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Plymouth City Council (18 017 093)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 05 Aug 2019

The Ombudsman's final decision:

Summary: Mr X and Mrs X complain about the Council’s handling of safeguarding issues regarding their father. They complain the Council told them their father was subject to a protection order, that the Council’s assessment of their father’s care and support needs were dismissive, and that the Council’s communication with them was poor. The Ombudsman finds fault with the Council’s actions. The Council has agreed to apologise and make service improvements.

The complaint

  1. Mr X and Mrs X complain about the Council’s handling of safeguarding issues regarding their father, Mr A. They also complain about how the Council treated their mother and father during this time. In particular, they complain:
  • the Council told them Mr A was subject to a protection order;
  • the Council’s assessment of Mr A’s care and support needs were dismissive, and;
  • the Council’s communication with the family was poor and unprofessional.

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

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How I considered this complaint

  1. I spoke with Mr X and considered the information he provided.
  2. I made enquiries with the Council and considered the information it provided.
  3. I sent a draft decision to Mr X and the Council and considered their comments.

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What I found

What happened

  1. In February 2018, Mr A was admitted to hospital after a fall. At hospital, Mr X spoke to hospital staff about his uncertainty about how his father had fallen and that Mr A was not sure whether his wife had pushed him. The records showed Mr A had disclosed he was a victim of domestic violence.
  2. Mr X made some enquiries around where the fall had happened. Following these enquiries, he confirmed his mother had not pushed Mr A.
  3. In February 2018, the Council opened a safeguarding referral about the concerns raised that Mr A’s wife, who suffered from dementia, was violent towards him. The Council closed the referral as it felt the referral did not meet the threshold for further enquiries. It also noted Mr A would move hospital wards to allow him the opportunity to consider what he wanted to do about returning home.
  4. Mr X said hospital staff told him a protection order had been put in place for Mr A and that he was not to tell his mother where Mr A had been moved to. Mr X said he had no reason to question what he had been told.
  5. The Council assessed Mr A’s care and support needs in March 2018, before he left the care home. The assessment decided Mr A did not have any eligible care and support needs as he could live independently.
  6. In March 2018, Mr A left the hospital and went to live in a care home. This was a short-term arrangement. The Council opened another safeguarding referral in March 2018. The Council closed the referral as it noted there was no immediate risk since Mr A was in the care home and away from his wife. The Council also noted the safeguarding team did not need to take further action as the adult social team were involved.
  7. The safeguarding assessment noted Mr A told the Council he did not want to return home while his wife was there. Mr X disputed this and said Mr A did not tell the Council this.
  8. There was no evidence the Council had put in place any safeguarding protection orders or safeguarding measures for Mr A that would have prevented him from living with, or seeing, his wife.
  9. Mr A left the care home at the end of March 2018. Mr A went to live with Mr X and Mrs X. The Council completed another care and support needs assessment in April 2018, when Mr A was still living with Mr X and Mrs X. The assessment noted Mr A was independent and did not have any eligible care needs. The assessment did not contain any detail what was observed during the assessment or explanation of why Mr A was independent.
  10. Mr and Mrs X said the Council told them there was no protection/safeguarding order in place in April 2018. Mr X said by this time the relationship between Mr A and his wife had broken down.
  11. The Council completed more care and support needs assessments in July 2018, October 2018, December 2018, and February 2019. These assessments assessed Mr A as having eligible care and support needs.
  12. Mr X and Mrs X made a complaint to the Council. The Council confirmed the points of complaint in May 2018 and responded to the complaint in September 2018. The Council did not uphold Mr X and Mrs X’s complaint that they were told there was a protection/safeguarding order in place for Mr A.
  13. The Council provided a further response in October 2018. In this response, the Council accepted that irrespective of whether the term protection/safeguarding order was used, it was clear the Council had not told them that no legal order was in place. The Council apologised for this and for the confusion and distress this caused.
  14. The Council also accepted that it missed important opportunities to fully explore the options available and that it did not have enough discussions with Mr X, Mrs X, and Mr A. The Council accepted there could have been a different outcome had these discussions taken place. The Council also accepted some of the difficulties between Mr A and his wife could have been avoided, or at least greatly reduced, had it followed a different process.
  15. The Council held a workshop with Mr X and Mrs X in December 2018 to discuss the areas of practice they felt needed improvement. At the end of this workshop, the Council identified some suggested actions to make improvements to its service.

Analysis

Safeguarding and communication with Mr X and Mrs X

  1. It is clear the Council had not put in place any safeguarding measures or protection order for Mr A. From Mr X’s evidence, it appears the first mention of a protection/safeguarding order was from hospital staff rather than Council staff. Mr X said he had no reason to challenge the information he had been told. This is understandable.
  2. While I have not seen any evidence to suggest the Council had used the specific term protection/safeguarding order in their communication with Mr X and Mrs X, I can see why they believed there was one in place.
  3. The evidence suggests Mr A told the Council he did not want to return home while his wife lived there. The Council therefore dealt with the situation on this basis.
  4. The Council never explained to Mr X and Mrs X there was nothing legally keeping Mr A from returning to live with his wife. Therefore, I can see why Mr X and Mrs X would assume the reason why Mr A could not return home while his wife lived there was because of the protection/safeguarding order they had been told was in place.
  5. Therefore, it is clear there has been miscommunication between the Council and Mr X and Mrs X. The Council had tried to respect Mr A’s wishes not to return to his home while his wife was there by making alternative arrangements for Mr A to live with Mr X and Mrs X. Mr X and Mrs X, however, believed this arrangement was because of the (non-existent) protection/safeguarding order. This is fault.
  6. I find the fault identified did cause an injustice to Mr A. This is because there is uncertainty about what the outcome could have been and, potentially, the damaged relationship between the two could have been avoided or reduced. This is distressing for Mr A. The fault also caused an injustice to Mr X and Mrs X. This is because it was distressing for them to see their mother and father’s relationship deteriorate.

Care and support needs assessment

  1. The Council completed a care and support needs assessment in April 2018. This was completed when Mr A was living with Mr X and Mrs X. The assessment decided Mr A did not have any eligible care needs. The record of the assessment is very brief and does not include any detail of what was observed or discussed with Mr A during the assessment. There is also no analysis of the information to explain how the assessor reached the decision that Mr A had no eligible care needs.
  2. At this stage, I am of the view this is not good practice and therefore, this is fault. Care and support needs assessments should be clear and detailed. All relevant information should be included in the record to allow people to understand what has been observed and how the decision was reached. It has not been possible for me to do this because there is so little information recorded in the document. Therefore, I cannot be satisfied the Council completed the April 2018 care and support needs assessment properly.
  3. I find the fault identified caused an injustice to Mr A. This is because there is uncertainty about whether the Council properly assessed his care and support needs in April 2018.

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Agreed action

  1. To remedy the injustice caused by the faults identified, the Council has agreed to complete the following.
  • Provide a sincere and meaningful apology to Mr A for failing to properly assess his care and support needs in April 2018 and for the avoidable distress caused.
  • Provide a sincere and meaningful apology to Mr X and Mrs X for the avoidable distress caused.
  1. The Council should complete the above within four weeks of the final decision.
  2. The Council has provided the Ombudsman with a list of suggested actions to take. I find the suggested actions to be appropriate in the circumstances. The Council should review this list and decide which actions it will pursue. The Council should create a SMART action plan to demonstrate how, and when, it will complete the actions. If the Council decides not to pursue some, or all, of the actions listed, the Council will provide the Ombudsman with a rationale for its decision.
  3. The Council should complete the above within three months of the final decision.
  4. I would normally have recommended a financial payment to remedy the injustice identified. However, Mr X and Mrs X have declined this.

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Final decision

  1. I find fault with the Council for its poor communication with Mr X and Mrs X. I also find fault with the way the Council completed Mr A’s care and support needs assessment in April 2018. The Council has accepted my recommendations. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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