Council to undertake wide ranging internal review following criticism from Ombudsman over failure to meet care needs

The woman behind the complaint, Ms D, complained on her own behalf, and that of her daughter Miss E, who is an adult with learning disabilities.

Ms D complained in April 2025 that the council had not provided Miss E with care and support since around November 2022, when Miss E stopped attending a day centre.

Ms X represented Ms D and supported her to make her complaint.

Ms X told the Ombudsman that from summer 2023 onward, Ms D had contact with multiple social workers in response to referrals from organisations concerned with Ms D and Miss E’s safety and wellbeing. This included concerns raised by Ms X.

Ms X said the council’s contacts left Ms D confused, not understanding the different decisions taken by the council or roles of social workers involved. She said Ms D also received promises the council would arrange care for Miss E which it did not keep.

Ms X said the council’s actions led Ms D to experience prolonged and unnecessary distress, which compounded the stress she experienced meeting Miss E’s needs without support.

Ms X said that during events covered by this complaint, Ms D’s caring role had become unsustainable, and she needed urgent relief.

The Ombudsman investigated events between July 2023 and May 2025.

Considering the case, the Ombudsman said: “I noted first that when the Council arranges to meet the care and support needs of a vulnerable adult it should review the support it provides at least once a year. Given the Council issued a care and support plan to Miss E in September 2022, it followed that it should have reviewed that by September 2023.

“However, the need for it to review the care and support plan here was more urgent. First, this was because the Council knew from July 2023, that Miss E was not getting the support set out in the September 2022 plan. Second, because it also knew something of her vulnerability, and that of Ms D, because of the safeguarding enquiries it began in July 2023. This coincided with a referral from a NHS service also saying Miss E needed a care needs assessment.”

The Ombudsman therefore found that the council delayed for ten months before beginning an assessment of Miss E’s needs.

The council was also found at fault for:

• poor communications around its review of Miss E’s needs;
• not following a clear process in undertaking that review;
• making an unacceptable offer of short-term support through a day centre;
• failing to acknowledge any of the above as it went on to try and complete its assessment;
• delay in instructing an advocate to support Miss E;
• delay in offering Ms D a carer’s assessment;
• making offers of short-term support via CP2 which it then had to withdraw or otherwise did not happen.

The report concluded that Ms D suffered “repeated and avoidable distress” which compounded that caused by meeting Miss E’s needs without support.

The council accepted the Ombudsman’s findings. It agreed to proposals to remedy the injustice caused by its faults to Ms D and Miss E including:

• To apologise to Ms D and Miss E accepting the findings of the investigation.
• To make a symbolic payment to Ms D of £2,335 and to Miss E of £585.
• To appoint a senior officer, not previously involved in oversight of the case to liaise with Ms D in commissioning an independent social worker (ISW) and instruct the ISW to:
  • undertake a quick review of Miss E’s care needs assessment completed in January 2025 to ensure it remained up to date;
  • complete a carer’s assessment of Ms D’s needs;
  • work with Ms D and Miss E in drawing up a joint care and support plan;
  • retain oversight of the case while the Council commissioned any services identified in the care and support plan;
  • aim to complete steps 1 to 4 within three months of their instruction;
  • undertake a review six to eight weeks after services went into place to ensure they were meeting any assessed needs of Ms D and Miss E and that the care and support plan remained appropriate.

Alongside the personal remedy, the council agreed to undertake an internal review, to cover the following:

• The procedures used to prioritise cases where no care is in place, while someone waits for a needs assessment. The review would ask if the council has the appropriate triage arrangements in place and resources to avoid delay in it beginning an assessment of need, such as happened in this case. If not, it would ask what steps the council could take to improve its triage arrangements or reduce delays;
• The communications it has with those who are waiting for a social care needs assessment. The review would consider what procedure it has in place to let people know when it has decided to complete a needs assessment and when it anticipates completing that. And what it tells them about the priority it gives their case and how it has decided this. Also, what arrangements it has to keep in touch with them if they are waiting more than four weeks for the assessment to begin? The council agreed the review would consider if it needed to produce or update advice for staff, and how it ensured they were aware of that advice. Also, what checks it has in place to ensure such communication happens;
• The communications it has with people once it begins the process of assessing social care needs. The review would ask if it made clear the different steps involved between assessment and services starting. And if it routinely shared needs assessments, indicative personal budgets and care and support plans. It would ask if there was more it needed to do to improve its procedures and staff awareness of the same;
• What advice or procedures it has in place to support social workers when they are looking to set up urgent packages of care before completing a needs assessment and care and support planning. How could it avoid situations like Ms D and Miss E’s experience where repeated negotiations around care packages took place, but without a care needs assessment or care and support plan completing.

Sandwell Metropolitan Borough Council has been approached for comment.

Lottie Winson