Date of decision: 08 October 2025
Summary
A disabled man with serious mental and physical health conditions moved into the Council’s area. He was left without essential daily support, unable to go out, shop, eat properly, or manage safely at home. The Ombudsman found the Council failed to secure continuity of care on his move, contrary to the Care Act, carried out a poor initial assessment, delayed offering a reassessment, and then delayed putting in place care it had accepted that he needed.
What happened
In April 2022, the first authority, referred to as Council K, assessed the man under the Care Act and found his physical and mental health conditions, including agoraphobia and post‑traumatic stress disorder, meant he needed care and support to meet six of the ten eligibility domains.
In June 2022, Council K’s care plan awarded him 15 hours a week of support via direct payments plus a daily 20‑minute care agency visit for personal care, although direct payments and commissioned support were not in fact put in place because of a dispute about his assessed financial contribution. [That was of course wrong in terms of the legal framework but no point is taken about that by the investigation report].
Council K instead arranged support from its own reablement and adult social care teams: an officer carried out weekly shopping visits, a social worker helped him view and move into his new flat, and food parcels were provided when he lacked money, although he received no shopping support in the six weeks before his move out of area to Salford.
Council K referred him to Salford City Council on 19 May 2023, notifying the Council of his intention to move and sending his needs assessment and care plan.
A Council record dated 24 May 2023 recorded that he had previously had a direct payment but had declined it because he felt the contribution was too high, and that he reportedly felt no need to start care calls when moving to Salford, but there was no clear record of the Council speaking directly to him before deciding not to provide interim support.
The man moved into the Council’s area by 30 May 2023 and contacted the Council that day, saying he urgently needed support because he could not go outside due to agoraphobia, needed to collect medication and see his GP, and then continued to call repeatedly over the following weeks reporting falls and lack of help.
On 13 June 2023, Salford Council and Council K held a meeting about him, with Council records later noting that Council K said commissioned support had never started because he had refused his contribution; that its reablement service had been doing weekly shopping as a goodwill measure, that he sometimes declined visits due to lack of money, and that he had still received food parcels and practical help with viewing and moving into the flat. Council K also reportedly told the Council it considered his main needs to be linked to mental health and medical or psychological issues rather than social care, and that Salford’s own assessment might conclude he did not meet Care Act eligibility criteria.
A Salford Council social worker carried out a needs assessment on 16 June 2023 and concluded he had only one eligible need – difficulty maintaining a habitable home environment – and therefore was not entitled to Care Act support.
The assessment recorded that he could prepare his own meals and drinks, used taxis or could order online shopping, could shower independently albeit at some risk when exiting the shower while awaiting a grab rail, and was independent in toileting, dressing, home safety, relationships, work, training and education, so it suggested needs should be met by mental health services and the NHS for medical appointments.
On 20 June 2023 the social worker told him the outcome by phone, provided details of a befriending service and a mental health charity, and said his case would be closed; the Council then sent the written assessment on 26 June 2023, after which he began submitting complaints.
The Council met with him on 14 July 2023 to discuss the assessment and his complaints. At that meeting, he said the assessment was factually wrong, explaining he had been unable to leave his home unaccompanied for 15 years because of agoraphobia and PTSD, could not attend appointments, use taxis or public transport, or go shopping without support, and that he had only attended a reported event in town with accompaniment rather than alone as stated. He also said he could not make meals or wash without support, struggled to move items and keep his home in order, could not maintain relationships unaided, and had continued to receive practical support such as shopping and appointment help from Council K after his commissioned package had stopped.
The Council accepted some statements were factually inaccurate and said they could be amended, but told him the overall assessment would stand and that it promoted “strength‑based working,” expecting him to use online shopping and relying on the NHS, not the Council, for help with health appointments.
When he questioned why a reassessment was refused despite what he described as lies and incorrect information, and asked whether his account was disbelieved, the manager who chaired the meeting said they would not say but that the assessment had been signed off and that if he disagreed he could appeal through the complaints process, which would be considered by senior management.
From June to September 2023 he made multiple complaints, saying the transfer of his care from Council K was not Care Act‑compliant; that he could evidence ongoing support from Council K up to his move but the Council refused to consider it; that the 16 June assessment consisted of only a handful of questions, was fabricated and dishonest, and did not reflect that he could not achieve the outcomes the Council said he could; and that the Council would neither correct the assessment substantively nor reassess him. He said he was alone in his flat, unable to go out, not eating properly, suffering falls, unable to attend his GP, and living in clutter that ambulance staff considered a health hazard. During this time, police and ambulance services became involved as he reported suicidal thoughts, and the Council received safeguarding referrals about him.
On 28 July 2023 the same Council manager who had chaired the 14 July meeting issued a complaint response, repeating later responses, stating that he had never received commissioned services from Council K, that Council staff had carried out regular but non‑commissioned visits, and that the Council’s own assessment had been comprehensive with signposting to befriending and community services rather than direct support with shopping or appointments. The response said he had only one eligible need (maintaining a habitable home) and that two eligible needs were required to qualify under the Care Act, and asserted the Council did not support adults to attend health appointments because that was the NHS’s role. [This is not in fact what the law is; there is a case on it called Heffernan].
In September 2023 the Council changed its stance [there is no explanation sought by the investigator as to why] and agreed to reassess his needs; on 14 September 2023 the social worker completed a new assessment concluding he now had eligible needs in relation to six outcomes: nutrition, personal hygiene, safe use of the home and maintaining a habitable environment, maintaining relationships, and making use of community services (5 out of the original 6 found by Council K, and one new one). The reassessment recorded that he mostly ate cereal, relied on a friend for cooked meals and shopping, only showered when someone was present because of fall risks and could not apply creams, lived in a very cluttered and unclean home, was socially isolated in a new area and unable to go out without support, and could not use local facilities or services independently.
On 21 September 2023 the social worker discussed the reassessment with their manager and it was agreed the Council would arrange a deep clean of his property and transfer him to the Integrated Care Team for support planning; the social worker rang him the same day to explain the outcome, but he continued to call over the following weeks while waiting for allocation and the start of a support package. However, a social work note dated 10 October 2023 recorded that the worker had been told to explore community options to meet his needs and that commissioned support “would not be considered,” a position the worker relayed to him, prompting further complaints.
The Council kept receiving safeguarding referrals and on 6 November 2023 decided the statutory threshold for a section 42 Care Act enquiry was met because he might be at risk of self‑neglect in relation to personal hygiene, nutrition, and his cluttered, hazardous home environment, which created trip and fire risks and potential difficulty escaping in an emergency. A safeguarding officer visited him on 1 December 2023, after which it was agreed to close the safeguarding enquiry on the basis that the Council would arrange a property clean and implement a care plan discussed with him beforehand.
On 18 December 2023, the Council issued a care plan stating he was entitled to 10 hours a week of support, including help with decluttering, organising and cleaning his property, and commissioned a care agency to deliver the support.
What was found
The Ombudsman found the Council failed to comply with its Care Act continuity‑of‑care duties when the man moved in May 2023. It had not yet assessed the man’s needs for care and support when he moved, so the Council had a statutory duty to continue to meet his needs for care and support, as identified by Council K.
It relied on limited information from Council K, did not adequately explore his views, preferences or changed circumstances, and did not provide or clearly consider interim support before its own assessment.
The Ombudsman found no evidence that the Council spoke to the man before it decided not to provide any support to the man while he waited to be assessed. It had produced an inadequate June assessment and then resisted reassessment despite his detailed challenges, and after the September reassessment had delayed commissioning services despite clear evidence of eligible needs and safeguarding concerns.
The June 2023 assessment was brief, relied heavily on two contested statements about his ability to go out and shop alone, and, once he raised detailed concerns and evidence of inaccuracy, the Council should at least have reviewed or repeated the assessment instead of insisting it stood, especially given the large discrepancy with Council K’s earlier assessment and the later September 2023 assessment that again found six eligible outcomes.
There was a procedural fault when the same manager who chaired the July 2023 meeting, and whose practice he had challenged, then authored the July complaint response despite having told him senior management would consider his appeal, and there was no evidence any senior manager actually did so.
The Council only put in place the care package after the man made further complaints, and there was a safeguarding enquiry which said he was at risk of neglect.
The Ombudsman accepted the Council could, in principle, use community or universal services to meet needs, but found no evidence it had checked whether such services actually existed, were available, and would meet his needs before deciding not to commission support, which was unlawful under Care Act duties to “meet” eligible needs in practice, not just in theory. This was fault.
The failures meant he missed out on support from at least 14 September to 18 December 2023 and may also have lost earlier support had the Council reassessed sooner, leaving him distressed, at risk of self‑neglect and harm, and reliant on crisis responses and safeguarding referrals instead of planned care.
To remedy the injustice, the Council agreed to provide a written apology, pay him £400 as a symbolic financial remedy for distress and loss of service, and remind relevant officers of their duties to review and reassess care plans when circumstances change or when people reasonably challenge assessments, as set out in the Care and Support Statutory Guidance.
The Council reported that it had already reminded staff that complaint responses should not be drafted by officers whose practice is under complaint, reinforcing basic standards of fairness and independence in complaint handling (although not actually required by the complaints regulations!)
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public – additional commentary on the law and guidance
Section 38 provides that since the Council had not yet assessed the man’s needs for care and support when he moved it had a duty to continue to meet his needs for care and support as identified by Council K. Its side heading is ‘Case where assessments not complete on day of move‘ so the manager had absolutely no excuse for not knowing about it.
That duty cannot be absolutely to match the package in every sense, because a person’s move may be such as to put them in a completely different situation from the environment they have departed from, with different levels of informal support and no possibility of having the same provider. But the previous paperwork is more than a steer, in this architecture for continuity. It leads to a presumption that unless there’s a good reason for not honouring the old care plan, it should be regarded as necessary.
The Ombudsman said that it was difficult to establish what needs Council K had identified. We find this surprising given that Council K’s needs assessment set out that the man needed support in relation to nutrition, personal hygiene, developing personal relationships, accessing work, training, education and making use of the local community. We appreciate it could just have been domain box ticking but these domains naturally generate the need for particular types of input, which are mainstream.
Although a commissioned service was not put in place by Council K, it did put in support from its own resources. To our mind this fact suggests that Council K was very concerned about the man’s well-being and should have alerted the destination Council to his vulnerability.
Public law principles and community care case law also require a lawful, proportionate assessment to cover impact on all aspects of wellbeing and to engage properly with the person’s own account and desired outcomes.
A failure to analyse impact across the wellbeing domains, or to record how disputed evidence has been weighed, may render an assessment unlawful; the s19 power to meet need should have been considered and a decision articulated for not exercising it.
The Ombudsman describes the June assessment as “brief”, noting that a lot of the conclusions particularly in relation to the man’s ability to leave his home unsupported were based on two statements which the man later denied. The implication is that the June assessment was flawed and potentially unlawful.
There appears to have been a failure to apply the assessment duties for example by not exploring how agoraphobia and PTSD affected the domains of managing nutrition, personal hygiene, use of community facilities, relationships and work, and by not documenting a rational basis for rejecting his detailed challenge about being unable to leave home alone.
The late decision to commission 10 hours of support was not just a delay problem, but a failure to comply with the statutory duty because once a council has accepted eligible needs and moved to support planning, it must finalise and implement a plan within a reasonable time. Support in an existing or newly agreed care plan must continue or start unless and until there has been a lawful reassessment and a rational decision to change provision. The post‑September inaction was a separate breach of the duty to meet needs.
It is perhaps fortunate that, despite the man’s difficult circumstances, he was able to pursue complaints procedures, but it seems to have been the safeguarding referrals that were raised by the police and the ambulance service after he had several falls and said he was suicidal, which triggered a change in the Council’s position. We think these circumstances show the seriousness of the failings in this case.
If this man had used judicial review, he would have been able to claim restitution for money (and probably significantly more than £400) that he must have had to have spent on keeping himself going, which input should have been covered by adult social care input. We would say that he might even have been able to claim a larger sum even if he had spent nothing, because the duty is to honour the original care plan UNTIL the new council has done a proper assessment. So that would be several weeks of 15 hours of direct payment he could have claimed, and been awarded.
The Ombudsman recommended that the Council should remind officers of their duties to carry out review assessments in certain circumstances. We think that a recommendation for broader training on the Care Act and statutory guidance would have been warranted in this case and that a referral to the professional regulatory body would have been given serious attention, had one been made about the manager’s practice.
A risk that any council takes in ignoring the Section 38 duty is that if something then happens to change the status of the individual, they will already have become ordinarily resident in their destination council, despite not having received services. That means that the Council is betting on nobody in this position ever getting sectioned under s3 Mental Health Act or needing CHC.
After episodes of either of those typse of care, Salford would have inherited the s117 or future Care Act responsibility for the next however many years, under s39(4) or s39(5) Care Act.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Salford City Council (23 014 128) 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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