Summary: There is evidence of fault by the Council in this complaint. It failed to act properly following a safeguarding alert made by a Care Provider. It later failed to deal with a complaint under its complaint’s procedure.

The complaint

1. Mrs X complains on behalf of her sister, Miss Y.
2. Mrs X is dissatisfied with the process and outcome of the Council’s investigation into the actions of a United Response, a Care Provider acting on behalf of the Council.

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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. We may investigate matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)
5. 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

6. I have:

• considered the complaint and discussed it with Mrs X
• considered the correspondence between Mrs X and the Council, including the Council’s response to the complaint
• made enquiries of the Council and considered the responses
• taken account of relevant legislation
• offered Mrs X and the Council an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

7. Section 42 of the Care Act 2014 (the Act) defines an adult at risk as an adult who:

• has needs for care and support (whether or not the local authority is meeting any of those needs) and;
• is experiencing, or at risk of, abuse or neglect; and
• as a result of those needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect;
• the local authority retains the responsibility for overseeing a safeguarding enquiry and ensuring that any investigation satisfies its duty under section 42 to decide what action (if any) is necessary to help and protect the adult, and to ensure that such action is taken when necessary.

8. The Act sets out a clear legal framework for how local authorities and other parts of the system should protect adults at risk of abuse or neglect. It must:

• lead a multi-agency local adult safeguarding system that seeks to prevent abuse and neglect and stop it quickly when it happens;
• make enquiries, or request others to make them, when it thinks an adult with care and support needs may be at risk of abuse or neglect and,
• determine what action may be needed.

9. The Council’s safeguarding adult’s policy stage 2 set out ‘Responding to the Concern/ Gathering Information

• Assess risk and ensure safety of the adult at risk within 24 hours
• Decide on the proportionate response to the concern within 5 working days

What happened

10. Miss Y has a learning disability and lives in residential accomodation comissioned by the Council. The care home is owned and managed by United Response (the Care Provider)
11. On 6 May 2019 Miss Y was assulted by another resident. Mrs X says the Care Provider reported the incident to the Council’s safeguarding team and asked for assistance, but the Council refused.
12. The Care Provider removed Miss Y from her accommodation and placed her in temporary alternative accommodation, where she remained for five weeks, an environment Mrs X says was not suitable for her needs.
13. The Council says it was contacted by the Care Provider on the 7 May 2019 to report alleged physical abuse. The person alleged to have caused harm to Miss Y and another service user who resided at the accommodation.
14. The Council says “…immediate safety measures taken by the Care Provider appeared to be that [Miss Y] had been seen in hospital for her injuries, the police had been informed of the assault and [Miss Y] was temporarily residing in an alternative accommodation”.
15. The Council does not appear to have been involved in the decision to temporarily rehouse Miss Y. It is not clear how the temporary accommodation was assessed as suitable for Miss Y.
16. The Council’s records show Mrs X visited Miss Y’s permanent accommodation on 9 May 2019 to ask if the alleged perpetrator would be moved to different accommodation. The staff said the situation was complex. Mrs X obtained the contact details of the social worker and then contacted the Council the same day. The officer “Advised [Mrs X] to contact provider for a response for future updates”.
17. The Council says it implemented stage 3 of its safeguarding procedure on the 10 May 2019 for further enquiries to be completed. The records show the manager at the Care Provider contacted the Council on 14 May 2019 asking that a social worker be allocated to Miss Y. The officer recorded “passed to CTLD duty” later the same day an officer recorded “…Case is already on waiting list, no new referral is required”.
18. The manager at the Care Provider contacted the Council again later the same day chasing the allocation of a social worker. The Council officer noted that Miss Y was living away from the care home, and that she needed a social worker allocating to make a best interest decision about moving back to the care home.

The Council says the CTLD (Community Team Learning Disability) allocated a social worker, as an outcome from the safeguarding work completed on 14 May 2019.

19. The Care Provider appointed its own investigating officer. The officer interviewed Miss Y on 22 May 2019. Mrs X was not informed about the interview. When she later received a transcript, she believed the interviewer had asked Miss Y leading questions. Mrs X was also concerned the report recorded Miss Y spoke in long sentences, Mrs X says this is unlikely because Miss Y speaks in whispers and uses a maximum of two words. The notes also record Miss Y said that she had to complete all her jobs before she was allowed to eat, drink or go out. Mrs X was concerned this was not investigated further by the Care Provider or the Council.
20. The Council says a social work review of Miss Y took place via telephone on the 28 May 2019 and a follow up took place on 7 June 2019.
21. Mrs X says there was a lack of communication from the Care Provider and the Council. The records show Mrs X contacted the Care Provider and the Council by telephone and email on numerous occasions asking to discuss ‘her sister’s case’ and enquire what action was being taken to facilitate Miss Y’s return to her permanent placement, day centre attendance and about charging issues.
22. On 3 June 2019, Mrs X sent an email to the Council saying she had been trying to contact the social worker because she wanted to discuss her concerns about Miss Y’s temporary placement, that Miss Y was upset by the behaviour of another resident in the temporary accommodation, that the staff were unfamiliar, and this was having a detrimental impact on her mental health. Mrs X wanted to know when Miss Y could return to her permanent placement.
23. On 5 June 2019 Mrs X exchanged emails with a social worker, asking about the outcome of an internal meeting about Miss Y. She was not satisfied with the reply, so she telephoned the officer. The social worker told Mrs X she could not discuss actions relating to residents other than Miss Y. The officer told Mrs X she intended to visit Miss Y the following week. Mrs X sent a further email the same day to say she and/or her brother would like to be present when the social worker visited Miss Y. She asked to be informed when the visit would take place. The social worker sent an email the same day to the Care Provider to inform it of Mrs X’s request and said she was concerned Miss Y may feel under pressure and may not feel able to express her views and said, “Please can you ask your staff not to tell the family when I am going to be seeing her please?”.
24. The following day Mrs X telephoned the Council to says she was “unhappy with service, saying she had been waiting for 5 weeks to discuss Miss Y’s case. A council officer told Mrs X the social worker was on leave and “…relevant people would be in touch to advise on case.”
25. A social worker visited Miss Y on 7 June 2019. The officer, an approved mental health professional, did not consider Miss Y was experiencing low mood, although she had expressed sadness about the loss of her mother. She also said she wanted to return to her permanent placement. The social worker updated Mrs X, saying she could arrange counselling for Miss Y.
26. Mrs X complained to the Care Provider on 11 June 2019. She was dissatisfied with the way it had dealt with the assault on Miss Y, a lack of communication and that a care worker had not supported Miss Y to buy appropriate clothes for a planned outing. Mrs X also reported the matters to the Care Quality Commission (CQC).
27. The social worker contacted Mrs X again on 14 June 2019 to inform her ‘management’ would be meeting with the Care Provider. She also said she had been informed by the social worker supporting the perpetrator of the assault, that there was no suitable alternative accommodation for him.
28. The social worker contacted Mrs X again on 19 June 2019 to inform her the perpetrator of the assault would be accommodated elsewhere from the following day so Miss Y would be able to return to her permanent placement the following afternoon. The records show Mrs X said she was “happy to hear this and stated that the planned meeting with higher management on Friday does no longer need to go ahead as the issue has now been resolved”.
29. Miss Y moved back to her permanent accommodation on 20 June 2019.
30. Mrs X contacted the social worker again on 4 July 2019 to ask if counselling for Miss Y had been arranged. She said she had visited Miss Y at her permanent placement and said although Miss Y was happy to be back, she was not herself, she appeared distracted and sad and she felt she would benefit from counselling. The social worker responded saying, “I have tried looking to find the counselling service for those with LD in Keighley. However, I have not been able to find this. It maybe that it has closed? I would advise that you take her to the GP and they will be able to access the proper services for her”.
31. The social worker completed a closing summary record on 16 July 2019. She recorded “Case was referred following Safeguarding concerns… The provider is United response and the provider moved both [Miss Y} and [resident X] out of the property… [perpetrator] has now moved out of the property, and [Miss Y] and the other tenant [X] have now moved back to [Care Home]. No other actions at this point, and case is to close.
32. On 2 August 2019 Mrs X telephoned the Council to submit a complaint about the Care Provider. The officer gave Mrs X the contact number for the Council’s commissioning team. The records show Mrs X telephoned the Council again on 16 August 2019 asking to speak to officer in CTLD “in regards to a meeting that was done a couple of months ago in relation to an incident that occurred with [Miss Y]”. The officer sent an email to officer in the CTLD to request that someone contact Mrs X as soon possible.
33. The Care Provider investigated Mrs X’s complaint. I have seen a copy of the investigation report. It sets out the action it took immediately the incident occurred. It reported:

• Social service duty were contacted and they were advised to ring the crisis team.
• The crisis team stated that they wouldn’t get involved as it was police matter.
•  Safe guarding were contacted in which an answer phone gave advice to ring 999 they left a message on the answering machine at 15.45 hours.

34. The report confirmed the Care Provider had contacted the Police. The Police deemed it not to be a priority so care staff contacted the Council again and reported “two of the people we support as extremely frightened and saying they did not want to stay in the property with the other person supported at the service. On call contacted the crisis team again to explain the situation in relation to the police not responded and the presentation, they informed on call that as the providers we needed to get it sorted, and it was our responsibility to keep people safe. Extra staffing resources had been sought and one person was supported to the hospital”.
35. The Care Provider wrote to Mrs X in July 2019 with a response to her complaint. It acknowledged that Miss Y had been in temporary accommodation longer than expected, and said some decisions taken were as a result of “not feeling supported from the out of hours support offered by social services duty manager, crisis team, safe guarding team”. In response to Mrs X’s complaint about a lack of communication, it apologised if Mrs X felt communication was not effective and said it intended to explore this further with the staff member concerned and would draw up a communication agreement. It said Miss Y had been interviewed about the assault alone because it was deemed she had capacity, that she had been offered support from a staff member, but in light of the complaint residents would be offered support from a family member in the future. It acknowledged a care worker had not supported Miss Y to purchase appropriate clothing for an outing and said care workers would seek Mrs X’s approval for any future ‘one off’ spending over £50. The Care Provider also responded to other matters relating to care staff and the perpetrator of the assault.
36. Mrs X was dissatisfied so submitted an appeal. The Care Provider responded in August 2019, reiterating its position.
37. Mrs X was dissatisfied with the response, believing it to be dismissive of her concerns. She made a complaint to this office. The complaint was assessed and deemed to be premature because it not been through the Council’s complaints procedure. The Council subsequently investigated the complaint.
38. I have seen a copy of the Council’s investigation report dated 12 December 2019. It upheld 5 points of the complaint, partly upheld 4, was inconclusive on 1 point, and did not uphold 4 points. It wrote to Mrs X in January 2020 to inform her of its findings. It acknowledged there was a lack of record keeping by the Care Provider, and that there were issues when Miss Y moved to alternative accommodation. It also agreed that there was a lack of communication from the Care Provider and that Miss Y was not supported appropriately to make informed choices about spending
39. The Council accepted it had not followed the the correct process when the Care Provider reported the assault, that the response from the Council’s emergency duty team lacked guidance and support, and it had not responded properly when Mrs X raised safeguarding concerns about the temporary accommodation.
40. The Council apologised that Mrs X’s “...sisters support from United Response was not as you had expected”.
41. Mrs X says the investigation report says she was offered £400 compensation. She says this was the first she knew of this; she has not been contacted about this before or after she received the Council’s complaint response. The Council says the Care Provider offered Miss Y £422.48 to reimburse her for money spent on inappropriate clothes.
42. Mrs X is dissatisfied with the Council’s response and believes it has not investigated her complaint properly.

Analysis

43. A section 42 enquiry must take place if there is reason to believe that abuse or neglect has taken place. Under the Care Act, local authorities have overall responsibility for dealing with safeguarding concerns, although they have the power to delegate safeguarding enquiries to other bodies, but it should satisfy itself that the body will meet agreed timescales and follow up actions.
44. The Care Provider acted correctly in contacting the Council immediately after the assault took place. It is clear from the records the Care Provider was seeking intervention and support from the Council’s safeguarding team.
45. The Council failed to respond to the alert appropriately. It failed to follow the legal framework and its own safeguarding procedures.
46. The Council’s policy says when a safeguarding concern has been raised, it should “Assess risk and ensure safety of the adult at risk within 24 hours. Decide on the proportionate response to the concern within 5 working days”. The Care Provider reported the assault to the Council on 7 May 2019, despite the Council being told that Miss Y needed hospital treatment, was frightened, and not wanting to return to her accommodation, it saw no urgency in the matter. It wrongly told the Care Provider it was its responsibility to keep people safe and advised it to report the matter to the Police. This is fault.
47. The Council took no action to ensure the temporary accommodation Miss Y was moved to was suitable for her needs. This is fault.
48. Seven days later, on 14 May 2019 the Care Provider contacted the Council again, the Council said the case was on the waiting list. It was only because of the Care Provider’s persistence that the Council allocated a social worker. The social worker conducted a telephone review of Miss Y’s needs on 28 May 2019, this was not sufficient. Given the circumstances the social worker should have visited Miss Y and involved Mrs X. This did not happen, the social worker intentionally excluded Mrs X. There was no good reason for this. This is fault. It caused Mrs X additional stress and left Miss Y without the support of a family member.
49. To the Care Provider’s credit, it took steps to respond to the incident. It allocated extra care staff and accommodated Miss Y in temporary accommodation when it was clear extra staffing was not sufficient to keep Miss Y safe. It also launched an investigation. The temporary accommodation may not have been entirely suitable for Miss Y, but in the absence of any other option at the time I cannot criticise The Care Provider’s decision. The fact that Mrs Y was in temporary accommodation for five weeks, is as much the fault of the Council, as it was the Care Provider. It is difficult to say whether the outcome would have been different had the Council acted sooner.
50. I have considered the Care Providers complaint response sent to Mrs X in July 2019. Mrs X believes it to be dismissive. I cannot agree. It addressed the issues in an open and transparent way and acknowledged that its handling of the situation fell short in some areas and set out the action it would take as a result.
51. The Council’s safeguarding investigation concluded the Care Provider should have kept better records, and communicated better with Mrs X.
52. Mrs X contacted the Council to submit a complaint in August 2019. It should have been dealt with under the Council’s formal complaints procedure. This did not happen. A council officer wrongly directed Mrs X to its commissioning team. It was only after Mrs X made a complaint to this office that the Council investigated the complaint. By this point Mrs X had suffered considerable stress and distress dealing with the whole situation. This should not have happened.
53. The Council’s complaint response apologised that the support Miss Y received from the Care Provider did not meet Mrs X’s expectations, but it failed to properly address its own failures, and the impact this had on Miss Y and Mrs X. Miss Y, a victim of an assault, was left in a vulnerable situation for five weeks. This has clearly had a detrimental impact on her, so much so, she is now having counselling. Mrs X suffered uncertainty and worry, and she has been put to significant time and trouble complaining to the Care Provider, the Council, and this office twice.
54. This left Mrs X feeling that her concerns have not been properly addressed

Agreed action

55. The Council will within four weeks of the final decision

• write to Mrs X apologising for its failings and pay her £300 for the distress caused, and the time and trouble she has been put to dealing with the whole situation
• pay Miss Y £500 for the distress caused.
• ensure Miss Y receives the payment offered for reimbursement of clothes purchased.

56. Within three months

• undertake a review of safeguarding procedures

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Final decision

57. There is evidence of fault by the Council. It failed to act properly following a safeguarding alert made by a Care Provider. It later failed to deal with a complaint under its complaint’s procedure.
58. The recommendations above are a suitable way to remedy the injustice caused.
59. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman