Summary: the complainant complained the Council did not follow up his concerns about abuse and lack of care and support from the supported living care provider commissioned by the Council. The Council said it followed usual practice by passing the safeguarding referral to the agency providing support to Mr X. The Council recognises more could and should be done to check the quality-of-service Mr X received. I found the Council at fault, and it agreed to my remedy.

The complaint

1. The complainant whom I shall refer to as Mr X, complained the Council failed to properly consider and respond to his complaint about abuse, lack of care and support from his commissioned supported living care provider. Mr X says this has a significant impact on his mental and physical wellbeing.
2. Mr X wants the Council to properly investigate his concerns and provide a reasoned response and ensure he receives the support he needs.

Back to top

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 investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

5. If 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)

Back to top

How I considered this complaint

6. In considering this complaint I have:
• Spoken with Mr X and read the information presented with his complaint;
• Put enquiries to the Council and reviewed its responses;
• Researched the relevant law, guidance, and policy.
7. I shared my draft decision with Mr X and the Council and have considered the comments received before reaching this my final decision.

Back to top

What I found

8. 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)
9. Where a person is not receiving direct social worker support but receives support from another agency the Council will refer any safeguarding concerns to the Multi Agency Safeguarding Hub (MASH). MASH gather information as needed and decide whether to open a formal Section 42 investigation or pass to an agency for action such as a social care review.
10. Where the Council receives complaints including safeguarding concerns about a partner agency it passes those safeguarding concerns on to the partner agency for investigation. The Council does not separately consider the complaints under its complaints’ procedure. The Council does not expect follow up under this procedure.
11. The Council has exercised its powers under the NHS Act 2006 and delegated its social care duties for residents needing a mental health service to the Greater Manchester Mental Health Foundation Trust (the Trust). The Trust employs social workers to undertake Care Act duties including safeguarding on the Council’s behalf. Therefore, the oversight of such staff is carried out through partnership arrangements rather than by direct supervision or management.

What happened

12. The Council funds Mr X’s supported living at a Care Provider arranged by the Trust. Mr X moved into the supported living scheme in July 2018.
13. In February 2020 Mr X contacted the Council by email outlining his experience of historic abuse and the impact on his mental health of the care he was receiving in his supported living home. The Council referred Mr X’s safeguarding concerns to MASH and in turn to the Trust for action by the Community Mental Health Team. The concerns included the impact on Mr X’s mental health of the care he received from the Care Provider. The Council says having passed this to the agency supporting Mr X it had no further involvement in the safeguarding enquiries or the decision not to begin a Section 42 investigation.
14. The Council says in response to my enquiries the Trust opened a safeguarding enquiry and appointed a Care Coordinator for Mr X. The Care Coordinator made appointments to speak with Mr X in February and March 2020. The Trust told the Council Mr X did not attend the appointments. After March 2020 the Trust could not arrange face to face meetings due to the Covid-19 pandemic restrictions. The Council says the Trust decided not to carry out a Section 42 safeguarding investigation. Instead, the Trust decided to assess Mr X’s mental health and offer support and bereavement counselling.
15. In July 2020 Mr X agreed to his admission to hospital following a suicide attempt. The hospital recorded he needed admitting because his care provider could not provide suitable supportive care over a weekend.
16. The Trust told the Council in response to my enquiries that it had arranged for a doctor to see Mr X in April and June 2020. The Trust says it also referred Mr X for therapy as well as support from a housing worker. The Trust’s care coordinator and housing worker carried out a joint visit to Mr X to discuss referring him for alternative accommodation.
17. In response to further enquiries the Council says it needs to improve its quality monitoring of this supported living scheme. It recognises that officers should not rely solely on the Trust’s care coordinators to report concerns. The Council’s commissioning officers plan to visit the scheme shortly as part of a new quality assurance procedure.
18. Similarly, the Council recognises that in relying on the Trust’s care coordinators to carry out safeguarding enquiries and looking into quality issues the Council has not actively engaged with Mr X. It has not discussed with him directly his concerns about collusion or failure to address allegations of abuse. On reviewing the evidence gathered by the Trust the Council says it believes the decision not to start a Section 42 enquiry may have been a proportionate decision. However, the Council recognises it, and the Trust did not consult Mr X or ask him about his concerns about the Care Provider. The Council says it has helped Mr X find an independent tenancy and he has the help of a resettlement worker to support him in bidding for a new home.
19. Records show the supported living scheme where Mr X lives is now a short-term provider offering places for two years and Mr X has now exceeded that time. He has with his mental health worker bid on some alternative properties.
20. In commenting on my draft decision statement of reasons the Council said it does not directly engage with service users about their mental health service. To do so it says may create duplication and blur the boundaries in the working relationship it has with the Trust. However, its comments set out in paragraphs 17 and 18 still apply.

Analysis- was there fault leading to injustice?

21. My role is to decide if the Council properly reviewed the standards of care received by Mr X and followed up complaints about that care, and about abuse. It is not to decide the facts of those allegations. If the Council acted with fault I must decide if that had an impact on Mr X and recommend a remedy.
22. The Council funds Mr X’s supported living provision. The Trust provides Mr X’s day-to-day support. Therefore, I have considered issues about complaints about Mr X’s supported living service commissioned by the Council not the actions of the Trust. The Trust’s actions may be considered by the Parliamentary and Health Service Ombudsman when acting under its own powers. However, where the Trust acts on the Council’s behalf the Council remains responsible for that service. Therefore, I may make recommendations to the Council about that service.
23. As the commissioner of the supported housing scheme any complaints about the quality of that scheme should be considered by the Council. It may liaise with the Trust. However, the Council should not simply pass concerns on to the Trust without engaging with Mr X. The Council should consider if there are any issues it should or could independently review which touch on the quality of the service it has commissioned.
24. I find the Council at fault for not engaging with Mr X and discussing with him the concerns he raised about the impact of his home environment on his mental health. This delayed the Council reviewing if it was funding a suitable placement. Once the supported living scheme changed to a two-year support project a review became necessary. The change suggests long term care at this care provider may no longer be suitable. Therefore, I would expect the Council to have engaged with both Mr X and the Trust to discuss his choices.
25. The Council correctly referred the safeguarding referral to the Trust. It considers the decision by the Trust not to start a full safeguarding investigation a proportionate decision. However, I find the Council at fault for not following up the safeguarding referral. Although no full safeguarding investigation took place the Council should have followed up to see if there were any issues identified in the enquiries that it could address as the commissioner of the service. As part of that procedure, the Council should have engaged with Mr X and reassured him all the agencies involved in his support had considered his concerns. In that engagement the Council could have explained its limited role and that of the Trust. That would help Mr X understand better what he could expect from the Council. I recognise the Council’s concerns about blurring boundaries in the relationship with the Trust. However, those concerns should not risk someone falling between the gaps in the services provided by both the Council and the Trust. To fully assess the service’s continuing suitability the Council as the commissioner of Mr X’s supported housing needs to engage with him, the Trust and the Trust appointed social workers. I am satisfied this failure did not cause a significant injustice however because the Council properly referred the safeguarding concerns and a decision reached on whether to take further action.
26. In our “Guidance on Remedies” we recommend a symbolic payment where we cannot place the complainant in the position, they would have been but for the fault. The Guidance suggests a scale of between £100 and £300 in recognition of any delay or distress caused. Mr X experienced delay in the review of the quality and continued suitability of the service he receives, and avoidable distress caused by the lack of earlier engagement with him.

Back to top

Agreed action

27. In recognition of the poor service received I recommend the Council within four weeks of my final decision:
• Apologises to Mr X;
• Outlines to both Mr X and the Ombudsman the improvements it proposes in its quality assurance and complaint procedures;
• Pays Mr X £200 in recognition of the poor service that led him to feel the Council had not addressed his concerns fully.

Back to top

Final decision

28. In completing my investigation, I find the Council acted with fault leading to an injustice.

Back to top

Investigator's decision on behalf of the Ombudsman