Date of decision: 28 October 2025
Summary
A woman with learning disabilities and autism housed in Council-owned and funded accommodation, repeatedly suffered distress and fear from a co-tenant’s loud, angry and sometimes threatening behaviour over many months. Leeds City Council failed to safeguard her properly, underestimated the seriousness of the emotional impact and did not use its housing powers to enforce the ‘licence’ conditions, causing prolonged distress to her and her close relative.
What happened
The Council owned a small supported living property with three bedrooms, housing two disabled adults under individual licence agreements that required occupants not to be aggressive, and to avoid nuisance or annoyance to others. The Council contracted with St Annes Community Services (the Care Provider) to deliver support under individual service agreements that set the level of care hours.
In May 2023 Miss F moved into the house to live with an existing occupant, Miss E, an older adult with learning disabilities and autism, after several introductory visits and shared meals; both women already knew each other from a day centre and early Council records in June and July 2023 said Miss F had settled well.
In November 2023, Miss E’s sister, Miss D, told the Council that Miss E was becoming upset by Miss F’s shouting; around the same time the Care Provider recorded an incident of Miss F shouting, noting that it was not directed at Miss E but that Miss E became distressed.
The Council opened a safeguarding enquiry, advising the Care Provider to encourage Miss E to report concerns and to contact Miss D to discuss them.
In January 2024, the Care Provider recorded Miss F “shouting and screaming” at Miss E and banging on Miss E’s bedroom door, with staff noting that attempts to intervene only escalated Miss F’s behaviour, and that Miss E felt scared.
In March 2024, the Care Provider recorded an incident where Miss F shouted at Miss E over clothing, in front of another relative visiting Miss E, who removed Miss E from the situation and later reported that Miss E remained upset for several hours and that Miss F had made a threat of physical violence. When Miss E returned home, Miss F again shouted at her, slammed doors and caused further upset, as recorded by staff. In a separate March incident, the Care Provider recorded Miss F shouting and slamming doors over a prolonged period but failed to record whether Miss E was present or affected.
Around this time, in its communications with the Council, the Care Provider described conflict between Miss E and Miss F that could “escalate quickly” and said both women had at times expressed a wish to move; the Council recommended contacting an NHS service for input. It later became clear that the NHS service would work only with Miss F and that Miss E did not meet its criteria. A note from roughly the same period said Miss F had experienced previous “placement breakdowns” because of her behaviour, and that she “escalated conflict” with Miss E.
In April 2024, the day centre reported “incidents of conflict” between them that caused agitation and distress, and the Council agreed they should attend on different days to reduce incidents. Around the same time, the Council agreed to fund extra support hours for Miss F, and a social worker’s supervision note recorded that Ms F’s behaviour caused “much distress” to Miss E. Later that month the Care Provider notified the Council of another “verbal incident” and contacted Miss D to reassure her it had been dealt with.
In August 2024, the Council recorded that “things appear to have settled down in the home,” but a few days later the Care Provider recorded another incident of Miss F shouting at Miss E. Around two weeks after that, Miss D again contacted the Council, expressing concern that Miss E continued to be upset by Ms F’s behaviour; when the Council checked with the Care Provider it was told Miss E was “super sensitive,” a phrase the Care Provider later said it did not itself use, even though it accepted that it thought Miss E was sensitive. The Council’s notes referred to a “difficult situation” for the Care Provider and highlighted that Miss F’s behaviour had not yet involved physical aggression towards Miss E.
In September 2024, Miss D made an official complaint in writing and met with representatives from the Care Provider to set out her concerns as her sister, Miss E, was still very upset with the behaviour of Miss F. The Care Provider dismissed these concerns, stating that Miss F was just ‘still adjusting’ and they would not move her from the property.
Around a month later, Miss D expressed her unhappiness with the outcome of the meeting to Miss E’s social worker.
In December 2024, the council replied to Miss D’s complaint in writing by stating that it recognised there was ‘occasional conflict’ and they would offer support to both tenants to lower tensions and provide support as well as reviewing their activity plans, health needs and explore education opportunities.
What was found
The Ombudsman found no fault in the initial decision to place Miss F with Miss E, as there was no reliable evidence of foreseeable conflict at the outset, and early reviews suggested the placement was settled.
However, from late 2023 onwards the Care Provider repeatedly under‑recorded or incompletely recorded incidents of Miss F’s disruptive and aggressive behaviour, meaning the official record did not match the frequency and seriousness described by Miss D, the day centre and some internal notes; this was fault and suggested potential non‑compliance with Regulation 17 (good governance) and concerns about meeting the duty of candour under Regulation 20.
The Ombudsman concluded that by early 2024 a clear pattern of regular, distressing behaviour by Miss F towards or in front of Miss E had emerged, but the Council and Care Provider delayed taking robust safeguarding action for about three months, and then failed to adequately review whether their limited interventions (separating day‑centre attendance days, increasing Miss F’s support hours, and seeking NHS input) were effective; that delay and lack of systematic review were faults.
The Council also failed to treat the situation consistently as a safeguarding concern focused on the impact on Miss E, did not reopen or sustain section 42 safeguarding enquiries despite repeated reports, and downplayed emotional abuse because there was no physical assault, raising concerns about compliance with Regulation 12 (safe care and treatment) and Regulation 13 (safeguarding), as well as with its Care Act safeguarding duties.
When responding to Miss D’s complaint from September 2024 onwards, both Leeds City Council and the Care Provider became defensive, minimised Miss F’s behaviour as “occasional conflict,” suggested Miss E was “very sensitive” or “fixated,” and emphasised Miss F “settling in” after 17 months, instead of squarely addressing the cumulative distress and the clear pattern of aggression; this complaint handling was also fault. The Council said that both Miss E and Miss F began conflict but the Ombudsman saw no evidence for this during the period under investigation. The Ombudsman found that if the Council and Care Provider had kept complete records, recognised the pattern earlier, actively reviewed interventions, treated the behaviour as possible abuse, and fully considered use of the Council’s housing powers to end Miss F’s licence, the frequency, severity or duration of Miss E’s distress would probably have been reduced. These were all faults.
The identified faults caused significant, prolonged distress and anxiety to Miss E, who lived for many months with repeated shouting, threats, door‑slamming and fear in her own home, and whose behaviour later deteriorated as she began shouting back and trying to leave at night. Miss D also suffered avoidable distress, frustration and a sense of powerlessness when her repeated safeguarding concerns and complaint were not properly heeded or acted upon, despite her central caring and informal advocacy role.
The Council accepted the Ombudsman’s findings and agreed to remedy the injustice with written apologies to both Miss E and her sister (in an accessible format for Miss E) and symbolic financial payments: £1,000 to Miss E, at double the Ombudsman’s usual “higher end” distress figure due to the seriousness and duration of her distress, and £500 to Miss D.
The Council also agreed within two months to review and strengthen how it can improve its response when one service user is distressed by another’s behaviour. The review would cover, but need not be limited, to:
- considering if the Council used its powers to safeguard adults from abuse sufficiently in such cases;
- whether it sufficiently considered such cases through the perspective of the victim of any disruptive or aggressive behaviour,
- whether it could do more to encourage social workers to draw up action plans to tackle problem behaviour and monitor their effectiveness;
- and considering where applicable if it should use its power to end licence agreements in cases where a user of services in supported living accommodation it provides, breaches a ‘good behaviour’ clause in its licence.
It will provide evidence of compliance to the Ombudsman.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The Ombudsman’s account recognises emotional distress and fear as real harms but could have pointed out that when a disabled adult is repeatedly exposed to another person’s escalating behaviour in their own home, a care plan review is likely to be urgently required, since the adult is no longer able to make use of their own home safely and there will be a serious impact on their well-being. If such a review had taken place, this might have led to more focus on the safeguarding issue and the need for a speedy and effective outcome.
The report could have gone further in suggesting at least that Miss E’s wellbeing was impacted, and that her ability to use her home safely is a core Care Act outcome which required explicit analysis, not just narrative recognition of her distress.
Where repeated incidents affect mental and emotional wellbeing, social participation and safe use of the home, it is arguable that any social service council should consider those domains and revise the care and support plan and personal budget accordingly; it seems that the Council did not review Ms E’s plan to address the fact that her home environment had effectively become unsafe, because that domain is thought of in the sector as just being about mobilising around the home and the environment in the home.
The Ombudsman highlights delays in safeguarding but is relatively light on the duty to use all relevant Care Act and housing powers in combination, including urgent responses where needs appear pressing. Where an adult’s needs are urgent or where the home environment itself is the source of risk, the council may need to act under its powers to meet needs urgently and to consider changes to accommodation, not merely incremental support tweaks; the report criticises the failure to use licence‑enforcement powers but could have located this more explicitly within broader Care Act duties.
The Ombudsman could see why, in response to single or sporadic incidents, the Council would not want to take the step of ending a licence with a vulnerable adult, but there were many incidents and they went on for months. If the Council had gone down the route of ending the licence with Miss F it would have had another problem on its hands, as it would in all probability have had to find Miss F another placement. The Council’s approach may have been influenced at some level by this consideration, and by the fact that Miss F had apparently had other placement breakdowns.
Miss F in fact left the property in September 2025, so it appears that a different placement had to be found for her eventually. It is unfortunate for Miss E that this did not happen sooner.
The issue of whether Miss E OR Miss F had capacity to sign a licence as part of her stance on the care support and residence arrangements they had been offered is not mentioned within this report.
The fact that Leeds was the owner of the accommodation, is treated by the report as meaning that the Housing Authority owned it and had provided the ‘licence’.
We do not know for sure, but we suspect that if it was a licence, then that was because no rent was being paid and in that sense, we think it is much more likely that this was accommodation other than a care home being provided directly to disabled people as an inherent part of their care and support needs, which is contrary to law since the interpretation of s23 Care Act in Campbell (May 2024) in the Court of Appeal, unless (possibly and logically in legal terms) the persons concerned lack capacity to sign a tenancy.
If that is the case they also likely lacked capacity to sign a licence requiring them to be of good behaviour, which would explain why no thought was given to the nature of the women’s tenure, and using termination rights, during the conflict between them.
So, to our minds, this is possibly another example of an inadequate personal budget for the job in hand – or an inadequate care plan from the statutory care planner for both women, or inadequate disclosure of Miss F’s history to the provider with regard to fees negotiations for taking the clients’ needs on. This is key because it suggests that the fee being paid may not have been enough to regulate the two clients’ relationships, keeping them on an even keel in a 24 hour genuine ‘placement’ setting. Use by the investigator of the word ‘tenant’ on several occasions in the report also suggests that the Council presented it as a housing arrangement with separation of the ‘tenure’ from the care and support, perhaps so that it did not look like a care home providing care together with accommodation in one integrated package, through the decision-making of the Council.
We would suggest that the fact that the report can have emerged without addressing these points is a serious issue of inadequate scoping by the Ombudsman’s team.
The report also tends to frame Ms F’s behaviour and Ms E’s distress as a joint “conflict” between two occupants, rather than as a situation in which one disabled person’s condition-driven behaviours, known to have caused previous “placement breakdowns,” came, foreseeably, to be undermining another disabled person’s freedoms and interests in living in a settled home. If both Council and Care Provider knew Ms E to be sensitive, or to become easily upset because of her needs (as indicated also in her care plan), that was more reason, not less, to intervene sooner.
Public law principles and community care case law would support a sharper distinction between legitimate efforts to support both tenants and the obligation not to allow cost or organisational convenience to trump the victim’s safety, dignity and settled expectations, particularly where previous breakdowns were known and where the victim is described as “sensitive” rather than as a person whose vulnerabilities necessarily heightened the care planning duty to meet needs appropriately.
The Ombudsman’s team referenced these provider duties:
- Regulation 12, which covers ‘safe care and treatment’. Providers must be able to show they have taken all reasonable steps to ensure the health and safety of those in their care and can manage risks arising while providing care. Guidance says this includes reviewing incidents and sharing details, where relevant, with families.
- Regulation 13, which covers safeguarding. Providers must take action to safeguard users of their services from abuse. Guidance says providers should use incidents and complaints to identify potential abuse and take preventative actions where appropriate.
- Regulation 17, which covers ‘good governance’. Providers must keep accurate, complete and detailed records about each person using their service.
- Regulation 20, which refers to the ‘duty of candour’. Providers must act in an open and transparent way with people who receive care and treatment.
Only the CQC can decide if the care provider has sufficiently met these requirements or if they have breached them. We would point out however that the only extent to which a provider can be found liable for negligence is where they are under contract to provide an actual service; taking on a 24 hr watching brief, if a member of staff was not there all the time means, in effect that the provider was warranting both person’s safety, even though they could not possibly do that without being there. And that is a foolish remit to take on, or, from the other perspective, to commission as if it could possibly meet needs under the Care Act.
Since Miss E is an adult with learning disabilities, she is likely to have had substantial difficulty with being involved in any assessment of need or review. It is fortunate that she had Miss D to support her and to support her involvement with informal advocacy. In this situation the authority should have been transparent, shared sufficient information, explained its reasoning and actively involved Miss D in key decisions about risk management and possible moves; the description of Miss D’s experience suggests shortcomings in these areas that go beyond poor tone, but the legal significance of that could have been more fully drawn out in the report.
For councils and providers, the broader implication is that where one supported living resident’s behaviour repeatedly causes another significant distress, there should be:
(a) a fresh, well‑documented assessment of each person’s needs, capacity and risks;
(b) transparent, reasoned decisions about whether needs can still be safely and suitably met in that setting;
(c) compliance with safeguarding duties,
and
(d) timely use of powers to change support, placement or licence arrangements if safety and wellbeing cannot be secured – and to do that lawfully.
Not getting along with one’s housemate is not, in the ordinary run of affairs, a reason for termination of a tenancy. These women had licences, and that means that they did not have security of tenure, and that means that they were always seen as people who could be told where they must live. That is not within the powers of social services unless it was ready to make another direct placement, which means for these purposes, a funded arrangement for the accommodation part of the package, not just care, and not just signposting to a tenancy, for which the individual would have to pay rent. The Ealing (Campbell ) case says that that can only be done lawfully by social services, as ‘accommodation plus’ care, for people lacking in capacity to use the Housing Act, (disregarding the CQC registration issue if personal care is needed) so, in fact, there is a lot more law underlying this report than one would first think.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Leeds City Council (24 017 661) 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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