Summary: Mrs X complained about the failure of a Council, an ICB and a care provider to keep her daughter safe in a shared living placement. We found fault by the Council and the ICB for not doing enough to address the situation in a clear, measured and timely way. The situation caused Mrs X and her daughter avoidable stress and upset. We recommended the Council and the ICB apologise, make symbolic payments and improve their services.

The complaint

1. Miss A lived in a shared living placement. Her mother, Mrs X, said that another resident developed behavioural problems and targeted Miss A with verbal abuse and threats and acts of physical violence. Mrs X said this traumatised Miss A and meant she could no longer live at the placement.
2. NHS West Yorkshire Integrated Care Board (the ICB) fully funded Miss A’s care. Calderdale Metropolitan Borough Council (the Council) was responsible for responding to safeguarding concerns in the area. From early 2023 the ICB commissioned Voyage Care to run the shared living placement, replacing the previous provider.
3. Mrs X complains the ICB, the Council and Voyage Care individually and collectively failed to adequately address the cause of these problems.
4. Mrs X complains the organisations failed to tackle the behaviour of the other resident and failed to provide acceptable and suitable support to Miss A which would have allowed her to keep her placement. As part of this, Mrs X complains the responsible organisations failed to thoroughly investigate her concerns or examine evidence and, instead, accepted evidence presented to them without questioning it. Lastly, Mrs X complains that no one has been held to account for avoidable failings in Miss A's care, or the avoidable impact those failings had.
5. For the impact, Mrs X said a psychologist diagnosed Miss A with complex post traumatic stress disorder (c-PTSD) relating to the actions of the other resident and lack of support around this. Mrs X said Miss A could not live in the placement which was her home. Mrs X said she had to give up work to support Miss A and experienced significant stress which affected her health and relationships. Mrs X also said the family had to pay privately for weekly therapy sessions for Miss A.
6. Mrs X said she would like the Ombudsmen to hold the relevant parties to account for their failings. Mrs X would also like the organisations to fund the psychological support that she has privately paid for.
7. Mrs X also raised concerns about the way the ICB responded to Subject Access Requests (SARs) she made for copies of records. Mrs X complains the ICB did not properly consider the issue of Miss A’s capacity and unfairly questioned her ability to properly advocate for Miss A.

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The Ombudsmen’s role and powers

8. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
9. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
10. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
11. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
12. We cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant organisation has to make. Therefore, my investigation has focused on the way that the body made its decision.
13. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 

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What I have and have not investigated

14. I have not investigated Mrs X’s complaint about the way the ICB handled her SARs. The Information Commissioner’s Office is more suited to do so.

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How I considered this complaint

15. I considered Mrs X’s written complaint to the Ombudsmen and spoke to her on the telephone. I wrote to the ICB, the Council and Voyage Care to explain what I intended to investigate and to ask questions and for relevant evidence. I considered all the papers I received in response. I read relevant legislation and guidance.
16. I shared a confidential version of this draft decision with Mrs X and the organisations and invite their comments on it. I considered all the comments I received in response.

What I found

Legislation and guidance

17. The Department of Health and Social Care’s National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (July 2022 (Revised)) (the National Framework) is the key guidance about Continuing Healthcare (CHC). It states that where an individual is eligible for CHC funding the Integrated Care Board (ICB) is responsible for care planning, commissioning services and case management.
18. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse (section 42, Care Act 2014).

Brief history of events

19. The following account is a brief summary to give some context to the analysis of the complaint. It is not intended to be a full and comprehensive history of the events.

2019

20. In 2019 Miss A moved into a four-bed apartment within a supported living placement (the Placement). It had communal living, dining and kitchen areas. A social care provider, Provider A, staffed it 24 hours a day. Toward the end of the year the ICB determined that Miss A was eligible for CHC funding. The ICB became responsible for funding and managing Miss A’s care and support.

2021

21. Mrs X said that in early 2021 another resident began assaulting and verbally abusing Miss A. Mrs X emailed the ICB to voice her concerns about this. She noted the negative impact it was having on Miss A’s wellbeing. Miss A left the Placement and returned to live with Mrs X.
22. The ICB asked Mrs X if she wanted to look for an alternative placement for Miss A or if she wanted Miss A to remain in the family home with funded support. Mrs X said Miss A wanted to return to the Placement but would not do so until the organisations resolved the issues.
23. During February and into March both the ICB and the Council told Mrs X that it was looking into the situation and trying to work out how best to resolve it.
24. At the start of May 2021 Mrs X emailed a Council adult services director. Mrs X set out her concerns about the situation at the Placement caused by the behaviour of another resident, Ms H. The director said he would make some enquiries and get back to Mrs X.
25. Throughout the rest of 2021 Mrs X continued to have concerns about Ms H’s behaviour and the impact it was having on Miss A. There was no follow up from the director Mrs X had contacted.

February 2022

26. At the start of February 2022 Mrs X emailed the Council director again about her concerns about Ms H’s behaviour. The director said he would ask staff to look into her concerns.
27. Provider A also contacted the Council at the same time. It noted that Ms H had made threats to kill Miss A and had verbally abused her. Provider A said there were no obvious triggers for this behaviour. It also said “This has been going on for the last two years but has escalated recently”.
28. The Council logged a safeguarding alert. It asked Provider A what it had done to address the immediate risks. Provider A said that Mrs X had taken Miss A home. The Council advised Provider A to:

• contact the police about the threats to kill;
• contact a specific learning disability team to ask for an urgent assessment of Ms H; and,
• provide it with a copy of a risk assessment detailing how it would manage the relationship between Miss A and Ms H.

29. The Council also advised the ICB of the alert and what it had done. During this time the Council told the ICB that “This has apparently been going on for longer than Social Services have been made aware”.
30. In the following days staff from the Council spoke to the family of the other resident. Provider A also sent the Council copies of Positive Behaviour Support (PBS) plans for Miss A and Ms H. It later said that it had completed a risk assessment which it had incorporated into the PBS plans. Provider A also said the clinical lead for its PBS Team had spoken to the manager of the Placement and would work closely with Ms H to assess her needs.
31. Later in February staff from the ICB met staff from Provider A to discuss the strategies it would put in place to ensure it kept all residents safe. The following day the Council closed its safeguarding file. It did so because more support was now in place for Ms H and because the police was not taking any action. The Council said it had asked Provider A to monitor the situation and come back to its safeguarding team if necessary.

March to May 2022

32. In the middle of March the Placement contacted the Council and said the situation with Ms H’s behaviours was escalating. At the end of the month the Council attended a meeting with various professionals. The meeting noted there were “ongoing organisation issues” at the Placement, and that it would be “difficult to put behaviour strategies in to practice” while these issues persisted.
33. Toward the end of April Mrs X emailed the Council and said she did not have any confidence the measures put into place would resolve the problems. Mrs X said Ms H’s behaviour continued to affect Miss A. A social care director said they would ask an assistant director and a service manager to look into Mrs X’s concerns and ensure they were addressed properly.
34. In May Mrs X contacted the ICB and said she was taking Miss A home until the situation at the Placement was resolved. The ICB asked if there was any further support they needed while Miss A was at home and Mrs X said she would think about it.
35. Around the same time the manager of the Placement contacted the Council and noted concerns that the situation was unmanageable. It also raised a safeguarding concern about actions of Ms H. It said her actions had caused Miss A to be:

“extremely frightened…she was inconsolable…she was scared to be in the same apartment as [Ms H]…[Miss A] was shaking and sweating. [Miss A] is mild mannered and often gets frightened by [Ms H’s] behaviour. This has caused a massive impact on [Miss A’s] mental health as she does not know how to behave around [Ms H] as she doesn’t want to trigger [Ms H’s] behaviours”.

36. The Council director emailed Mrs X and said they understood her decision to remove Miss A. The director said he would ask his officers to progress the safeguarding investigation for all the people living in the house.
37. A safeguarding meeting took place in late May 2022. A social worker agreed to book a meeting with a learning disability nurse and the Placement “to look through the behaviours and what needs to be done”. The social worker said she would report her findings back to management “as this situation…will continue to escalate”.
38. In the following days the learning disability nurse told the social worker they did not feel the management or staff at the Placement took on board any of the advice they offered. There was a plan for a healthcare assistant from the learning disability team to visit the Placement over the next four weeks to go through the behaviour plans and complete assessments. The social worker said she would communicate with the healthcare assistant over the next four weeks to get an insight into the other resident’s behaviours, assessments and incident reports.
39. Also in late May, staff from the ICB visited Miss A to complete a review. It asked if she wanted to move to a different placement. Mrs X said Miss A did not and wanted to move back to the Placement if Ms H was not there.
40. The ICB also visited the Placement and met with management. The ICB noted that all care plans were up to date and relevant and staff had signed to say they had read them. The ICB noted “the service can meet [Miss A’s] needs at this time”. The ICB then had an internal discussion about Miss A’s case. It recommended that, once the review was complete, they should complete a pros and cons list about Miss A staying at the Placement. Also, that the ICB should provide some alternatives – such as living on her own with support or living at home with a Personal Health Budget (PHB).
41. At the end of May 2022 the Council director met Mrs X. The director said they would set up welfare visits for all residents. He also said he would like to keep in touch with Mrs X every two weeks.

June and July 2022

42. At the start of June Council staff made an unannounced visit to the Placement and looked at paper care records. At the same time the ICB wrote to Mrs X and said that, based on its review of the Placement’s care plans and paperwork, the Placement was meeting Miss A’s needs. Mrs X disputed this and raised concerns about the abilities of the staff at the Placement.
43. The ICB case worker asked for managers to become involved in the case. The ICB planned to meet with Mrs X and Miss A to provide choices and recognise that the Placement was not working for Miss A. The ICB noted that managers would support with case management to try to move the situation forward.
44. The ICB held a virtual meeting with Mrs X in the middle of the month. The ICB said it would have a meeting with the Council and the Placement.
45. Mrs X raised a safeguarding alert in late June 2022, about the impact of Ms H’s behaviour. Mrs X noted concerns that nothing appeared to have happened in response to the previous safeguarding alerts. Mrs X said staff had told her that a behavioural specialist was working with Ms H and offering strategies to staff to help deal with the outbursts. Mrs X said none of this had worked and the other resident’s behaviour had only intensified. Mrs X also said a director had promised her two-weekly contact but this had not happened.
46. In the first half of July the ICB spoke to Mrs X and discussed three alternatives:

• Miss A returning to the Placement and Mrs X working with staff to help improve the situation,
• Miss A moving into a different flat within the facility,
• Miss A remaining in the family home with support from a care provider.

47. The ICB’s contemporaneous records state that Mrs X told the ICB caseworker that she would consider the options put forward. Mrs X told me this is incorrect as the alternatives were unviable.

August and September 2022

48. In August Mrs X’s MP wrote to the Council and noted they had met with several families about the Placement. The MP said that no-one had been in touch to check on Miss A for several weeks. She also said that three families were stressed and concerned for their loved ones because of a lack of strategy for dealing with the other resident’s behaviour. The MP said there needed to be a plan for the other resident so the other tenants could live there without fear.
49. In early August Miss A returned to the Placement. Mrs X said that, in the days after she returned, Ms H threatened Miss A again.
50. The Council replied to the MP in the second half of August. It said that Ms H was doing well in the Placement and the number of incidents had reduced. It said there were no plan to evict Ms H from the Placement. The Council suggested it would be possible for all residents to continue living at the Placement with sensitive and suitable management.
51. At the end of August 2022 the Council contacted the ICB and suggested a meeting to discuss the situation. The ICB agreed this would be useful. The Council also planned to assign a social worker to Miss A to work alongside the ICB to move things on.
52. Around the same time Mrs X logged a fresh safeguarding alert with the Council, about a threat made to Miss A by Ms H.
53. In the middle of September the Council told Mrs X it had allocated a named social worker to work with Miss A. However, this worker did not materialise.
54. Also in mid-September, a social worker (not Miss A’s allocated worker) recorded that a review had been completed in early July 2022. They said the review had concluded that the Placement was not the right place for Miss A. At a similar time, an ICB worker noted a call with a social worker. They recorded that the social worker told them that the Placement had told them that it was not the right environment to meet Miss A’s needs.

October and November 2022

55. In early October the Placement told a Council officer the strategies in place for managing Ms H’s behaviour were not working. The Placement said it was going to contact the learning disability team again. It reiterated these concerns in late November.
56. The Placement also logged a safeguarding concern with the Council about aggressive behaviour from Ms H toward Miss A. The Council noted this was an ongoing situation with a social worker currently making enquiries.
57. In the middle of October Mrs X had a meeting with Council staff. Mrs X said that during the meeting the Council admitted that it had failed Miss A. Throughout these months Mrs X continued to raise concerns about the situation and the lack of any resolution.

December 2022 to January 2023

58. In early December Mrs X raised a fresh safeguarding alert about verbal abuse from Ms H to Miss A. The Council spoke to Miss A and Mrs X and decided this did not need further investigation.
59. At the end of the month Mrs X emailed the Council. She said she had been contacting the Council for the last 22 months about a failure to effectively deal with a situation which had resulted in Miss A being unable to live in the Placement. She said they remained without any support or a way forward.
60. In early January 2023 the Council emailed the ICB and suggested it attend a planned meeting. The ICB could not attend.
61. Toward the end of January the Council emailed Mrs X and said it agreed that Miss A “has been away from her home for too long”. The Council apologised that it had not yet assigned a social worker to Miss A, for safeguarding and hearing her views. The Council accepted there had been a “significant” delay.
62. In January 2023 there were plans for care provision at the Placement to change from Provider A to Voyage Care.
63. At the end of January 2023 the Council emailed Mrs X and apologised for the time it had taken to reallocate Miss A’s case. It said it had now assigned Miss A’s case to its practice lead. The Council said the practice lead would:

“fully look at all the safeguarding concerns that are currently open…and ensure that concerns are listened to from [Miss A’s] point of view. [The practice lead’s] role is specifically around any safeguarding concerns that are present for [Miss A] but she will liaise with [Miss A’s] ICB worker with regards to the support in place or required for [Miss A] moving forward”.

February 2023

64. In the middle of February a housing manager met Miss A and Mrs X. Miss A said she wanted to return to the Placement. She said that for this to happen the other resident could not be there. The housing manager said Ms H “will not be leaving and there are not any plans for [Ms H] to be asked to leave…”
65. The manager said that circumstances could not remain as they were and they needed to decide whether:

• Professionals would support Miss A to return to the Placement,
• The Placement would serve Miss A notice to end her tenancy, or
• Miss A would stay at home.

66. In the middle of February 2023 the Council practice lead asked for a meeting with the ICB. Toward the end of February 2023 the Council said it had asked an independent management to consultant to investigate Mrs X’s concerns. The Council said it had asked an independent management consultant to do so.
67. A social worker spoke to Miss A about the safeguarding concerns around the same time. Internally, the social worker noted concerns that, given the length of time the situation had continued for, it may not be possible for Miss A and Ms H to live together. They suggested a multi-disciplinary meeting.

April 2023

68. In April 2023 Voyage Care took over from Provider A, having acquired the service. As noted in paragraph 34, Miss A had left returned to live with Mrs X in May 2022. This situation remained unchanged and Miss A had not lived in the Placement since May 2022.
69. In the first half of April a meeting took place, attended by Mrs X, the Council and Voyage Care. It noted that “Initially this meeting was to be held as safeguarding case conference”, to consider safeguarding concerns raised while Provider A had been in place. However, the attendees said there were “outstanding investigative needs” which needed further exploration. They said this investigation needed to happen before professionals could address the safeguarding concerns and decide what action to take. The attendees said “Planning meetings are required with clear outcomes to be determined by each service involved”.
70. The meeting discussed what would need to be in place to safeguard Miss A. It said that “risk assessments and behavioural analysis needs to take place, contingency plan, care plans…so care staff know how to support [Ms HH H] appropriately and consistently”. A professional also noted that a “wider investigation [is] needed to determine whether these safeguarding concerns are investigated individually or whether an organisational investigation needs to take place”. The meeting was rescheduled for early June 2023.
71. In the days after this meeting the Council’s practice lead emailed the ICB and said she could “substantiate that behavioural incidents have occurred which have impacted on [Miss A’s] emotional and psychological wellbeing”. The practice lead said her concern was that she could not “fully determine whether this behaviour is likely to re-present when [Miss A] moves back to the Placement.” She said this was because she had found that “the support at the Placement has not been managed efficiently [and she had found] significant issues with the quality of care provided.” This related to the period when Provider A had managed the service. In particular, the practice lead noted that learning disability team had received, from Provider A, “very minimal information in respect of the behaviours that have been reported through as safeguarding concerns.” The practice lead raised the possibility that the relevant behaviours could be a result of an unmet need.
72. Toward the end of April Mrs X told the ICB that Miss A was now seeing a privately funded psychologist each week. Mrs X raised concerns that professionals had not properly supported Miss A’s mental health or addressed her problems. Mrs X said the psychologist was looking into whether Miss A may be suffering from PTSD.

June 2023

73. In early June, the day before a scheduled follow-up safeguarding meeting, the Council cancelled it. The Council said it needed to review all the safeguarding concerns and contact all relevant parties. It also said it felt there was a lack of clarity about the purpose of the meeting.
74. In the middle of June a professionals meeting took place. Before the meeting a Council officer had produced a chronology of safeguarding referrals made to the Council since February 2022, with details of the actions taken in response. The officer shared this at the meeting.
75. The attendees agreed that:

“it was not acceptable that [Mrs X] felt so concerned…that [Miss A] needed to return to [Mrs X’s] home address, and that the amount of time that [Miss A] remains at home is now approx. two years & two months. [Miss A] has clearly been affected by this situation and she has become much more anxious and lacking in confidence in returning to the placement, the longer this issue remains unresolved”.

76. Voyage Care shared their view that the support from the learning disability team had been unsatisfactory and inconsistent and ineffective. The attendees noted that:

“Part of the reason for this, was the inability of the staff team at the time [i.e Provider A] to take on board the new ways of supporting the client involved, and it was acknowledged that the implementation of the [positive behavioural] support, was not managed well by the managers [of Provider A], and the staff [of Provider A] were not trained to implement the plan”.

77. Voyage Care said it was training staff on how to support the tenants. It also described how it intended to support Miss A’s transition back to the Placement. It said it still felt that Miss A and Ms H were compatible but understood that Miss A may struggle to overcome her anxieties about returning to the placement.
78. The attendees said the ICB case manager would need to be closely involved as, if Miss A could not stay at the Placement, they would have to find alternative provision. There was a plan which included arranging a meeting with Miss A and Mrs X to go through the actions of the meeting and to get their views.
79. In the following week Voyage Care emailed Mrs X and asked if they could set up a four-week timetable. Mrs X said this followed her contact with Voyage Care as she had not heard anything from them. Voyage Care said it aimed to work with Miss A back into spending time in the service with the eventual goal of her returning. It said it hoped that, by the end of week four, it could include visits to the Placement in the timetable.

August 2023

80. In early August Miss A stopped engaging with Voyage Care. Voyage Care noted at the time that this followed a report from the private psychologist which diagnosed Miss A with complex PTSD. Mrs X said the decision was a result of a lack of adequate or appropriate care planning or support from Voyage Care. In the psychologist’s report they said Miss A had developed this “as a direct consequence of being subject to physical, emotional and psychological abuse perpetrated by a tenant in her domestic residence, over a protracted period of time”.

September 2023

81. In early September a Council officer met Miss A, Mrs X, and Miss A’s private psychologist. They discussed the outstanding safeguarding concerns. The Council officer “accepted that the team had not provided a good enough response to the concerns, and that the delay in responding until today, was not good enough.” However, they decided the risks to Miss A were not present while Miss A stayed with Mrs X.
82. The Council officer also noted that:

“it was clear from my observations, that [Miss A] has suffered a significant trauma whilst residing in her tenancy, and is continuing to suffer anxiety related to her experiences, and to the thought of moving back when the perpetrator remains living there.”

83. The Council said it would not get involved in discussions about placement options as it was the ICB that funded Miss A’s placement. The attendees agreed there would be a further meeting with the ICB, the Placement and the landlord to discuss available options.
84. Toward the end of September 2023 Voyage Care set out a position statement before a meeting with Miss A, Mrs X and the ICB. It said all the people it supported at the Placement and all its staff would remain the same “with some consideration as to the sensitivities of [the PA]”. It said that before it could resume Miss A’s visits to the service it needed to discuss and consider realistic outcomes with Miss A and her private psychologist.
85. A meeting took place toward the end of September. Mrs X and the psychologist said there needed to a comprehensive plan to enable Miss A’s return. An action plan included an intention for Voyage Care to work with the psychologist to develop a plan. This depending on funding for the psychologist’s time and work.

October and November 2023

86. During October Voyage Care noted concerns to the ICB that it could not complete a clear transition plan for Miss A without professional input from psychology. Miss A remained without access to through the NHS, on a long waiting list.
87. A professionals meeting took place in the middle of November 2023, attended by the ICB, Voyage Care and the landlord. The ICB declined to fund any work from between Voyage Care and Miss A’s private psychologist. Voyage Care said it could not produce a meaningful plan without involvement from psychology.
88. The ICB agreed that Voyage Care would no longer provide Miss A’s 14 hours of funded support. The ICB said it would look to fund a personal assistant to support Miss A, as a temporary measure, until a psychologist could clarify how best to move forward.

December 2023 to February 2024

89. In December 2023 the ICB recorded that it had been looking for an alternative placement for Miss A. Mrs X said she also looked and found a placement which she considered to be suitable. She asked the ICB to use this placement. In January 2024, as part of these discussions, Mrs X served notice on Miss A’s tenancy at the Placement. The ICB agreed a new placement for Miss A, as identified by Mrs X.
90. At the end of February 2024 the new placement reported that Miss A had settled really well.

Complaint processes

91. After raising concerns earlier, Mrs X made a ‘formal’ complaint to the Council in January 2023. In its responses of April and November 2023 the Council:

• Accepted it did not complete the promised welfare checks,
• Apologised for poor communication.

92. Mrs X complained to the ICB in September 2023. In its response the ICB said the Placement had “not provided the safe environment and quality of support to fully meet [Miss A’s] needs”. However, it said that it had acted correctly in offering alternative care and by working with the Placement to improve the situation.

Analysis

2021

93. Mrs X raised concerns with various professionals in 2021. She was told at points that staff were looking into it. However, there is little evidence to show that anything specific happened. This was not good enough, and is fault. There were serious concerns and warranted a proportionate response with a clearly articulated outcome.

Response to safeguarding alert in February 2022

94. By this time Mrs X and Provider A had let the Council know that there were issues involving Miss A and another resident, with threats made against Miss A. As such, the Council had a reasonable concern that Miss A could be at the risk of harm. It, therefore, had a duty to analyse the situation. It if felt there was a risk to Miss A it needed to consider whether the risk could be removed or mitigated.
95. At this stage the ICB and Council responses to the risk posed to Miss A were proportionate. They asked Provider A to document what was happening and to do more to keep everyone safe. It was fair to allow an opportunity to try to address the relevant issues. It was also appropriate to expect Provider A to act on this and take the necessary steps.

March to May 2022

96. By the end of May 2022 it seems evident that the initial attempts at resolving the problems in the Placement had not worked and that further action was required. Further, there is evidence to show that Council staff already had concerns that this was not an isolated issue affecting Miss A and Ms H. Rather, that it was a symptom of wider issues and concerns about the overall management of the Placement by Provider A.
97. During this time there does not appear to be any conclusion about whether Miss A was at risk of harm on not. There is evidence to show that staff understood the impact the situation was having on Miss A, including that she had left the Placement.
98. At this stage, on balance, it seems that both the Council and the ICB should have been conscious of the need to begin working together to resolve the situation. Further, given this was essentially a second attempt at resolving a difficult situation, there should have been a firmer plan about: the possible options; and, how the success of any given plan would be measured. The organisations should have been working together to address the fundamental question of whether it was realistic and feasible for Miss A and Ms H to continue to live together in this environment. And, if so, what needed to happen to ensure if could work. Or, if not, the next steps.
99. Both the Council and ICB identified actions and plans that would have been useful (regular welfare visits and an analysis of the situation and options, respectively). However, neither of these plans came to fruition.
100. It was not until August that the Council and the ICB started to make plans to work together on the case. This should have happened sooner; probably around three months sooner.
101. As such, there was fault here by both the Council and the ICB. The impact was a lost opportunity to define and address the situation in a clear and focused way which could have been monitored effectively. It is not possible to say what would have happened if there had been a clear, well communicated, multi-agency plan of action at this time. There are too many variables and unknowns to be able to say that it would have led to Miss A’s continued, successful tenancy at the Placement. However, the uncertainty it has left is an injustice in its own right.

June 2022

102. Mrs X made a safeguarding alert at this time. There is no evidence that the Council considered this alert through the safeguarding process. Miss A remained at the family home at this point. At such, it is possible that the Council did not consider Miss A to be at immediate risk of harm. However, there needed to be explicit response to the safeguarding alert. Also, the Placement was still Miss A’s home and she had a clearly stated desire to return there. As such, it was not enough to ignore the safeguarding concerns until she returned and the risk became “active” again. Given the history it could have been confidently predicted that the risk would still be present if Miss A returned. As such, it would have been appropriate to continue to plan how to mitigate and reduce that risk through the safeguarding process.
103. In the middle of August Mrs X chased for an outcome of this alert. The Council noted that:

“this case is one that has been escalated to Senior management due to the complexities and [a manager] had asked [two colleagues] for a discussion on 27th June but I haven’t heard anything further”. Also, at the start of September, when another alert had come in, staff queried whether to opened as a new, separate case as “I can see from case notes that this is sat with senior management”.

104. It seems the Council elected to try to handle this situation outside of the usual processes. Those processes are there to allow a defined, transparent process to happen. Electing to disregard these processes and to handle the issue behind closed doors, without records or regular, open communication was fault. This fault further fed in to the lost opportunities and avoidable uncertainty.

Comments about the suitability of the Placement for Miss A in September 2022

105. In September 2022 both the Council’s and the ICB’s records contain references to views that the Placement not being the right place for Miss A.
106. I cannot see where these views stemmed from. I have not seen evidence of an assessment which concluded that the Placement could not meet Miss A’s needs. If staff at any level had determined this was the case it should have been clearly documented with a rationale. There should also have been a corresponding plan for the next steps and clear communication with all of the relevant stakeholders. The lack of anything like this is fault. It confused the situation.

October and November 2022

107. Throughout these months there is clear evidence in the Council’s records that the previous strategies for managing the situation had not worked. Also, that the risks to Miss A, if she was in the Placement, remained the same. However, there is no evidence of any new, specific, measurable plan to address the situation. Instead, the situation drifted along without any meaningful action or plan.
108. After Miss A first left the Placement there were some reports that, initially, Ms H’s outbursts had declined. This may have suggested to staff that, for whatever reason, the interactions between Miss A and Ms H were a significant factor in precipitating the outbursts. This could have led a more specific plan to understand, analyse and address the dynamic.
109. However, later there were reports that Ms H’s behaviour had worsened again, to the detriment of others.
110. The Council (and others) still needed to work out whether:

• Miss A’s behaviour was in anyway unreasonable or inappropriate and provoking an avoidable reaction. And, if so:
• Whether Ms H’s response was understandable or disproportionate. Or, whether:
• There was no correlation between Miss A’s actions and Ms H’s behaviour.

111. These issues needed to be bottomed out in order to make an explicit decision about whether it was reasonable and realistic for Miss A and Ms H to live together. And, if not, to work out who would need to leave.
112. There should have been a positive, explicit decision about whether it was viable for both people to continue living in the same apartment. This never happened and, instead, the matter drifted without any real direction or any clear decisions. This was further fault.
113. Also, there were clear warning signs about the ability of Provider A to provide safe and effective care for the residents of the Placement. This included concerns about how well staff were adhering to advice from a learning disability nurse, and concerns about its level of staffing. These concerns were significant enough to warrant more of an explicit, formal decision about their significance and how they would be addressed.

February 2023

114. In February 2023 the landlord gave a clear statement that Ms H would remain at the Placement. It was appropriate to be clear and direct about the situation and the possibilities. As above, the Council and the ICB should have set this out and addressed these core considerations much earlier. And, if they were going to try to maintain Miss A's place at the Placement, there needed to be a clear plan of how this would happen and how it would be monitored and measured.

April 2023: aborted safeguarding meeting

115. This meeting called for “risk assessments and behavioural analysis” along with contingency plans and care plans. As before, it should not have taken this long to reach this point. These directions – aimed at producing reliable, measurable evidence with which to base set plans on – was necessary (and evident) from much earlier on.

April 2023: practice lead’s concerns about support provided by Provider A

116. The practice lead raised significant concerns about the level of care being provided at the Placement. They related these failings to their impact on Miss A’s care. However, there is little evidence about what the Council and/or the ICB planned to do to address these concerns.

June 2023: cancellation of a planned safeguarding meeting

117. This was about two months after the first meeting. The first meeting identified that further investigation was required. This very late cancellation suggests that nothing of substance was done in the interim. This is fault. It is apparent that the cause of this was staffing issues within the Council. But, regardless of this, the Council did not provide Miss A and Mrs X with a service they were entitled to expect.
118. By the end of June it was still felt that it was feasible for Miss A and Ms H to live together at the Placement. It had also been acknowledged – internally – that the other tenant’s behaviour had not been properly managed and that it had negatively impacted Miss A. However, there were still no explicit plans about the next steps with details of how progress could be measured and monitored, or about contingency plans.

September 2023

119. This is the point at which the Council’s consideration of various safeguarding concerns finished. Alerts had been made in February, May, June, September, October and December 2022. As before, and as accepted by the individual officer, it should not have taken so long to conclude the safeguarding process. This is a significant failing.
120. Also, while it may have been correct that Miss A was not in any immediate risk of harm, plans remained in place for her to return. It was clear that she had been affected in the past and would have been fair to predict she would be at risk again if she returned. I do not consider it was appropriate for the Council to end its involvement at this point. It should have continued to play a part in planning how to manage and mitigate risks to Miss A.
121. Further, given what various officers had accepted, it should have addressed the historic impact this situation had had on Miss A. This might not have been through safeguarding, but via whatever route or channel was the most appropriate.

Voyage Care

122. Voyage Care inherited a very messy and entrenched situation when it acquired the Placement from Provider A in April 2023. Miss A had not lived in the Placement for close to a year when it took over. And, throughout the period it was responsible for support at the Placement, Miss A did not spend one night there. There is evidence to show that Voyage Care engaged in discussions with various professionals along with Miss A and Mrs X. It was also clear about its need for professional psychological support. This was appropriate given the condition the private psychologist had diagnosed Miss A with, and the stated triggers for this.
123. Taking account of position it started in, alongside the ICB’s and the Council’s overarching responsibilities, I have not found any specific fault on the part of Voyage Care.

Summary

124. Deciding whether Miss and Ms H could live together was a difficult, complex decision. A decision that it was not possible, and deciding who to “evict”, would have been stressful and unpalatable for all concerned. However, this core, fundamental decision still needed to be made in a clear, transparent way.
125. As was highlighted at various points and by different personal, the decision needed to rest upon a cold and careful analysis of properly documented evidence. This would take time, in order to properly consider the circumstances leading to any difficult situations and the efficacy of any techniques for handling them. I do not discount that this, in itself, would have been challenging as it was likely to be an emotive, contested subject for the families concerned. It is much easier to look back on these events from an independent perspective.
126. However, as has been acknowledged at various points, the management of this case did not happen quickly enough. Promised actions did not happen. This meant the situation drifted and remained unresolved. This, in turn, meant that Miss A and Mrs X remained in limbo. They were not told that Miss A could not return but nor were they given a clear plan of how her return would be managed.
127. There was fault on the part of both the ICB – as the organisation responsible for meeting Miss A’s needs – and the Council – as the organisation responsible for safeguarding her. Both could and should have done more to take charge of the situation and drive toward a more definitive, accountable plan.
128. On balance, from the available evidence, this situation had a significant impact on both Miss A and Mrs X. They experienced prolonged avoidable stress, uncertainty and upset. I have noted the private psychologist’s diagnosis of complex PTSD and her thoughts about the cause of this. The Ombudsmen cannot determine either way whether Miss A was caused a psychological disorder by the Council’s and the ICB’s role in these events. Nevertheless, on balance, the impact was sizeable.
129. Due to the amount of variables and unknowns I cannot say what would have happened if the situation had been handled effectively early on. However, it is more likely than not that Miss A and Mrs X would have suffered considerably less stress and upset than they did. This is a significant injustice which both the Council and the ICB are responsible for. I have made recommendations to address this below.

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Agreed actions

130. Within one month of the final decision the Council should write to Miss A and to Mrs X to acknowledge the fault identified in this decision. It should also apologise for the impact these faults had. The Council should refer to section 3.2 of LGSCO’s Guidance on remedies, about how to make an effective apology.
131. Within one month of the final decision the ICB should write to Miss A and to Mrs X to acknowledge the fault identified in this decision. It should also apologise for the impact these faults had. The Council should refer to section 3.2 of LGSCO’s Guidance on remedies, about how to make an effective apology.
132. Within two months of the final decision the Council should pay Miss A £1,000 and Mrs X £500 as tangible, symbolic acknowledgements of the impact of its part in the faults in this case.
133. Within two months of the final decision the ICB should pay Miss A £1,000 and Mrs X £500 as tangible, symbolic acknowledgements of the impact of its part in the faults in this case.
134. Within three months of the final decision the Council should complete a review of its handling of this case. It should try to identify the cause of any failings and work out ways to address them, and improve performance, in specific and measurable ways. It should also set out how this learning will be shared with relevant staff to ensure they are properly prepared and supported when handling similarly complex and difficult situations.
135. Within three months of the final decision the ICB should complete a review of its handling of this case. It should try to identify the cause of any failings and work out ways to address them, and improve performance, in specific and measurable ways. It should also set out how this learning will be shared with relevant staff to ensure they are properly prepared and supported when handling similarly complex and difficult situations.

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Decision

136. I have found that there was fault by the Council and the ICB which caused an injustice to Miss A and Mrs X. I have closed this investigation on the basis that the recommendations I have made will provide a suitable remedy.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman