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Leicestershire County Council (20 007 059)

Category : Adult care services > COVID-19

Decision : Upheld

Decision date : 17 Mar 2021

The Ombudsman's final decision:

Summary: Mrs X complains about the Council’s handling of safeguarding concerns relating to the care home her son, Mr Y, lives in. Officers failed to do a risk assessment before visiting the care home, which could have put Mr Y at risk of harm. The Council needs to apologise for the distress it caused Mr Y.

The complaint

  1. The complainant, whom I shall refer to as Mrs X, complains about the Council’s handling of safeguarding concerns relating to the care home her son lives in.

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What I have investigated

  1. I have investigated the actions of the Council.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I have:
    • considered the complaint and the documents provided by Mrs X;
    • discussed the complaint with Mrs X;
    • considered the comments and documents the Council has provided in response to my enquiries; and
    • shared a draft of this statement with Mrs X and the Council, and invited comments for me to consider before making my final decision.

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What I found

What happened

  1. In July 2020 the Council was alerted to safeguarding concerns about the care home Mrs X’s son, Mr Y, lives in. The Police, the Council and the Care Quality Commission all visited the care home at the same time. The Police made enquiries into potential criminal activity. The Care Quality Commission inspected the care home and found it required improvements to make it safe and well-led. The Council attended in case the Police enquiries resulted in the need to move people living at the home to alternative accommodation.
  2. After the visits Mrs X complained to the Council about the actions of Social Worker B who took part in the visit, having been called twice by her son who was upset about the way he had been treated. Mrs X said Social Worker B:
    • had accessed her son’s notes without his permission and did not tell him how the information gathered would be stored;
    • had put her son at risk of contracting COVID-19 by not sanitising her hands, failing to wear a medical face mask, a face shield, gloves or an apron;
    • had spoken to her son for 50 minutes and sat less than 1.5 metres away from him; and
    • failed to share the risk assessment with her son.
  3. When the Council replied in August it said Social Worker Manager C:
    • had visited the care home with her team, the Police and the Care Quality Commission in response to safeguarding concerns;
    • had spoken to Mr Y in a smoking shelter and explained they were investigating allegations made by a former resident;
    • maintained a two-metre distance from Mr Y at all times, wore a cloth mask and gloves provided by the care home, and used hand sanitizer when moving between tasks; and
    • did not access Mr Y’s records; and
    • did not store information on the Council’s system about him.
  4. Mrs X was not satisfied with the Council’s response. She said:
    • she had not been complaining about Social Worker Manager C but Social Worker B;
    • however, Social Worker Manager C had not worn a face mask and had not been able to keep two metres away from her son as the smoking shelter is less than two metres;
    • when her son told Social Worker B she could not access his records she said “You think you are the boss; you are wrong, I am” and read them without his consent;
    • Social Worker B asked staff at the care home to log incidences of him swearing, which he found upsetting and demeaning; and
    • Social Worker B had disrupted the work of the care home through her many visits, causing fear and dread to the residents, including her son.
  5. Mrs X asked the Council to provide the risk assessment made before visiting the care home and the “unfounded allegations made by the former resident”.
  6. When the Council replied to Mrs X’s complaint in October 2020, it said:
    • the safeguarding enquiries resulted from an allegation of abuse and were continuing;
    • the care home had no concerns with Social Worker B leading the safeguarding enquiries;
    • the Police were leading the enquiry into potential criminal activity;
    • although care plans had been made available to its Officers, they had not accessed Mr Y’s notes;
    • it had asked the local authority which funds Mr Y’s placement at the care home to review his needs under the Care Act;
    • it had not asked the care home to gather information about Mr Y’s use of swearing; and
    • it could not share details of the safeguarding concerns or the risk assessment carried out before visiting the care home as they contained confidential information.
  7. The Council says the visit to the care home in July 2020 followed its Personal Protective Equipment (PPE) Guidance for Frontline Care Pathway Staff Undertaking Essential Visits, which had been in place since May 2020. This says:
    • to consider alternatives to visits;
    • PPE was not required if it was possible to remain 2 metres apart; and
    • to wear a fluid repellent/resistant surgical mask if it was not possible to maintain 2 metres distance.
  8. The Council says:
    • it was essential for its officers to visit the care home over the safeguarding concerns; and
    • there was no need for its officers to wear PPE because they could remain more than two metres away from the people at the care home.
  9. The Council has provided no specific risk assessment over the visit to the care home.

Is there evidence of fault by the Council which caused injustice?

  1. I cannot find fault with the Council for taking action over the safeguarding concerns by visiting the care home. However, the Council should have been able to provide a copy of the risk assessment relating to the visit to the care home. The fact that it has been unable to do so is fault by the Council. It is difficult to understand how officers could have known what PPE they would need until they arrived at the care home. They should therefore have been prepared for the possibility that they would need to wear face masks and had surgical masks with them. The failure to do so was fault. That could have put Mr X at risk of harm. It is also clear Mr Y was distressed by the officers’ visit. That should not have happened.
  2. The Government had issued no specific guidance for social workers on the use of PPE. However, on 31 July 2020 it issued a PPE guide for community and social care settings. This says to wear:
    • a type II surgical mask (or a fluid repellent type IIR surgical mask if that is all that is available) when within 2 metres of the person but not touching them;
    • either a type I or type II surgical mask (or a fluid repellent type IIR surgical mask if that is all that is available) if more than 2 metres away from the person.
  3. Even after 31 July, there would have been no specific need for officers to wear gloves or aprons when visiting Mr Y at the care home. However, individual care settings will have their own requirements and it appears that is why the Council officers agreed to wear gloves provided by the care home.

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Agreed action

  1. I recommended the Council:
    • within four weeks writes to Mr Y apologising for the distress it caused to him and the failure to do a proper risk assessment before visiting the care home;
    • within eight weeks take action to ensure officers do risk assessments and record them before visiting people in their homes and take appropriate PPE with them to cover all possibilities.

The Council has agreed to do this.

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Final decision

  1. I have completed my investigation with a finding of fault causing injustice.

Parts of the complaint I did not investigate

  1. I have not investigated the actions of the Police or the Care Quality Commission, as it is not within the Ombudsman’s power to do so.

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Investigator's decision on behalf of the Ombudsman

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