Date of decision: 06 October 2025
Summary
A man’s specialist care package was managed by SENSE, Halton Borough Council and NHS Cheshire and Merseyside NHS Integrated Care Board (ICB). His jointly funded package included a day service placement, but this was terminated on short notice by the provider, although he had attended for many years. His mother complained that poor communications, delay, and unresolved concerns led to the breakdown of the placement, causing significant distress. A joint ombudsman’s investigation found fault all round.
What happened
Mr X, who is autistic, deaf, and visually impaired, attended a bespoke day centre run by SENSE within the context of needing 24-hour care which he received at home. Although he stopped attending in March 2020 due to the pandemic, he returned in May 2020 on reduced hours. Miss X, his mother, repeatedly raised concerns over COVID safety, poor communication and poorly managed safeguarding actions.
The Council and SENSE investigated Miss X’s safeguarding concerns and agreed to improve communication and trust. After a social worker had attempted to ramp up the provider’s compliance with requirements made of it and funding was suspended, and a key phone call agreed as a safeguarding follow-up as between the provider’s new manager and Miss X did not in fact occur in November 2020, SENSE then served notice to end the placement ten days later, when care plan revisions and provider actions arising from safeguarding had been outstanding for months.
Since then, Mr X had been unable to access an alternative day centre, and Miss X had had to provide most of Mr X’s care at home.
The Care Provider’s recent responses to the investigator’s enquiries minimised the Care Provider’s role in the communication breakdown and asserted that the complaint against it is “unfounded in respect of [its] involvement”.
What was found
The Ombudsman found fault with SENSE management for repeated poor communication. This included missing agreed phone calls, untimely responses, and incomplete safeguarding actions.
SENSE did not take enough steps to rebuild trust or complete the agreed-upon actions.
This caused Mr X and Miss X significant frustration, distress and uncertainty.
Although the Ombudsman did not fault SENSE’s decision to end the placement, the report records that the Care Provider’s poor communication contributed directly to the deterioration in the relationship with Miss X, and it recommended that a financial remedy of £500 should be paid for the injustice experienced.
The fact that the Provider seemed unable to recognise the multiple failings on its part lead up to that point, left the investigator unsure the complaint about poor service and communication was genuinely recognised and fully accepted by the Care Provider. It was aware Mr X’s care was a bespoke package and that it would be very difficult to source a suitable alternative placement.
The initial ICB complaint response said it was satisfied with the way the Care Provider had dealt with Miss X’s complaint and that an apology was sufficient, but without engaging with the impact on deteriorating relationships that there had been. Nor did it properly recognise the delayed handling of the safeguarding actions.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The Ombudsman’s outcome recognises significant failures in communication and a lack of timely safeguarding actions.
Community care law makes clear that before any change or termination of a care plan, a proportionate re-assessment should be carried out and consultation of all relevant parties should ensue especially when involving safeguarding or breakdown of trust.
We are surprised that the thrust of this report is levelled against the provider, and not Halton’s management, even if it was not the commissioner of the service, and only acting in a safeguarding role. In fact, it is fair to say that the investigator is complimentary of the efforts made by the individual social worker, who was presumably trying to take the safeguarding issues forward.
Commissioning bodies such as the ICB should investigate and ensure concerns are independently examined. The ICB was found at fault because it failed to recognise SENSE’s poor communication and safeguarding actions, without engaging directly with the complainant and securing evidence. This risks compounding injustice and causing frustration and implies a complete lack of grasp of the relationship between commissioning and the duties to meet health needs.
Commissioners, care providers and specialist professionals should ensure that they meet the specific and specialist needs as defined in the formal care plan. In this case, SENSE consistently failed to provide Mr X with staff trained in British Sign Language and tailored visual aids, which were required by Mr X’s care plan. At the same time, Mr X’s personal files on an Ipad were wiped, without giving the family a chance to preserve the information. The insufficient staff training directly caused Mr X and his family to suffer substantial injustice.
The report is another interesting example of the lack of connection between the man’s formal care plan (which recognised his communication needs, and said ‘Staff who support Mr X are to have the necessary BSL skills and be aware of his methods of communication’) and the contract. The Care Provider said it was not commissioned to provide BSL qualified staff as part of its contract with the Council but ‘seeks to recruit staff with the appropriate sign language skills’. The Investigator called that lack of compliance with the Care Plan ‘service failure’ whilst recognising the pandemic likely caused additional difficulties when recruiting highly specialised staff and noting that SENSE had introduced a new internal role of BSL tutor for staff training, which is good to know.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Halton Borough Council (24 017 538) 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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