Summary: Ms X complained about failings by the Council’s Adult Social Care service to support both her and her adult son, Mr Y. We found the Council at fault for failing to follow-up on respite care, and for failing to properly consider what support it could offer when Mr Y’s behaviour escalated. The Council agreed to provide a symbolic financial remedy for the distress this caused. The Council was also at fault over the advice it gave on emergency accommodation, but this did not cause significant injustice.

The complaint

1. Ms X complained about failings by the Council’s Adult Social Care (ASC) service. She said the Council did not respond to her reports of concerning behaviour and violence from her son, Mr Y, made prior to his arrest, and did not provide the family any support.
2. Ms X also complained the Council did not provide an emergency respite placement for Mr Y when he was due to be released from police custody. Mr Y’s care provider found him a hotel, but Ms X said the Council left him at risk.
3. Ms X said Mr Y’s social worker did not understand the risks of Mr Y living at home. They also did not understand his communication needs and used long words, causing him distress.
4. Ms X said the Council’s ASC service let the family down and considers Mr Y’s arrest could have been avoided if the Council acted on her reports.

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The Ombudsman’s role and powers

5. 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)
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. As part of the investigation, I considered the complaint and the information Ms X provided.
8. I made written enquiries of the Council and considered its response along with relevant law and guidance.
9. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What happened

10. I have summarised below some key events leading to Ms X’s complaint. This is not intended to be a detailed account of what took place.
11. Mr Y has care and support needs, but the Council’s case notes state he does not lack capacity to make decisions. Ms X disputes this. She said Mr Y’s psychiatrist found Mr Y lacks capacity to make decisions about all areas of his life. Mr Y previously lived in supported living accommodation, but moved back into the family home after an incident at his accommodation. The Council offered Mr Y other supported living arrangements, but he declined.
12. Whilst back at the family home, Mr Y was receiving 35 hours of support a week from a personal assistant (PA) arranged by his care provider. Mr Y’s PA took him out into the community as part of his support. Mr Y had a joint housing application with his sister, but they did not have high priority.
13. Ms X telephoned the Council on 17 April 2023. She wanted to speak about what had been happening at home the last few nights. She asked for a call back.
14. Ms X telephoned the Council again on 20 April to report that Mr Y had got angry and damaged furniture at home. She agreed to speak to the Council again when she had more time.
15. Ms X spoke with Mr Y’s social worker on 25 April to report that Mr Y grabbed her shoulders the previous day while she was lying in bed. He also damaged items in the house, and was jealous of his siblings. Ms X said the house is overcrowded, and Mr Y needed to leave. The social worker said it is better if Mr Y moves out in a planned way. Ms X said she felt like killing herself. The social worker said she had made comments like this before, and the Council signposted her to support. The social worker said if Mr Y’s actions put Ms X in fear, she should call the police. They also asked Ms X if she had spoken to her GP about Mr Y’s behaviours. Ms X said she had. The social worker said they could ask Mr Y’s care provider to encourage him to improve his behaviours. Ms X said she would speak to them.
16. The Council spoke to Mr Y’s care provider on 11 May 2023. It discussed Ms X’s difficulties coping, and the need for Mr Y to move. The Council said it gave Ms X advice, but she does not always accept it. The care provider said it had no issues with Mr Y’s behaviour. His challenging behaviour is mainly targeted at his Ms X after incidents at home. Ms X told me the only advice the Council gave was to call the police if Mr Y became violent.
17. The Council spoke to Mr Y’s care provider again on 15 May 2023. It asked if Mr Y would consider respite care. The care provider said it would speak to Mr Y.
18. On 18 May 2023, the care provider told Mr Y’s social worker that Mr Y tried to strangle Ms X twice in the same day. This was because Ms X was not listening to Mr Y, making him angry.
19. Mr Y’s social worker telephoned Mr Y the following day. Mr Y did not want to go into supported living where there are staff. The social worker tried explaining Shared Lives, which is a different form of supported living, but Mr Y did not understand. The social worker agreed to see Mr Y face-to-face and encouraged him to keep things calm at home with Ms X. Mr Y said he would try.
20. Mr Y’s care provider contacted his social worker on 18 June 2023, telling them the police arrested Mr Y on 16 June for assaulting Ms X again. The police held Mr Y overnight and would not let him return home. The care provider arranged a hotel for Mr Y, otherwise he would have had to stay in police custody over the weekend. The police had telephoned the Council’s Emergency Duty Team (EDT), but it told the police there was no emergency accommodation available.
21. Ms X telephoned the Council on 19 June 2023. She was scared to have Mr Y back home after he strangled her without reason. She also said Mr Y’s sister no longer wanted to share accommodation with him as she cannot manage his behaviour.
22. Mr Y’s social worker telephoned his care provider. They said Mr Y does not want social care housing with staff on site, but asked the care provider to encourage him to be flexible, as he needs somewhere to live. They gave the care provider the telephone number for the Council’s urgent homelessness assessment team so they could support Mr Y in contacting them. The social worker considered the best outcome was for Mr Y to have accommodation where the care provider can continue supporting him.
23. The social worker then contacted two care providers about the possibility of emergency accommodation. They also emailed the Council’s housing team asking for advice.
24. Mr Y sent his social worker a text message, saying he did not want to move into supported living accommodation. He wanted his own flat, and did not want to share. The social worker said no one can force Mr Y to live somewhere, but encouraged him to be flexible as he needs accommodation urgently.
25. The Council’s housing service offered Mr Y temporary accommodation (TA) in a shared multiple occupancy home.
26. Mr Y’s social worker spoke to Mr Y’s psychiatrist on 20 June. They had no concerns since Mr Y moved into TA. The social worker telephoned Mr Y to confirm this. Mr Y said he was fine, and his TA was OK.
27. The social worker then contacted Mr Y’s care provider about Mr Y having support at weekends as well as through the week.
28. Ms X asked for an urgent case review and needs assessment for Mr Y on 21 June.
29. Mr Y’s social worker spoke to Ms X. She was stressed and off work. She felt let down by the Council and said the incident could have been avoided. She also said there was no ASC support at weekends. The social worker said Mr Y was due to move in with his sister, who was bidding on properties. The plan has now changed and there is nothing else the Council could have done. Ms X said Mr Y’s care provider told her the Council was looking to reduce Mr Y’s support hours. The social worker said this is not true. They asked the care provider about spreading Mr Y’s 35 hours’ support over the weekend, or if he needs more hours. The care provider had not responded yet, but the social worker said they would speak to them about increasing Mr Y’s hours.
30. The social worker then emailed the care provider asking how many extra hours support a week Mr Y needed.
31. Mr Y said he did not want extra support at weekends as he wanted to visit his aunt’s shop. He did agree to having help with medication though.
32. Mr Y’s social worker held a review on 29 June 2023. Mr Y engaged well but did not always understand everything explained to him. At times he would say yes when asked if he understood, but when told it was OK to say no, he would change his answer to no.
33. Ms X complained to the Council in April 2024. She said she reported Mr Y was physically and verbally abusive to her before the incident in June 2023, but the Council took no action.
34. Ms X also complained the Council did not respond when Mr Y was in police custody. His care provider had to find him a hotel as he could not go home. Ms X said the Council left Mr Y at risk of serious harm, abuse, or exploitation.
35. Last, Ms X complained about the way Mr Y’s social worker communicated with him. She said they did not understand Mr Y’s condition and vulnerabilities, and Mr Y’s current care package does not meet his needs.
36. The Council responded to Ms X’s complaint in May 2024. It said the incident in June 2023 happened outside office hours. The police contacted its EDT asking for respite accommodation as Mr Y could not return home. The EDT said it could not provide respite at weekend. The police called back later to confirm Mr Y’s care provider arranged a hotel for the weekend.
37. The Council said Mr Y’s social worker contacted the housing service on their first day at work after the incident, ensuring Mr Y had TA. They also temporarily increased Mr Y’s support hours with the care provider.
38. The Council found no problems with the social worker’s communications with Mr Y. The social worker met Mr Y in late June to discuss his ongoing care and accommodation needs. Mr Y was clear he did not want to live in supported living and wanted to live independently. The social worker had weekly conversations with Mr Y between August and October, and Mr Y did not raise any concerns at his review meeting in November. The social worker asked Mr Y’s psychiatrist to provide therapeutic support and referred him for speech and language therapy.

My investigation

39. Ms X’s representative told me Mr Y moved back to the family home in July 2021 after refusing to return to supported living. Mr Y’s social worker tried to arrange a move to different supported living, but Mr Y refused because he was traumatised by his experience.
40. Mr Y made a joint housing application with his sister in October 2021. His social worker wrote a letter of support, saying Mr Y needed his own accommodation due to anxiety.
41. Ms X said she reported many incidents where Mr Y became aggressive, including several occasions where he pushed his younger brother. Ms X felt the Council should have arranged TA for Mr Y to stop this behaviour.
42. Ms X said Mr Y’s behaviour worsened from January 2023, when he started getting jealous of her showing affection to his siblings. Ms X reported an incident to the Council where Mr Y twisted her arm. The Council told her to call the police if it happened again, but did not do anything to help.
43. Ms X said she told Mr Y’s social worker he would harm someone. They then put pressure on Mr Y to move back into supported living accommodation, which caused him distress.
44. The Council told me it had regular contact with Mr Y and Ms X between August 2022 and May 2023. Ms X did not want Mr Y to live with her, but he declined housing support as he wanted to live with his sister. The Council increased Mr Y’s care package to 35 hours a week, which he used for accessing the community for about five hours a day.
45. The Council said it made two referrals to an organisation offering community support and short breaks, but the organisation did not respond. The Council recognised it should have chased the organisation, or looked at alternatives, but it did not do so.
46. The Council also asked Mr Y’s care provider to offer respite, and it agreed to take him away for the weekend if he paid for transport and hotel costs. Mr Y and Ms X did not respond to this. Ms X told me they were keen for Mr Y to have a trip away, but they heard nothing more about it after the Council officer who proposed the idea left the Council.
47. The Council referred Ms X for a carers assessment on 31 January 2023. Ms X told me despite the referral, she did not have a carers assessment in 2023.
48. The Council said its EDT was wrong to tell the police it could not arrange respite for Mr Y. The Council has amended its processes to ensure EDT has a list of care providers with vacancies to support incidents like this over weekends.

Analysis

49. Ms X and the care provider told the Council about Mr Y’s increasing behavioural problems in April and May 2023. This included Mr Y grabbing Ms X, and two occasions where he tried to strangle her. I can therefore appreciate why Ms X feels the assault and arrest in June could have been avoided with earlier intervention or support from the Council.
50. The Council gave Ms X general advice about speaking to her GP, speaking to Mr Y’s PA, and to call the police if Mr Y’s behaviour escalated again. I do not consider the Council did enough. On the evidence seen, the Council was at fault for failing to properly consider what support it could offer both Ms X and Mr Y at that time.
51. The Council should have considered whether Ms X was a victim of domestic abuse, and whether it needed further information or advice on this. It should also have considered whether Ms X needed training or advice in de-escalation or restraint techniques to diffuse the situation when Mr Y had behavioural outbursts.
52. The Council said it referred Ms X for a carers assessment in January 2023. It should have considered whether it needed to review or fast-track this process in light of Mr Y’s behaviour.
53. While I appreciate the Council made earlier referrals to an organisation providing respite care, it acknowledged it failed to follow this up. On the evidence seen, it also took no action when Mr Y did not respond to his care provider’s offer of a trip away. Mr Y was expected to pay for this trip, which may be why he did not respond, but I have not seen evidence the Council followed up on this with Mr Y, to establish the reasons or look at alternatives. That was fault.
54. Last, the Council should have considered whether Mr Y needed more support with his behaviour, and whether his current support package was meeting all his needs.
55. Although the Council did not follow up on respite care options, or properly consider the support it could offer Ms X or Mr Y, there is insufficient evidence to say whether this would have prevented the incident in June where Mr Y was arrested. However, there was distress in the form of frustration at not getting more help or support, plus uncertainty about whether timely support could have improved the situation. This is Mr Y and Ms X’s injustice.
56. The Council acknowledged fault by its EDT in telling the police it could not provide emergency accommodation. Thankfully, Mr Y’s care provider found him a hotel, so he could leave the police station. That meant Mr Y did not suffer significant injustice because of this fault.
57. The EDT should also have made a referral to the Council’s homelessness team. This was highlighted by Mr Y’s social worker when they found out about the incident after the weekend. Again, I found Mr Y did not suffer significant injustice from this failing, because the social worker made the referral as soon as they were aware, and the Council’s housing department offered Mr Y TA without delay.
58. I did not find there was fault in the support Mr Y’s social worker gave, or in their understanding of Mr Y’s communication needs. I found the social worker knew Mr Y did not understand things at times, and tried to explain things. Examples of this were in letting Mr Y know it was OK to say no if he did not understand, and in arranging a face-to-face meeting when Mr Y did not understand by telephone.
59. I did not find evidence the social worker contacted Mr Y by text message often. And on those occasions, I did not find the social worker used overly complex or unsuitable language. I found several examples of the social worker speaking to Mr Y by telephone. And I did not see any occasion where Mr Y, or his care provider, raised concerns about a lack of support from the social worker.

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Agreed action

60. Within four weeks of my final decision, the Council will:
• Apologise to Mr Y and Ms X for the identified failings. This apology should be made in accordance with the Ombudsman’s guidance Making an effective apology.
• Pay Mr Y and Ms X £250 each (£500 in total) in recognition of the uncertainty and distress caused by its failure to follow up on respite care options, and its failure to properly consider suitable support when Mr Y’s behaviour escalated.
• Remind staff in its ASC service about the importance of taking proactive steps to consider suitable support at the earliest opportunity in cases where there are reports of domestic violence, to try to prevent the situation escalating.
61. The Council should provide us with evidence it has complied with the above actions.

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Final decision

62. I completed my investigation. The Council was at fault for failing to follow-up on respite care, and for failing to properly consider what support it could offer when Mr Y’s behaviour escalated. It agreed to provide a symbolic financial remedy for the distress this caused. The Council was also at fault over the advice it gave on emergency accommodation, but this did not cause significant injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman