Date of decision: 09 October 2025
Summary
A young man with complex disabilities lost the respite care he relied on when he became an adult because the Council failed to plan his transition in time and then took far too long to secure a safe, suitable adult respite placement. This left him and his family without essential breaks, which caused serious stress, exhaustion and disruption to family life, despite his clear assessed need for regular respite.
What happened
Mr Y, a young man with complex needs, including severe learning difficulties, no danger-awareness and double incontinence, received Council‑funded children’s respite care before turning 18. His social worker referred him to the Council’s transition team in 2021 and checked in November 2022, because Mr X and Mrs X the parents wanted to start planning his move to adult services, but they were told his case was sitting in the “transitions pending tray”.
The Council assigned a transitions social worker in March 2023, and she first visited Mr Y at home in May 2023, about one month before his 18th birthday. At this point his parents stated they wanted his respite care to continue.
The social worker referred Mr Y for 30 days’ respite per year at an adult provider (Provider A).
In late June 2023 Mrs X visited Provider A, which then emailed the Council to say Mrs X had reported Mr Y could not use a shower and the home only had showers/wet rooms. The provider suggested an urgent occupational therapy (OT) referral to explore whether Mr Y could use alternative equipment.
Mr X described Mr Y’s severe learning disability, lack of danger awareness and double incontinence to the OT but at the end of June the parents stated Provider A could not meet Mr Y’s needs and asked what other respite options were available.
Mrs X raised safety concerns: Mr Y was unsteady on his feet, rooms offered were on upper floors, and there was no bath, only showers.
The placement team had not found any respite provider with a bath, a month later, and asked whether they would re-consider Provider A with a ground‑floor room while an OT assessed alternative bathing equipment such as a shower chair; Mr X was clear that Mr Y needed a bath for safety and evidenced this with Housing Needs forms.
Council officers discussed the case internally, feeling they needed an OT report to understand Mr Y’s bathing needs and queried whether a bath was really required for short (1–2 night) stays. The Council only held a 2009 report on Mr Y and he was a lot bigger now; the OT said the assessment would be difficult and could only be done in Mr Y’s home environment where a bath was available.
The Council then located an alternative respite provider with a bath (Provider B).
Mrs X visited Provider B in August 2023. Mr X told the social worker Provider B was unsuitable because there was no one‑to‑one support, the stairs were steep and narrow, bath grab rails were in poor condition and there were no activities for Mr Y.
Mr and Mrs X visited a third service, Provider C. It was unsuitable because there was no bath and Mr Y required more support than the provider could offer.
The social worker continued searching for respite and reviewed the case in mid‑September 2023. A senior officer decided a specific bathing assessment was essential to see if any alternative equipment could be used safely.
The OT concluded that a shower chair or shower trolley would not be safe for Mr Y and noted his apparent sensitivity to water pressure; the OT recommended trialling a bath board to support safe transfers in any respite facility with a bath.
After the OT report, the Council proposed another provider, Provider D. Mr and Mrs X visited Provider D in February 2024 and said it was unsuitable because the bath and bathroom were too small for Mr Y’s needs, upstairs areas were inaccessible and the stairs were too steep. The placement team then recorded that it had exhausted all local respite providers and there was nothing available in the area that met Mr Y’s assessed needs.
The Council allocated a new social worker, and in late May 2024 Mrs X said she was struggling to cope without respite and the social worker noted that Mr Y’s care needs were high. After a review of his overall need, the placement team confirmed it could not find a suitable provider within the borough. Some weeks later, after checking with her, Mrs X said she had already made clear she was content for the Council to look in neighbouring boroughs. The Council identified Provider E in a neighbouring borough, and in November 2024 Mr and Mrs X confirmed they were happy with that provider.
Provider E sent its costs to the Council in early December 2024. The Council took the case to its panel in early January 2025, and, following further discussion, the panel approved funding at the end of January 2025.
In January 2025 Mr X lodged a formal complaint about the failure to address Mr Y’s urgent respite needs; in February 2025 the Council replied that it had exhausted available respite options, partly upheld his complaint, accepted that service and communication had not been good enough, and apologised, saying his complaint would inform an ongoing review of transition arrangements and highlighting a gap in in‑house adult respite services.
Mr Y finally received his first overnight adult respite stay at Provider E in March 2025, almost two years after his children’s respite ended.
What was found
The Ombudsman found the Council at fault for failing to start transition planning and assessment early enough; they only assessed Mr Y a month before he turned 18, contrary to Care Act 2014 transition duties and statutory guidance requiring timely planning and continuity of care.
The Ombudsman also found a serious gap in provision between June 2023 and March 2025, when Mr Y went without his assessed respite care, which was not compatible with the Care Act requirement that there be no break in services when moving from children’s to adults’ care.
The records showed the Council searched extensively for a respite provider for Mr Y within the borough but could not find suitable provision for him that met his needs. The Council’s delay in finding suitable respite for Mr Y was a service failure. The duty to meet needs does not depend on finding services within borough.
Once the Council received OT input in December 2023 it accepted that only a bath, rather than a shower, was appropriate for Mr Y. It did not suggest any further providers without baths after this. However there were some examples in the case records which suggest the Council had not fully understood Mr Y’s needs. This was fault. The Council suggested a placement without 1:1 support, even though a 1:1 need was stipulated in Mr Y’s assessment. It also questioned whether Mr Y needed to have a bath when he was only staying for up to two nights, even though he was doubly incontinent.
Mr X said the Council focussed on cost cutting rather than meeting Mr Y’s needs. There was an email where an officer stated, “My concern is that we are being led by the family to a potentially more expensive placement, without clarity of need.” There was also a reference in panel paperwork which said, ”what has been done to ensure that only the minimum of statutory care is provided.
The Ombudsman’s interpretation of that email (although it might have been poorly worded) was that they wanted to ensure the Council understood Mr Y’s needs fully, rather than sourcing a placement that was more expensive but was not necessary for his needs. This was not unreasonable. The reference to the minimum standard of statutory care was misleading. The file showed the Council made extensive placement searches and stipulated Mr Y’s needs when sending referrals to providers. It would not have done so if it was only focussed on cost cutting.
The Council’s fault caused Mr Y a significant injustice as he was without the respite care he was entitled to for nearly two years. He lost opportunities to socialise with his peers and gain independence away from home. He also experienced distress and a disruption to his routine.
The Council’s fault also caused Mr X significant distress and upset. He was left with uncertainty about what the outcome may have been if the Council had dealt with Mr Y’s transition to adult services sooner. He and Mrs X were struggling with not having a break from their caring responsibilities and not being able to spend time with their other children. The lack of respite care for Mr Y had a significant impact on the wider family.
The Council agreed to apologise to Mr X and Mr Y, pay £600 to Mr Y for loss of respite and impact on him, and £800 to Mr X to recognise his distress, upset, uncertainty and the effect on the wider family. It also agreed to review its transition planning procedures for young people approaching 18, focusing on completing assessments early enough to avoid any gaps and ensuring adult care packages are in place by the 18th birthday, and to provide evidence it has carried out these actions.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
There is clear guidance as to how local authorities should transition individuals between children’s and adult’s services. The CASS Guidance sets out what councils should do to facilitate the transition from support by children’s services to adult services. The CASS Guidance says:
‘Local authorities fulfil a range of different functions that have an impact on the health and wellbeing of individuals, in addition to their care and support responsibilities…It is therefore important that, in addition to ensuring co-operation between the local authority and its external partners, there is internal co-operation between the different local authority officers and professionals who provide these services.’
‘Local authorities must make arrangements to ensure co-operation between its officers responsible for adult care and support, housing, public health and children’s services, and should also consider how such arrangements may also be applied to other relevant local authority responsibilities, such as education, planning and transport. Arrangements that local authorities could make to ensure co-operation between officers include … establishing systems for information sharing or multi-disciplinary teams.’
The report refers to the requirement in the statutory guidance that if adult support is not in place on the child’s 18th birthday the council must continue providing services until adult care and support is in place to take over, (unless adult care and support is not needed) to ensure there is no ‘cliff-edge’, but does not comment on the fact that this did not happen in this case. It may be that if professional minds were focussed on this aspect the gap in services would not have been so severe.
A major problem in this case was the delay in commencing the transition assessment and a complete lack of attention to the need for comprehensive care planning. It is as if the staff were working in the dark with the placement team whereas anyone just seeing this man and speaking to the parents or an advocate should have understood his needs. This ought to have highlighted the need for an OT assessment much earlier which could have avoided some of the subsequent problems.
However, we wonder whether this assessment really was required to deal with the bathing issue, since Mr Y was receiving respite care through Children’s Services until just before his 18th birthday, and a simple examination of the records from Children’s Services might have provided the information required about bathing needs. We wonder whether part of the problem here was a lack of the required co-operation between adult and children’s services.
The Ombudsman does not comment on the lawfulness of the ‘transitions pending tray.’ We question whether the very existence of separate transition teams from adults’ services ONLY, actually do more harm than good, meaning that assessments are not undertaken by social workers who already know the family. A joint transitions team would appear to make obvious common sense.
Mr Y might have been able to move things along more quickly if he had obtained legal advice, and his representative might have been able to obtain information about the Council’s in borough list, and whether some suitable providers were being excluded by reason of cost.
There was also clearly a problem with communication here in that at least part of the delay occurred because the social worker or placement team did not realise that Mrs X had already said she was happy for the Council to look for providers in neighbouring boroughs.
The Ombudsman’s analysis of law and guidance correctly identifies failures in timing and continuity (principles mentioned in the above guidance) but does not fully reflect several important duties and public law principles developed in community care case law.
First, community care law treats the duty to assess and the duty to meet urgent needs as overlapping; where a young person’s respite is about to end and the family is clearly struggling, section 19 powers and section 27 review duties can require interim respite to be put in place immediately, even before a full transition assessment or final plan are signed off. Community care law has repeatedly stressed that councils cannot simply leave families unsupported while they “search” or await OT input when the need for breaks is urgent and obvious. The report criticises delay but could have gone further in spelling out that urgent interim respite was a legal requirement, not merely good practice.
Second, community care law on care planning and personal budgets emphasises that once eligible needs are identified the council must decide how they will be met, in what form, and with what budget, and that cost considerations can only influence how, not whether, needs are met. The report notes that local respite options were exhausted and that the council searched more widely, but it does not examine whether the council unlawfully fettered its discretion by effectively treating lack of in‑borough provision at a cost considered affordable, as a reason to leave needs unmet for such a long period. Public law principles prohibit blanket caps or unspoken “no out‑of‑area” rules where these lead to prolonged unmet eligible need.
Third, community care law gives carers their own rights to assessment, eligibility decisions and support where caring is having a significant impact on their wellbeing. The report clearly recognises the parents’ distress and exhaustion but does not question whether separate carers’ assessments should have been carried out, or whether the Council ought to have considered support to sustain them while it struggled to source respite. A stricter legal analysis would link the prolonged gap in respite not only to Mr Y’s needs but also to potential failures to identify and meet the parents’ own eligible needs for support.
Finally, public law principles on rational decision‑making require councils to grapple explicitly with key disputed issues, such as whether bathing (rather than showering) and one‑to‑one support were genuinely necessary for safe care in respite settings. The report records the disagreement and the eventual OT conclusion but does not interrogate whether the council had, for many months, been questioning clearly recorded needs without a lawful, evidence‑based reason. Community care law suggests that once an OT has confirmed that only certain forms of support (for example, a bath with appropriate equipment and staffing) will safely meet needs, the Council must treat those features as part of the eligible need, not as negotiable preferences.
From the perspective of community care law, therefore, the report is accurate as far as it goes but underplays the strength of the legal duties around urgent provision, carers’ rights, the strict separation between identifying eligible need and deciding how to meet it, and the prohibition on allowing service gaps or local market limitations to trump those duties.
If Mr X had sought legal advice he might have been able to unstick the position more quickly by reference to the law set out above. The family might also have been advised to consider a claim for restitution given the amount of unpaid care they provided.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s London Borough of Croydon (24 020 730) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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