Date of decision: 14 January 2026
Summary
A man receiving council‑commissioned supported living care experienced poor, inconsistent support that failed to follow his agreed routines, leading to distress, continence and behaviour problems, and avoidable reliance on family input. When the issue was raised repeatedly, the Council’s social worker did not respond robustly or quickly enough, and when the matter was escalated to managers, they treated serious care failings as mere ‘family concerns’ and delayed proper quality assurance.
What happened
In September 2023, the man, Mr Y, moved into supported accommodation run by Care Provider A, and commissioned by the Council, with a care plan specifying shared and 1:1 support, structured and meaningful activities, a secure property and sensitive handling of continence and personal care needs, under the oversight of a Council social worker (SW).
Soon after moving in, Mr Y’s uncle, Mr X, reported that the accommodation was not secure and that Mr Y absconded within days and twice more before Christmas; that agreed 1:1 support was not being provided, that Mr Y lacked a consistent key worker, and that staff were not following the structured routines needed to maintain his continence and personal care.
Mr X and his family said they repeatedly found Mr Y’s room in poor condition and Mr Y in soiled clothes, and believed the Provider’s failure to follow the plan led to entrenched poor routines, high anxiety and negative behaviour, while the SW did not take suitable action when these concerns were presented.
After around six weeks in the placement, a Quality Assessment was undertaken (not a care plan review) and an improvement plan for Care Provider A was agreed, but Mr X later complained this was not adhered to.
In May 2024, Mr X made a formal complaint to the Council, stating that the SW had failed in her duty by not acting on the problems, leaving the family to tackle issues directly with Care Provider A at significant levels of stress; that a capacity assessment about whether Mr Y was ‘happy’ in the placement was not carried out appropriately, and that the Provider’s admitted failure to deliver agreed care had effectively been condoned.
He also said that Mr Y’s needs were not being met, causing Mr Y distress and forcing Mr X to make frequent visits to manage behaviour and provide hands‑on care that should have been delivered by the Provider.
The Council commissioned an independent Stage One investigation covering June 2023 to May 2024, which produced a detailed report on each part of Mr X’s complaint. The investigation found no evidence that the SW had been negligent or breached a duty of care, and accepted that she had put a reasonable care plan in place and held review meetings, with some evidence that Care Provider A responded to security concerns, but noted that these meetings were poorly documented and that Mr X later had to provide his own summary of events.
It found the SW had engaged with Care Provider A and generated extensive correspondence in a challenging situation, but should have acted more quickly, assertively and proactively; escalation occurred only about four months into the placement, and concerns were inappropriately framed as “family concerns” rather than deficiencies in care which required formal quality assurance.
The investigation concluded that Care Provider A’s care fell short in several respects: staff did not consistently use planners and support tools to maintain Mr Y’s structured routine; agency staffing reduced consistency; some staff struggled to motivate Mr Y to get up and engage, and laundry and continence management records were inconsistent.
It noted that a short transition into the placement meant staff were unfamiliar with Mr Y’s plan, that greater early management presence might have improved adherence to routines and behaviour strategies, and that the SW should have sought a formal written response from the Provider at the October 2023 review on how these concerns would be addressed.
It also found that Mr X had clearly warned of the risk that Mr Y might abscond before the placement; that Care Provider A should have acted on this, and recommended an apology and consideration of alternative security measures, alongside examination of Deprivation of Liberty (DoL) issues.
On key structural points, the investigation found 1:1 support had been provided to the levels set out in Mr Y’s plan and that a key worker had been allocated, but there were divergent expectations between Mr X, the Council and the Provider about what “consistent key worker” meant and how agency staff would be used; it recommended setting these expectations out in writing in future placements.
It highlighted that Mr Y’s need for structured engagement was central: without regular activity, he became “stuck” in front of a screen, lost focus, disengaged from care, and continence and behaviour problems escalated, and it proposed a range of monitoring, regular updates and co‑designed strategies with Mr X to improve engagement and continence management.
The investigation further found that the SW had been too passive, causing Mr X to become the driving force in getting issues addressed, and that Council managers, once the matter was escalated still failed to carry out a robust, timely quality assurance assessment of Y’s care.
Following the investigation, the Council wrote to Mr X accepting all findings and recommendations, acknowledging that faults in care provision and its own handling had caused distress to Y, ongoing impacts on his wellbeing, and distress to his family, and it offered a sincere apology and £2,000 in recognition of the impact.
In August 2024, after the investigation concluded and the improvement plan was issued, Care Provider A gave notice on Mr Y’s placement, requiring a new provider to be found; Mr X raised further concerns about the subsequent arrangements, but the Ombudsman limited its investigation to the period and issues at Care Provider A and the Council’s response to concerns during that placement.
Mr X also complained about the independent investigation process itself, saying he had an initial two‑hour meeting with the investigators but the complaint scope was not later agreed with him, that his complaint was mainly about the Council’s management rather than the Provider’s actions, that welfare issues linked to routine and wellbeing were omitted, and that the improvement plan was so onerous that it prompted Care Provider A to serve notice on Mr Y.
What was found
The Ombudsman reviewed these process concerns and noted that the independent investigator had appropriately focused on whether Y’s care at Care Provider A was suitable and how the Council had responded, that the investigation was thorough, evidenced with references to records and correspondence, and that it did in fact consider the role of routine and continence; the Ombudsman’s investigator said that while it is good practice to share a written complaint summary, the failure to do so here did not cause injustice, because there had been a proper briefing and the scope of the report was good.
The Ombudsman also explained that, like its own approach, an investigator is not required to answer every individual question raised if the key issues are properly addressed and the investigation remains proportionate.
The Ombudsman found there was no fault in the content of Mr Y’s care and support plan itself, which reasonably set out his needs, but that Care Provider A failed to fully implement it, did not consistently use planners and routines, did not secure the property adequately despite known absconding risks, and did not manage continence and laundry reliably; these were service failings which caused Mr Y injustice, including distress, anxiety and risk of skin breakdown.
While needs were fully documented, the Ombudsman thought that the implications of a lack of structured routine and how this would affect behaviour and continence issues, were not fully understood, or were underestimated. Even if a carer was following all required care plan actions, it is possible that at times Mr Y might not engage, and issues with behaviour and continence might occur – but the investigation noted evidence that there were examples of Care Provider A not doing all they could to avoid this.
The Council’s SW did not respond robustly or promptly to Mr X’s early concerns, failed to escalate and challenge effectively, and did not raise safeguarding alerts when there were clear welfare worries, which amounted to fault. Although a safeguarding concern was later investigated by the local council where Mr Y lived in April 2024, which regarded the issues as care management rather than safeguarding, the Ombudsman found the failure to raise earlier alerts was fault, though it likely caused no additional injustice.
When the matter was escalated to managers, the Council still failed to act decisively: it framed serious quality‑of‑care issues as “family concerns”, delayed a robust quality-assurance assessment and did not get to the root of Provider failings, prolonging Mr Y’s poor care and Mr X’s stress and hands‑on involvement.
In terms of complaint handling, Mr X told the Ombudsman that the independent person who investigated his complaint discussed his complaint with him for around two hours to discuss the issues he was raising. The Ombudsman noted that an early conversation is good practice. The Ombudsman considered it best practice – and recommended that the Council ensure independent investigators share complaint summaries in line with the Complaint Handling Code, but concluded the scope and conduct of this particular investigation were proportionate and thorough and did not themselves amount to fault causing injustice.
Overall, the Ombudsman decided that faults by both the Provider (in delivering care) and the Council (in oversight, escalation and safeguarding response) caused significant injustice to Mr Y and to Mr X through distress, frustration, time and trouble, and avoidable worry about Mr Y’s wellbeing.
The Ombudsman concluded that £1,000 to Mr X would be suitable to reflect his significant inconvenience, frustration and stress, and £1,000 to reflect that Mr Y was negatively affected by the issues with his care.
As the Council had already offered £2,000 to the family to reflect the impact of the faults identified, this was at the upper end of the Ombudsman’s normal guidance and was a suitable remedy to be shared between the 2 men. It required the Council within four weeks to evidence payment and to review its guidance for independent investigators to reflect the Complaint Handling Code and Ombudsman’s own complaint‑handling guidance.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The report mentions the s27 duty under the Care Act to keep care and support plans under review, and quotes the Statutory Guidance on reviews, but did not specifically consider whether there should have been a review of the care plan, particularly given the early concerns about implementation, such as inconsistent routines and absconding risks. Changes in care delivery or Provider capacity affecting outcomes can trigger a proportionate reassessment to check if eligible needs remain met. Instead of framing issues as family concerns, public law principles required prompt escalation and formal quality assurance to avoid prolonging unmet needs and family burden, with the four-month delay breaching the expectation of 6-8 week light-touch reviews for new plans. The social worker did carry out Provider reviews but these may not have been as effective as they could have been if the care plan itself required review. We think the centrality of a structured routine could have been highlighted in the care plan, or a review of it, which should have made the provider aware of the implications of lack of a structured routine.
Where a relative, like the uncle, provides ongoing necessary hands-on care, such as managing behaviour and continence, carers’ rights to assessment arise regardless of terminology, yet the analysis misses analysing reliance on informal care as potentially shifting eligible needs back to the council, if unsustainable.
It was good that the Council commissioned an independent investigation, which is not a requirement of the Adults Complaint Regulations and which does not often happen. The Council also offered a payment of £2000 to the family – the Ombudsman normally recommends a payment for distress of up to £500 and can recommend higher payments for especially severe and/or prolonged aggravation or to take account of personal vulnerability of those affected.
The report makes only a passing reference to issues considered in the independent investigation about “how Deprivation of Liberty was considered.” It was part of Mr X’s complaint that when Mr Y’s social worker assessed Mr Y’s capacity she did not do this appropriately and Mr Y’s views could not be relied on as representative of his feelings. The report is silent, though, as to whether Mr Y had capacity to make decisions relating to residence and care. If he did not, and given the references in the report to ‘absconding risks’ it seems likely he was deprived of his liberty. Since this was a supported living placement or tenancy the deprivation ought to have been authorised by the Court of Protection. The report seems to treat this as a relatively unimportant detail, but if there was no authorisation in place then if Mr Y did lack capacity, any deprivation of his liberty was unlawful. A Court application would provide important safeguards, in light of the adequacy of the care plan, and would have given Mr X an opportunity to raise his concerns and that could have resulted in judicial scrutiny of the care arrangements.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s London Borough of Hammersmith & Fulham (24 018 569) 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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