. Z said he was out with a friend and asked to meet another time. They agreed to speak about this the following day;
• 31 December: JX staff saw Z on a home visit; and
• 2 January: JX staff called Z. He said he was on his way back from an event and planned to see Ms Y. He confirmed he would meet JX staff at his flat at 12pm on 4 January.

64. On 4 and 5 January:

• 4 January: JX staff attempted to visit Z at home but there was no answer. They called Z but there was no answer. JX said the JX staff member was not concerned at this because of Z’s positive mood when they last spoke;
• 4 January: Ms Y sent a text message to JX staff member around 9pm. She said she had seen Z on 2 January but he hadn’t come over on 3 January as planned. She asked when JX staff member had last seen Z. JX has accepted Ms Y asked its staff member for the keys to access Z’s flat;
• JX has said its staff member did not see Ms Y’s text until 11.30pm. It could not say whether it would have escalated action if Ms Y had had contact with its on-call senior management on 4 January. Ms Y and the staff member agreed to meet at Z’s flat at 10.30am the next day to gain access using JX’s keys; and
• 5 January: its staff member told JX, at 0.56am, Ms Y had reported Z as missing to the police. Ms Y said the police escalated her report to a welfare check but called her at 4am to say they could not get into the building to check Z’s flat because there was no key.

65. Ms Y and JX found Z dead at his flat on the morning of 5 January, having gained access with JX’s keys.

Action from January 2021: Ms Y’s complaint to the Council and JX

66. Ms Y complained to the Council about its failures to respond to her concerns about JX’s support for Z. The Council said it would not respond to the complaint until the Safeguarding Adults Review had been completed.
67. JX responded to Ms Y’s complaint in February 2021. It said:
1. Z’s support package was 3 hours a week;
2. its manager did not recall receiving any previous complaint;
3. it did not have the communal door key. It had given its key to Z when he lost his but had then been unable to get a replacement. It accepted this should have been progressed as it should have spare keys for all its properties; and
4. it agreed the photos showed the standard of Z’s property was not appropriate and:

• JX staff were not aware of any pest control issues or that the heating wasn’t working;
• they had not seen the bathroom on recent visits but encouraged Z to clean the flat as he needed motivation to do this;
• they had not seen the mould. This was behind curtains which were usually drawn when they went in; and
• JX had now arranged for its workers to complete monthly property audits. Issues raised would be addressed by a property manager.

68. JX also said it accepted:
1. there were areas within Z’s support where required intervention was not consistently provided;
2. it should have written support plans for the young people it works with. It did not have any such plan in place for Z; and
3. its communication with Ms Y was not always consistent. As she was a pivotal support for Z, it should have had regular structured contact with her.
69. But it did not accept there had been issues with the level of its support service. The issues with non-engagement in 2019 had improved by the end of 2020.

Council’s review of JX’s service

70. The Council reviewed JX’s service in 2021. Its key findings were:
1. lack of a management system in place, oversight, records of management decisions and follow-ups. These should be reviewed together with quality assurance and directors’ responsibilities;
2. staff recruitment, supervision, training and support should be reviewed by senior managers;
3. responsiveness to non-engaging young people seemed to be inadequate and should be reviewed;
4. complaint outcomes should be reported and reviewed on a regular basis by senior managers and recorded centrally with clear lessons learnt. This should be part of the improvement plan and quality of services provided by the organisation; and
5. the Council’s brokerage and quality assurance teams had recommended the suspension of referrals to JX should remain in place. Young people placed with JX were offered alternative provisions by the social care team.

May 2024: Safeguarding Adults Review

71. The Review covered the period from January 2019 to January 2021. It noted the impact of Covid-19 on delivery of services from March 2020. JX declined to participate in the review.
72. It confirmed its purpose was not to re-investigate or apportion blame but to establish whether there were lessons to be learned from the case about the way professionals and agencies worked together to safeguard adults. Its main points were:
1. regarding Ms Y’s concern the semi-independent accommodation was inadequate to meet Z’s needs: This was an appropriate balance to meet his level of needs, with the multi-agency package of support co-ordinated by YAS. Z wanted to move from this to his own council tenancy;
2. regarding the concerns about the standard of Z’s accommodation and support raised with YAS and directly to JX: Practitioners had noted at times JX was not proactive or consistent in engaging with Z. But as at December 2020, JX staff were in regular contact with him and worked collaboratively with other professionals;
3. the Council’s review of JX’s service had found its policy for young people not engaging with its support workers was too brief and inadequate. This meant the Council was not aware of the number of missed contacts and gave it false confidence about level of support Z was receiving. The Council had also found other concerns regarding JX’s service; and
4. the Council had shared its concerns about JX with Ofsted and now had a stronger system in place for oversight of concerns about providers.
73. The Review found Z had been provided with accommodation and a package of support suitable for his needs. But systems were not in place at the time to address the weaknesses in JX’s management, despite Ms Y’s repeated complaints.

Council’s actions following the Safeguarding Adults Review

74. In its response to our enquiries about Ms Y’s complaint, the Council said:
1. The Review had considered the appropriateness of Z’s accommodation and support and set out its findings and recommendations. A multi-agency action plan was in place to address the learning from the Review;
2. it had made changes since January 2021 which included:

• a review of service specifications for instances where a young person is not seen for two successive key working sessions or is not using the services commissioned. There is now a requirement for the provider to submit a report outlining the attempts made to engage with the young person. Providers are required to arrange a non - compliance /engagement meeting and ensure the allocated officer is updated;
• a generic email address for anyone to contact the commissioning team about concerns relating to a provider. These are reviewed and investigated swiftly based on the nature of the concern. Additional staff have been recruited to conduct quality assurance visits annually, as well as at short notice when a concern is raised;
• meetings held with providers where significant concerns have been raised regarding the quality of their services. These meetings are chaired by Council senior managers; and
• monthly meetings between the Young Adult Service and Placements Team. This enables the review of placements and early identification of concerns raised about providers. Any concerns are discussed, actions agreed, implemented and tracked.

My decision - was there fault by the Council and/or JX causing injustice?

75. I have taken account of the outcomes of the Council’s review of JX’s service, which recorded concerns about JX, and the Safeguarding Adults Review, which also referred to these concerns and that they had been shared with Ofsted. The Council told us about changes it has made to its systems for monitoring commissioned providers’ services.
76. The Review’s purpose was not to find fault with either the Council’s or JX’s actions. And I have not seen any review by the Council of its support for Z.
77. In my decision, I have focussed on the areas not covered by the Review or the Council’s review of JX’s service, and in particular the Council’s support for Z.

JX’s support for Z

78. There were significant failures in the way JX provided its support for Z. It accepted in its response to Ms Y’s complaint:
1. required intervention was not consistently provided;
2. it did not have a written support plan in place for Z;
3. its communication with Ms Y was not always consistent; and
4. it did not have the communal door key and had not monitored the standard of Z’s accommodation.
79. And, based on my investigation of what happened, I have found JX failed to:
1. respond to, or act on, the concerns Ms Y raised with it in October 2019 about Z’s support:
2. inform the Council about periods when there was no contact or engagement with Z, despite being instructed to do so;
3. properly monitor or supervise the delivery of its key worker support for Z;
4. provide the Council with regular reports of the support delivered to Z; and
5. put in place appropriate procedures for the escalation of, and action to be taken in response to, concerns about Z’s safety, in particular to ensure it:

• always had keys to access Z’s flat to check on his welfare;
• had a procedure for the escalation of concerns by key worker staff to JX management and to the Council; and
• had an appropriate plan for the action to be taken in response to concerns about Z’s safety.

80. These failures by JX were fault. I have considered their impact below.

Council’s support for Z, its response to Ms Y’s concerns about, and its monitoring of, JX’s support for Z

81. My findings are not directed at any individual professionals working with Z. My view, based on the information seen, is the Council’s YAS team were actively working to find the right support for Z. I have also noted the amount of positive work the specialist and other support workers were undertaking with Z in the month or so before he died
82. However, I have found a number of failures by the Council in its support for Z. These include failing to:

• to follow up on some of its agreed actions such as the proposed adult social care assessment and safeguarding referrals;
• review Z’s Pathway Plan in October 2020; and
• be clear and consistent in its records about the amount of support hours it had commissioned JX to provide (confirmed as three hours a week) and the separate amount of specialist support hours put in place for Z.

83. But, in my view, the Council’s most significant failures were in failing to:

• properly monitor JX’s support for Z and take effective action to address this; and
• ensure there was an appropriate plan in place to respond to concerns about Z’s safety.

84. I say this because the Council:
1. knew about Ms Y’s concerns about JX’s level of support for Z from 2019 and had its own concerns about JX’s service. But it did not take effective action to address these concerns. It failed to:

• obtain details of JX’s support plan for Z;
• confirm with JX what support it should be providing and how it was expected to provide this; and
• ensure JX provided it with monthly reports of its contact and support for Z. A few reports were provided although one of these covered more than a month. There is no evidence the reports which were provided were reviewed by the Council.
2. knew about the risks to Z’s safety and concerns about his periods of absence and lack of contact but failed to:
• properly address the concerns and risks caused by JX’s failure to notify it about Z’s periods of absence and lack of contact; and
• ensure there was an agreed, appropriate plan in place with JX and other professionals about action to be taken in response to concerns about Z’s safety.

85. These failures by the Council were fault. I have considered their impact below.

Council’s response to Ms Y’s request for details of Z’s support plan

86. Ms Y asked the Council if she could see Z’s support plan. And it knew she had asked JX for this. Ms Y was very involved with the arrangements for Z’s support and in constant contact with the Council about this.
87. In my view it was fault by the Council not to consider and respond to Ms Y’s request, including discussing with Z whether he agreed to details being shared with her. This caused Ms Y frustration and uncertainty about the level of support JX was supposed to be providing for Z.

Impact of the Council’s and JX’s failures

88. The Safeguarding Adults Review noted that as at December 2020, JX was in regular contact with Z and working collaboratively with other professionals supporting him. This view is supported by the records I have seen.
89. But the Council’s failure to clarify with JX what support it should be providing for Z, and how, and to properly monitor JX’s delivery of this support meant Z may not have received appropriate support from JX during the period from September 2019.
90. I note the Review’s reference to the Council being unaware of the number of JX’s missed contacts with Z and it being given a false sense of confidence about JX’s level of support for Z because of the inadequacy of JX’s policy for non-engagement. But in my view, any lack of awareness about missed contacts or false confidence about the level of support was also due to the Council’s own failure to properly monitor JX’s support for Z.
91. The inconsistency of JX’s support for Z and failure to monitor the condition of his accommodation meant he is likely to have received a lower standard of support than he should have done over the period from September 2019.
92. I have found the Council and JX failed to ensure an appropriate plan was in place for the escalation of, and action to be taken in response to, concerns about Z’s safety.
93. There is no way for us to say, even on balance, what difference it would have made had this been in place. It is sadly too late to put this, or the impact of the other failures, right for Z now.
94. But, in my view, the possibility that the outcome may have been different, and the worry that her concerns about Z’s support had not been properly addressed, have caused Ms Y extreme distress.

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Action

95. When a council commissions or arranges for another organisation to provide services, we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone.
96. Here we have found fault with both the Council and JX, its commissioned service provider. To remedy the injustice caused by the above faults, and within four weeks from the date of our final decision, the Council has agreed to:
1. apologise to Ms Y for the distress and uncertainty caused by; the failures in its support for Z; its failure to: properly monitor JX’s support for Z and take effective action to address this; and its failure to ensure there was an appropriate plan in place to respond to concerns about Z’s safety. This apology should be in line with our guidance on Making an effective apology;
2. apologise to Ms Y for the distress and uncertainty caused by JX’s failures, as its commissioned service provider, in the way it delivered Z’s support. This apology should be in line with our guidance on Making an effective apology ; and
3. pay Ms Y £500, as a symbolic amount, to acknowledge the uncertainty and extreme distress caused by the Council and JX’s failures, based on our guidance on remedies.
97. And within three months from the date of our final decision, the Council has agreed to:
1. share the learning from this case with the relevant teams;
2. provide us with an action plan showing how it will address its failures to:

• properly monitor the service provider’s support for the service user and take effective action to address this; and
• ensure, where there are risks to, and concerns about, a service user’s safety, there is an appropriate, agreed plan in place with professionals and others involved with the service user for the action to be taken in response to these concerns.
3. send a copy of this action plan to Ms Y.

98. The Council should provide us with evidence it has complied with the above actions.

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Decision

99. I find fault causing injustice. The Council has agreed to take the above action to remedy this injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman