Summary: Miss X complained about the Council’s lack of action when she reported serious concerns for her brother, Mr Y. She said there have been significant delays which are ongoing. We find the Council was at fault. This caused significant distress to Miss X and Mr Y. We make several recommendations to address this injustice caused by fault.

The complaint

1. The complainant, Miss X, complains about the Council’s lack of action when she reported serious concerns for her brother, Mr Y. She said there have been significant delays which are ongoing.

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The Ombudsman’s role and powers

2. 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)
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

4. I have spoken with Miss X about her complaint. I considered all the information provided by Miss X and the Council.
5. Miss X and the Council had an opportunity to comment on my revised draft decision. I considered their comments before making a final decision.

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What I found

Background

6. Mr Y has an acquired brain injury which left him with profound physical, mental and cognitive disabilities. This affects his behaviour and his ability to manage daily activities. Mr Y has short- and long-term memory loss and a short attention and concentration span. He has depression, anxiety and panic attacks and is prone to aggressive outbursts. He also has uncontrolled epileptic seizures and impaired sight. Mr Y is vulnerable to financial abuse and exploitation from others.
7. Our previous decision (22003847) stated Mr Y did not meet the criteria for supported accommodation for adults with autism or learning disabilities. He is not old enough to be considered for extra care supported housing schemes.
8. That decision stated the supported living panel considered Mr Y’s needs in April and May 2021 and decided he could be supported in general needs housing with a care package. If that arrangement proves not to work, the social worker will then have to consider other options.

Summary of the key events

9. In March 2023 Miss X raised concerns to the Council. She said unknown people were attending Mr Y’s address which she had reported to the police. She said Mr Y had been abused before and she was concerned it would happen again. Mr Y’s carers also raised the same concerns.
10. There was a police report which stated there were no signs of criminal activity at Mr Y’s address. But there was a possibility Mr Y was being taken advantage of.
11. Miss X reported further concerns in April 2023. She said men had broken into Mr Y’s property as he would not open the door. She said she did not think he should be living alone.
12. The Council contacted its housing department in the same month. It said Mr Y’s property did not appear safe for him going forward and asked it to support him with finding alternative accommodation.
13. The Council spoke with Miss X shortly after and said the case would be allocated for a review and completion of a mental capacity assessment.
14. The review stated:
• Mr Y demonstrated good capabilities regarding understanding, retaining and appropriately using the information provided to him. But it was noted that even though Mr Y appeared to perform well during the meeting, it remained the case he needed assistance and prompting to manage in some aspects of his daily life;
• better understanding and reviews of Mr Y’s functional capacity could be achieved through multiple specialist assessment and reviews of his evolving capabilities and strengths;
• Mr Y had let drug dealers access his flat who used it for cuckooing but after realising he asked them to leave. But they have now retaliated by breaking his window [cuckooing is a practice where people take over a person’s home and use the property to facilitate exploitation];
• Miss X said the housing department said if Mr Y was cuckooed, they would reconsider his housing needs and may consider putting him forward for either support living or extra care accommodation. She said she would like these options to be explored and it was noted the Council would look into it;
• it was possible Mr Y experienced delayed reactions to risks; and
• his overall package of care would be maintained. This consisted of 30-minute care calls daily. But it was noted the Saturday call would be increased to 60 minutes.
15. Miss X raised further concerns in May 2023 as Mr Y’s flat had been raided by the police.
16. The Council received safeguarding contact from the police in the same month. It was noted Miss X had called up due to known people being seen on the ring doorbell. But police noted they had no immediate concerns.
17. Following Miss X requesting Mr Y be moved to supported living, the Council gave her some guidance. It was noted there was no set criteria but in general for access to supported living, someone would need to have either a learning disability or autism diagnosis or similar. Miss X was asked to gather the necessary information, and the Council said it would apply.
18. In July 2023 the notes state the Council applied for extra sheltered care. But this was declined due to Mr Y not meeting the age criteria. The Council advised Miss X she could contact the housing team to discuss Mr Y’s housing needs and request for him to be re-housed if possible.
19. In August 2023, the Council met with Mr Y and Miss X following Miss X reporting further safeguarding concerns. It was noted there was a ring doorbell in place and carers visit once a day. Miss X also stated housing said they could not move Mr Y as they did not have secure accommodation.
20. A multi-agency risk assessment conference was held the following month. It was noted that:
• perpetrators had been using Mr Y’s address for drugs and weapons;
• Mr Y did not meet the threshold for extra sheltered accommodation and general housing was not appropriate;
• Letters from the epilepsy nurse and neurologist consultant were provided. It was noted these letters could support a property move;
• adult social care offered support to Mr Y which was declined by Miss X;
• police would continue with regular welfare visits;
• a professionals meeting would be arranged; and
• the Council would contact the solicitor regarding property options for Mr Y.
21. A meeting was held in November 2023 where it was agreed it was not safe for Mr Y to live on his own. It was noted he would need to be in some supported accommodation.
22. The Council asked the police how often they attend Mr Y’s property and whether they consider the property to be at risk of cuckooing. In response the police said suggestions of cuckooing had been made by Miss X. But they said there were no obvious signs of cuckooing when officers attended. But noted there was a risk as Mr Y allows people into the flat.
23. The Council carried out a mental capacity assessment across two visits. One in December 2023 and the other in January 2024. It was noted that:
• Mr Y lacks capacity to make decisions regarding his care and support needs and accommodation. He also lacks capacity regarding decisions about his personal safety; and
• a best interest meeting would need to be held once available options were explored and identified.
24. Between January and October 2024, the Council made referrals for several property schemes. It was noted the search was restricted as shared facilities were not suitable for Mr Y and he needed to be close to family. It also evidenced the Council requested self-contained flats. But it was noted some properties offered had shared facilities.
25. The Council advised Miss X of a potential property, but Mr Y thought it was too far from family.
26. During this time, Miss X did continue to raise concerns for Mr Y. The Council recommended increasing his package of care. But Miss X said due to increasing concerns around Mr Y’s recent behaviour towards the carers, she did not think it was appropriate. She said she would consider this when Mr Y has moved to a more supervised setting.
27. As of November 2024, an alternative property has not been sourced.

Analysis- was there fault by the Council causing injustice?

28. Miss X started to report significant concerns for Mr Y in March 2023. The Council initially acted quickly and completed a review the following month. It was also noted the Council would complete a mental capacity assessment. It agreed to look into extra care accommodation and supported living. The review also stated better understanding of Mr X’s functional capacity could be achieved through multiple specialist assessments. It was agreed his overall care package would be maintained. But the care call was increased on a Saturday from 30 minutes to 60. This was to provide support to Mr Y with meal preparation, laundry and maintaining a habitable home environment.
29. As stated in paragraph 28, the Council agreed further assessments were required to get a better understanding of Mr Y’s functional capacity. This is a decision for the Council to take and I cannot criticise it. But from the evidence seen, a further assessment of Mr Y’s capacity was carried out in December 2023 and January 2024. In my view, this delay is fault. Miss X said since the mental capacity assessment, she has had better support from the police. If the Council had completed this assessment sooner, it could have taken protective actions sooner.
30. The Council took three months to make the referral to the extra care accommodation. Whilst I acknowledge the referral was declined, the delay is fault. It also took three months for the Council to provide Miss X with guidance on the eligibility for supported living accommodation.
31. The Council received a safeguarding referral in August 2023. The Council worked closely with the community safety unit and the police. There was a meeting in September 2023. It was noted the police were to continue with regular welfare visits and a professionals meeting would be arranged. At this meeting, which was held in November 2023, it was agreed Mr Y could not live alone and needed to be in supported accommodation.
32. The Council began to search for suitable properties in January 2024. Miss X continued to report significant concerns for Mr Y throughout this time.
33. As stated above, the Council started its search for suitable properties. As of October 2024, the Council said it was continuing its search. From the evidence seen, the search has been consistent. But it is noted the search is restricted as shared facilities are not suitable for Mr Y and he needs to be close to family. In my view, the fact there are no suitable properties available to meet Mr Y’s needs is evidence of service failure.
34. I acknowledge that the Council had identified a potential property which was declined by Mr Y and Miss X as it was too far from the family home. We would expect the Council to evidence that it has properly considered whether this was offer was suitable. From the evidence seen, the assessments completed do not consider distance from family. This is fault and I cannot say whether this property offer was suitable as there is no evidence to suggest the Council considered it properly.
35. Mr Y remains living in an unsuitable property. The Council said the police continue to carry out regular checks and updates on Mr Y’s current property. The Council also said it has offered advice and support to manage risks of financial exploitation and abuse. It said it has ensured is finance deputy is aware and supporting Mr Y.
36. Miss X said throughout the Council continued to dismiss advise from the NHS neuro-consultant. She said she obtained head injury case manager and private consultants. Miss X said the NHS consultants were not always available to attend meetings, so the private consultants did. She asked if these costs could be reimbursed. We could not criticise the Council for the NHS consultant not being available and we therefore could not ask the Council to reimburse these costs.
37. Miss X said the review dismissed information from the neurologist consultant regarding Mr Y’s frontal lobe injury and associated vulnerability. The review notes acknowledge Mr Y’s brain injury and epileptic fits. But I have not seen any evidence to support that the neurologist consultant provided the Council with additional information. However, regarding any reports provided by the neurologist consultant, it would have been down to the Council to consider the circumstances. But I have already found fault by the Council as it did not properly consider Mr Y’s vulnerability.

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Agreed action

38. To remedy the injustice caused by fault, within one month of my final decision the Council has agreed to:
• write to Miss X and Mr Y with an apology that takes account of our published guidance on remedies and accepts the findings of this investigation. The Council should send a copy of Mr Y’s apology to Miss X;
• pay Miss X and Mr Y £500 each in acknowledgement of the distress caused by the delay in the Council’s actions to complete a capacity assessment and to offer accommodation. Mr Y’s payment should go directly to his court appointed deputy;
• review the suitability of properties to ensure the Council has considered distance from family;
• complete an action plan for Mr Y. This should include details of how often the Council will search for properties, details of when it will chase the properties for a response and the distance of properties from family. The Council should keep Ms Y updated; and
• go back and review whether any previous properties it approached now have availability. The Council should also keep Ms Y updated with the outcomes.
39. Within two months remind relevant staff of the need to complete a capacity assessment in situations such as these. The Council should use this case as an example.
40. The Council should provide us with evidence it has complied with the above actions.

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Final decision

41. There was fault by the Council. The actions the Council has agreed to remedy the injustice caused. I have completed my investigation.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman