Summary: Mrs B complains that Mr C’s Council-commissioned carers put Mr C at risk and he was injured as a result. She also complains the Council’s safeguarding investigation was inadequate and the family cannot be satisfied it was effective. Mr C was put at risk and this is fault. The Council will take steps to remedy the injustice to the family.

The complaint

1. Mrs B complains that the Council failed to ensure Mr C’s care provider, United Response, had appropriately trained staff to meet his needs as a vulnerable adult. In particular:
• On 18 October 2018, a support worker (Ms E) put Mr C in a child’s swing that was unsuitable. He fell out of the swing resulting in a hospital admission and serious injuries.
• On 31 January 2019, a different support worker (Mr F) drove Mr C to the seaside when the weather was particularly bad. The vehicle broke down leaving the two stranded for several hours in the cold, which was distressing.
2. Mrs B says the Council’s safeguarding investigation failed to answer the family’s questions about why the above incidents happened. Mrs B also says the care provider has failed to carry out the resulting recommendations. This has left the family feeling uncertain that the investigation was effective.

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The Ombudsman’s role and powers

3. 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)
4. 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, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

5. I have considered the complaint Mrs B submitted and I have discussed the matter with her. I have asked the Council to comment on the complaint and considered its response. I have reviewed the Council and United Response’s letters and the safeguarding documentation.
6. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

7. The Care Act 2014 gives local authorities a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the local authority must involve any carer the adult has.
8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
9. The fundamental standard on safety says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided.
10. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)

Key Facts

11. Mrs B is an independent advocate acting on Mr C’s behalf. Mr C has learning disabilities and is unable to bring the complaint himself.
12. Following the incidents complained of, United Response completed a fact-finding exercise. The key points from the document are:
• Ms E had moving and handling training in August 2018. She also had a handling competency assessment, specific to Mr C, in October 2018.
• When Mr C was in the swing, Ms E could not adjust the shoulder straps so only secured Mr C using the lap strap.
• On the morning of 31 January 2019, Mr C’s father told Mr F to keep Mr C ‘under cover’. He suggested taking Mr C to the local library and a restaurant.
• There was no parking in town, so Mr F drove to the seaside as he felt this was something Mr C enjoyed. When they decided to leave, the car would not start.
13. In March 2019, the Council held a safeguarding conference to consider the incidents. Ms E was not at the meeting and the record shows she was not working at the time. The minutes of the conference note that there was no support plan in place at the time of the swing incident and Ms E should not have put Mr C in the swing. A comment from a United Response Manager suggests Ms E took Mr C to the swings because she wanted him to ‘have a nice time’. The record further says that the swing was meant for a child. Mr C is in his 30s.
14. In relation to the January 2019 incident, the minutes suggest Mr F misunderstood the instructions from Mr C’s father, that Mr C was to remain under cover. Mr C’s father understood Mr F would keep Mr C indoors by taking him to the local library or a restaurant. However, Mr F thought ‘under cover’ included being in the car. Mr F claimed he did not know the weather was forecast to deteriorate and he had taken Mr C to the seaside as there was no parking available in town and Mr C enjoyed the activity. Mrs B has confirmed Mr F had taken Mr C to the same location on occasions previously.
15. The attendees agreed to convene another meeting in April. In the meantime, United Response’s Area Manager said it would send a letter to Mr C explaining what had happened and this would include an apology.
16. The second meeting went ahead in April 2019. The minutes note Ms E remained off work and therefore was unavailable for interview. However, United Response confirmed it had spoken with Mr F and addressed the incident in supervision. United Response’s Area Manager explained that at a recent meeting, managers had discussed support plans, planned activities and communication with family members.
17. The letter of explanation and apology was raised at the April meeting. However, United Response advised it was waiting for the safeguarding investigation to conclude before it wrote to the family. The Council concluded its safeguarding investigation on the basis that Mr C was not at risk.
18. On 19 June 2019, United Response wrote to the Council. It explained that it had met with Ms E, although she was still off work. The letter said Ms E had given further detail about how Mr E was supported in and out of the swing. However, it did not give any further information about what Ms E had said in the letter.
19. On 10 July 2019, United Response wrote to Mr C’s mother. It said that the letter was a formal response to the family’s concerns. The letter concluded that Mrs E had weighed the risk of putting Mr C in the swing against the fact that he would obviously enjoy doing so. It concluded the incident was simply an accident. There was no apology.

Analysis

The October 2018 incident

20. Mrs B says Mr C’s family ultimately want to know why Ms E put Mr C in the swing. The safeguarding notes refer to Ms E thinking Mr C would ‘have a nice time’. Ms E was unavailable for the Council or United Response to interview as part of the safeguarding process. However, all the parties accept Ms E should not have put Mr C in the swing. I can therefore only conclude that Ms E’s actions were a result of poor judgement, even though her intentions were good.
21. There is evidence that Ms E had completed appropriate manual handling training and had an assessment specific to Mr C. However, she put Mr C in a child’s swing that did not have appropriate safety straps and this put him at risk. This appears to be a possible breach of the fundamental standard on safety and is fault. Mr C fell out of the swing and injured himself as a result. There was no support plan in place at the time. This too is fault. Mr C was put at risk and injured as a result.

The January 2019 incident

22. I accept Mr F misunderstood Mr C’s father’s instructions. I consider it is reasonable to interpret being in a car as meaning ‘under cover’. Mrs B says Mr F must have known the weather would deteriorate as an amber weather warning was in place. However, I do not consider Mr F deliberately put himself and Mr C at risk and I therefore accept he genuinely did not know the conditions would deteriorate.
23. Mrs B says Mr F had previously taken Mr C to the seaside and the family knew about these occasions. I have seen no evidence to indicate Mr C’s parents did not approve of Mr F taking Mr C in the seaside in the past. I have accepted Mr F did not know the weather conditions would deteriorate to the extent they did, and this is unfortunate. It is also unfortunate that Mr F’s car broke down. However, this is not fault.
24. In summary, Mr F took Mr C to do an activity which he previously enjoyed and of which his parents approved. When he became aware the weather was deteriorating, he attempted to remove Mr C from the situation but was unable to, due to circumstances beyond his control, that is, his car breaking down. I do not consider this is fault.

The safeguarding investigation

25. The minutes from the safeguarding case conferences are detailed. Ms E was away from work shortly after the incident and the reasons why she put Mr C in the swing remain unclear. However, I consider it reasonable to conclude Ms E wanted Mr C to have a nice time. This was poor judgement and all the parties have accepted Ms E should not have put Mr C in the swing.
26. Mr F took Mr C to the seaside because he misunderstood the instruction to keep Mr C under cover. He also did not realise the severity of the weather that day. The fact that his car broke down was beyond his control. I consider the safeguarding investigation answers the questions, as far as it could in Ms E’s absence, about why the incidents happened. I therefore do not consider there is fault in relation to this part of the complaint.
27. The minutes from the first safeguarding conference confirm United Response would send an apology and letter of explanation. I have seen no evidence that this happened. The June and July 2019 letters from United Response are brief. The June letter refers to having met with Ms E and her giving more detail about how she handled Mr C. However, this detail is not in either letter and there has been no apology. This is fault and I accept the family has concerns about the Council’s safeguarding recommendations being followed.

Agreed action

28. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of United Response, I have made recommendations to the Council.
29. Within one month of my final decision, the Council will take the following steps to remedy the injustice to Mr C:
• If it has not already done so, put in place a care plan for Mr C, including information about his manual handling and mobility needs.
• Apologise for the faults I have identified and the injustice Mr C suffered as a result.
• Explain to the family the steps it has taken to ensure United Response complies with the recommendations from the safeguarding investigation. This should include a letter of explanation, including the further detail from Ms E referred to in United Response’s June 2019 letter, and an apology to the family as outlined in the safeguarding meeting minutes.

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Final decision

30. I have completed my investigation on the basis that there is evidence of fault in relation to one of the incidents and the Council’s actions following the safeguarding investigation. However, the Council has agreed to remedy the injustice to the family.
31. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Investigator's decision on behalf of the Ombudsman