Date of decision: 20 April 2026
Summary
A disabled man complained that the Council mishandled his care, support and accommodation, including advocacy access, hospital discharge arrangements, community support, information‑sharing, and housing/OT input. The complaint about advocacy and adaptations was upheld. Most of the other allegations, including claims of dishonesty, discrimination, failures around safeguarding, community access support and hospital discharge planning, were not upheld; the evidence showed staff generally recognised his needs, acted on risks and coordinated care appropriately.
What happened
In early 2022, the Council recorded that a man consented to information sharing between health and social care professionals, including a 30 March 2022 entry marked “Consent is Granted” and held an April 2022 conversation record confirming he agreed to such sharing. From January 2023, the Ombudsman investigated events; the man had significant mobility impairments, used a wheelchair and relied on social care and housing support.
On 20 January 2023, he contacted the Council from hospital, and the Council advised him to ask ward staff to arrange an assessment before discharge, consistent with normal discharge planning procedures.
On 27 February 2023, his social worker rang the hospital to discuss discharge but was told he was no longer a patient there; later, the man’s care provider reported it had been telephoned at 1am two days earlier to say he was on his way home, indicating a hospital‑led discharge that bypassed any direct social work co-ordination.
On 28 February 2023, the social worker submitted an advocacy referral, asking for help with correspondence, managing appointment letters and drafting letters about his circumstances and health conditions. In early March 2023, the man told his social worker he was back in hospital; the next day his care provider informed the Council that he had been discharged at midnight and later fell when going to the library in the early hours, after which paramedics took him home but decided he did not need readmission.
On 8–9 March 2023, he again went into hospital after a fall from his wheelchair; on 9 March the warden from his accommodation contacted the Council, said he had returned home, and raised concerns that the accommodation was unsuitable and that he needed more support. The social worker responded by phoning him and submitting an application for extra‑care housing.
On 11 April 2023, the hospital discharge team phoned the social worker to say he was ready to go home and had raised concerns about his home; the social worker explained they were already assisting with an extra‑care housing application, so the hospital transferred him to another hospital and the second hospital discharged him on 12 April, informing the social worker, who then contacted both him and his care provider to restart care calls from teatime the same day.
In April 2023, the Council also received a safeguarding referral after he reported missing money from his room, suspected a particular care worker and said other items had disappeared; a social worker discussed safety with him, the care agency investigated, identified concerns about a member of staff, dismissed that worker, changed key‑safe codes, notified barring authorities, and he told the Council he felt safer and was content for the safeguarding process to close, prompting the Council to decide that a formal Section 42 safeguarding enquiry was unnecessary, given the risk had already been removed.
On 27 February 2023, in a separate strand, the Council contacted his GP surgery because he had told the social worker that he felt like giving up and felt suicidal; this contact relied on his existing consent for information sharing. Later in 2023, the position on consent changed: during a visit in September 2023, he told the OT he did not want his GP contacted without permission, and on 8 February 2024, the Council recorded that he had asked social care staff not to contact his GP without checking with him first, so his preference was updated in the notes.
Meanwhile, the advocacy referral submitted in February 2023 did not progress quickly: the advocacy provider replied on 31 July 2023 explaining the referral was awaiting allocation and that there was a significant waiting list for generic advocacy in North Yorkshire, and in an email dated 15 February 2024 they told the social worker they had tried and failed to contact him and were checking whether he still needed support.
On 3 July 2024, he informed the Council that “the advocacy lady” had finally contacted him and arranged to help with his complaint letter, confirming that the service had eventually started after a prolonged wait.
Regarding housing and access, in September 2023, an OT helped him look for more suitable accommodation because he felt trapped in his property; the OT and the man viewed two potential houses, one needing major adaptations and another fully accessible, but he chose to remain where he was and planning for adaptations at his existing home began in mid‑October 2023.
During these discussions he said he was unhappy where he lived and asked about moving; as he was eligible for Disabled Facilities Grant funding and had shown interest in relocating, the OT felt unable to continue with major adaptations at that stage and instead focused on immediate access and safety, arranging equipment and minor works.
Initially a carpet fitter adjusted a door threshold and he reported he could then access the property, but in January 2024 he again reported difficulties entering; the OT ordered a temporary ramp, which was significantly delayed in delivery, arrived unsuitable and had to be returned for reassessment, leaving him without an effective ramp. To avoid further delay, the OT proposed removal of the front door and threshold to create level access, but this fell outside the minor adaptations budget so could not proceed immediately; as a stopgap, the OT advised him to use an attendant‑propelled wheelchair for access and to liaise with wheelchair services about adjustments to his powered chair.
In February 2024, he again reported access problems; the OT reassessed, recorded that he was no longer pursuing rehousing, and submitted a request for major adaptations including improved access, altered doorways and thresholds and other structural works. The OT then worked with the Home Improvement Agency to progress these adaptations as an ongoing process beyond the Ombudsman’s September 2025 cut‑off.
Alongside this, the Council’s care assessments and support plans throughout the period consistently recorded that he could not access the community independently because of severe mobility impairments and wheelchair use, causing isolation, low mood and anxiety; they funded three hours per week of community support (for coffee, shops and errands) when he lived at his previous property, and increased this to nine and a half hours per week of “social time” or “practical support” after his late‑2023 discharge and move to different accommodation, to help him attend appointments, shop and take part in social activities. The records note that he still sometimes struggled to leave home when his previous accommodation was inaccessible, and after moving, he could get out of the new property but had difficulty re‑entering until a suitable ramp could be installed, linking his functional isolation at times more to the physical environment and equipment delays than to absence of funded support hours.
In hospital episodes later in 2023, on 11 September, he told the Council he was again in hospital and said he would refuse to go home if discharged; the social worker contacted the hospital on 14 and 15 September, learned he was awaiting tests and then that tests showed no concerns, and he remained an inpatient until 19 September, after which, due to ongoing concerns about his accommodation, the social worker referred him for an OT assessment, aligning discharge and housing considerations.
In June 2025, the ambulance service made a safeguarding referral after he voiced worries about his medical care while travelling to an appointment; a safeguarding officer visited him at home, discussed his concerns, and the Council then consulted NHS safeguarding colleagues, who agreed that the issues related to dissatisfaction with healthcare rather than abuse or neglect by someone responsible for his social care, with no immediate safety risk and no identified perpetrator; the Council therefore decided the referral did not meet the threshold for a formal safeguarding enquiry, instead gave him information on how to complain through the NHS and closed the case once advice was provided.
Throughout these events, the Ombudsman considered extensive records including case notes, visit records, OT assessments, emails and telephone logs and confined the investigation to matters from January 2023 to September 2025, noting that later events were too recent (premature) for inclusion.
What was found
The Ombudsman found service failure in two main areas: first, a one‑year period from February 2023 to February 2024 when the man did not receive the advocacy support he had been referred for, due to a lack of advocacy capacity and a long waiting list; second, delay and problems in providing appropriate access adaptations at his later property, particularly the significantly delayed and unsuitable ramp, which left him struggling to get in and out safely and caused inconvenience. These shortcomings breached the Council’s duty under adult social care and Care Act principles to secure timely support and reasonable adaptations necessary to meet eligible needs, and they directly caused distress, loss of advocacy assistance, limited independence and avoidable difficulty entering and exiting his home.
In contrast, the Ombudsman found no fault in the Council’s handling of the man’s multiple hospital admissions and discharges in 2023, noting that after each discharge the social worker contacted the care provider to ensure his home‑care package restarted without gaps and that care planning was appropriately coordinated, with no evidence that any alleged lie about self‑discharge prevented Occupational Therapy input; when concerns about his home were raised by him or hospital staff, the social worker arranged an OT referral in September 2023.
There was also no fault in the Council’s contact with his GP in February 2023, as it relied on previously recorded consent and was driven by serious safeguarding concerns when he expressed suicidal feelings; once he later withdrew consent in 2023–24, the Council recorded and respected that change, meaning his Article 8 privacy rights and data protection principles were not infringed on the evidence seen.
On allegations that the social worker lied, discriminated or downplayed his needs, misrepresented independent living providers’ wheelchair policies, or mis‑stated his needs when changing care companies, the Ombudsman found no supporting evidence; the records instead showed staff captured his views about pain, mobility, anxiety and housing, responded to concerns by escalating issues to housing, OT, telecare, wheelchair services and mental health teams, acknowledged his worries and requests, and documented increasing care hours, equipment and safeguarding actions as his needs grew, with occasional explanations about the limits of social workers’ roles in providing medical advice considered appropriate rather than dismissive.
Similarly, the complaint that the Council delayed in arranging community access support was not upheld; assessments and support plans consistently recognised his need for help to access the community and increased funded hours from three to nine and a half per week after he moved, so any isolation he experienced flowed more from environmental barriers and equipment delays than from a failure to commission community support.
Safeguarding responses were also found to be without fault: in 2023, when he alleged theft from his room, the combination of the care agency’s prompt internal investigation, dismissal of the suspected worker, security changes and barring notifications, followed by his stated feeling of increased safety, justified the Council’s view that a Section 42 enquiry was unnecessary because risk had already been removed; in 2025, the ambulance‑triggered referral correctly proceeded as advice and signposting to NHS complaint routes, as there was no abuse or neglect by adult social care providers, no immediate danger and he had capacity.
Overall, the Ombudsman concluded that apart from the advocacy delay and the access‑adaptations delay, the Council broadly complied with statutory duties to assess and meet eligible needs, coordinate care, share information appropriately for safeguarding, and respond proportionately to safeguarding concerns.
The Ombudsman required the Council to apologise and make a total symbolic payment of £250 to recognise the distress and inconvenience caused by the faults identified (including £100 specifically for the lost year of advocacy and the remainder for access‑related delay), and to provide evidence within four weeks that it had done so; no specific training requirement was set out as part of the remedy.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This is an example of the Ombudsman exercising discretion to investigate a late complaint as the man explained why he could not complain sooner.
Although the Ombudsman found no fault with the Council’s handling of the man’s hospital discharges, our reading of the report suggests fault in the way that these were handled by the hospital. The man contacted the Council to advise he was in hospital on 20 January 2023, and the Council advised him to tell staff on the ward to ‘put through an assessment’ before arranging his discharge. The social worker called the hospital on 27 February to discuss the discharge arrangements only to be told that the man was no longer a patient there. The social worker could and arguably should have contacted the hospital sooner, rather than leaving it up to the man to tell the hospital to assess his needs but in any event the hospital should not have discharged him without making sure that suitable care was in place.
There was a similar problem when Mr Y was transferred to a second hospital which discharged him before discussions with the social worker.
This behaviour by hospitals is contrary to the 2024 guidance on hospital discharge which states that where someone may need support for social care after discharge, NHS trusts should inform the Local Authority of this as early as possible in the person’s hospital stay. The guidance also sets out that there should be multi disciplinary discharge teams and care transfer hubs. Relevant professionals should work together to plan the person’s discharge. None of this seems to have happened in this case, but the report does not refer to this point. Presumably this is because the man did not complain about the hospital’s actions, but perhaps because he was not aware of their duties. We think the report could usefully have referred to the guidance.
The Ombudsman’s analysis of law and guidance in this case recognises delay in generic advocacy and access adaptations as fault, but it underplays three distinct legal issues that are clearly engaged by the facts when viewed through public law and community care law principles.
First, there is the question of timely, lawful assessment and involvement under the Care Act when a person’s ability to enter and leave their home is materially impaired over many months.
Community care law makes clear that where a person appears to have needs for care and support, the authority must carry out an assessment that captures the total extent of those needs, and must consider their impact across all relevant wellbeing domains, including suitability of living accommodation and ability to make use of the home safely. In this case, the Ombudsman accepts that assessments and plans recorded his severe mobility problems and some community support, and treats the environmental barriers largely as an equipment and housing logistics issue. But the prolonged period during which he could not reliably get in and out of his home, combined with repeated reports of access failure and falls, plainly engages the outcome “being able to make use of the home safely” and the linked wellbeing outcomes of physical and mental health, control over day‑to‑day life and suitability of living accommodation. That is not simply a matter of inconvenience. A community care law analysis would ask whether the Council’s assessment and subsequent reviews explicitly treated those access failings as unmet eligible needs.By taking comfort from the existence of OT activity and eventual major adaptations, the Ombudsman risks overlooking the statutory expectation that care and support assessments and reviews must be sufficiently clear, holistic and reasoned to show how the authority understood the severity and cumulative impact of those access barriers, over time, on the person’s wellbeing, and how it proposed to meet those needs pending a full adaptation.
The second legal issue concerns the sufficiency and immediacy of the authority’s response once eligible needs are identified, especially where the person’s safety and independence depend on timely practical measures. Public law principles, as applied in community care cases, emphasise that once an authority has decided that needs are eligible, it must meet those needs in a way that is objectively sufficient; it can only rely on the existence of possible community or housing‑side responses to dilute or postpone its own duty, if those duties are clearly going to be discharged appropriately.
In this case, the Ombudsman finds fault in the delay and unsuitability of a temporary ramp, and accepts that this caused inconvenience and difficulty entering and exiting his home, but the remedy is framed as limited service failure attracting a modest symbolic payment. A stricter community care law approach would start from the position that an adult left effectively trapped or only intermittently able to access their home over an extended period has an unmet need of a kind that goes directly to physical safety, independence, and social and economic wellbeing. The Council’s proposal that he use an attendant‑propelled wheelchair and liaise with wheelchair services is recorded but not analysed as a question of sufficiency: was this realistically capable, in practice, of restoring safe, independent access, given his circumstances and the availability of helpers, or did it effectively presuppose informal assistance and goodwill as a substitute for a lawful, council‑backed solution?
Public law principles would require the authority to show that its chosen interim response was a rational, proportionate way of meeting needs, not merely an expedient response to tight budgets, Disabled Facilities Grant rules or contractor delays. The Ombudsman’s investigator’s reasoning does not ask that question, and therefore appears to accept a level of access restriction and reliance on stopgap measures that community care law would treat as at least a potential breach of the duty to meet needs in a way that is actually sufficient in the real world.
The third legal issue is the treatment of advocacy as a standalone Care Act function and, potentially, as a need in its own right where a person struggles to engage with assessments, manage correspondence, or pursue complaints. The Ombudsman correctly criticises the one‑year delay in securing generic advocacy and acknowledges that this caused distress and loss of assistance. However, the law distinguishes between statutory independent advocacy duties triggered by particular Care Act processes and more general “information, advice and advocacy” support that can itself be a way of meeting eligible needs under s8 Care Act.
Here, the social worker’s February 2023 referral expressly sought help with correspondence, managing appointment letters and drafting letters about his circumstances and health. That description maps closely onto Care Act concepts of support with maintaining control over day‑to‑day life, accessing necessary facilities and services, and maintaining psychological and and emotional wellbeing. Public law analysis of the advocacy delay therefore cannot be confined to whether the external advocacy service had a waiting list. The key questions are whether the Council, knowing he remained without advocacy month after month, reconsidered whether it had triggered any statutory duty to provide independent advocacy in connection with assessments, care planning, reviews or safeguarding, and whether it explored other lawful ways to meet his communication‑related needs in the meantime, for example by commissioning time‑limited support specifically described and costed in his care plan. Community care law makes clear that authorities cannot treat external capacity constraints as a complete answer when a statutory duty has been triggered, nor can they simply leave a person without the support that has been recognised as necessary to enable meaningful participation in decision‑making and to protect their wellbeing.
Taken together, these three issues show a gap between the Ombudsman’s relatively narrow findings of fault and the fuller implications of public law principles for assessment, sufficiency of interim responses, and the status of advocacy as both a procedural safeguard and a potential substantive need. None of this implies that the Council acted in bad faith; the records show many individual efforts by staff and a context of scarce services. But community care law requires more than “trying one’s best” within constrained resources – it is not the NHS! (not yet!).
For councils and practitioners, the practical lesson is to ensure that access problems and advocacy gaps are explicitly treated as potential eligible needs within the Care Act process, not merely as housing delays or third‑sector shortages, and that any interim arrangements are clearly reasoned as being sufficient to reduce the impact on wellbeing to an acceptable level rather than simply the best that could be managed at the time.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s North Yorkshire Council (24 017 167) 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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