Summary: The Council has accepted it took too long to investigate safeguarding concerns about Mr B’s late mother, and failed to communicate with Mr B sufficiently. The Council has also acknowledged it took too long to complete essential adaptations to the family home. This meant that Mrs Y was left without proper access to washing facilities and could not use the stairs. It caused Mr B distress, uncertainty and frustration. The Council has raised concerns at a senior level and completed a transformation programme of its adaptations service. It will also review its safeguarding practices. The Council should also apologise to Mr B for its shortcomings and pay him £500 in respect of the prolonged distress, uncertainty, inconvenience, and frustration its delays caused him.

The complaint

1. Mr B lived with his late mother, Mrs Y. Mr B complains about how the Council dealt with a safeguarding investigation and adaptations to their home. In particular, he says:
• The Council failed to fix a bannister it had installed on an Occupational Therapist’s (OT) recommendation, but had fallen from the wall in 2018. This meant that Mrs Y’s mobility needs were not met.
• The Council failed to progress adaptations to make an accessible washroom despite identifying this need in November 2018. It was not completed until December 2020.
• The Council took too long to complete a safeguarding investigation and did not communicate with Mr B about this. Mr B says this delayed Mrs Y’s discharge from hospital and caused distress and confusion to them both.
2. Mr B says the Council’s shortcomings impacted on the personal care Mrs Y could receive. He says that it contributed to Mrs Y falling and breaking her hip so that she became frailer, and in turn, this contributed to her death in early 2021.

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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 a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by their personal representative (if they have one), or someone we consider to be suitable. (Local Government Act 1974, section 26A(2), 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 considered the information provided by Mr B and discussed the issues with him. I considered the information provided by the Council including its case notes. I also considered the law and guidance set out below. Both parties have had a draft of this statement and were invited to submit comments. I have taken into account comments from both parties before reaching my decision.

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What I found

The law and guidance

7. 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)
8. Disabled Facilities Grants (DFGs) are provided under the terms of the Housing Grants, Construction and Regeneration Act 1996. Councils have a statutory duty to provide grant aid to disabled people for certain adaptations. Before approving a grant, a council must be satisfied the work is necessary and suitable to meet the disabled person’s needs and also reasonable and practicable.
9. Social care authorities must promote ‘wellbeing’ when carrying out any of their care and support functions. Wellbeing includes the suitability of living accommodation. The Care Act 2014 recognises that suitable accommodation is one way of meeting care and support needs. Prevention is critical to the Care Act, and home adaptations are an example of prevention.
10. A council should give the applicant a decision on a grant application as soon as reasonably practicable. This must be within six months of the grant application. If a council refuses a grant it must explain why. Once the work is complete the council must pay the grant in full before 12 months from the date of the grant application.

Background

11. Mrs Y had dementia and mobility problems. She lived with her son, Mr B and her granddaughter. The Council’s case notes say that Mrs Y was at risk of falls and could not use the stairs by herself. She had access to the downstairs toilet, was incontinent and would forget to change her pads. This meant that hygiene was very important, but Mrs Y could not easily access the upstairs bathroom to have a shower. She would crawl up the stairs with assistance or Mr B would carry her up the stairs. Mrs Y’s needs were met by family care, paid home care and attendance at a day care centre.

Home adaptations

12. In June 2017, and on the OT’s recommendation, the Council installed a handrail on the stairs. The handrail fell off and in October 2017, Mr B called the Council to ask it to reinstall it. The Council did not take any action on this until December 2017, when on a visit to the property, it decided that the wall was not suitable for supporting the handrail. However, the Council did not suggest an alternative way to allow Mrs Y to access washing facilities. The Council says it needed a specialist carpenter which took some time to organise.
13. The Council’s case notes show it visited Mrs Y and Mr B at home in January 2018, to review how her needs were being met. Mr B was becoming increasingly worried about his mother’s mobility around the house and her accessing the bathroom.
14. In August 2018, Mrs Y was in hospital. She had fallen whilst abroad and broken her leg. She returned for rehabilitation in a hospital in the UK. Mrs Y was discharged home in September and the homecare increased.
15. In November 2018, the Council’s OT visited Mrs Y and Mr B at home to assess whether they needed home adaptations. The Council’s case notes say there was a small downstairs toilet and sink. Mrs Y was doubly incontinent and unable to mobilise without support. She could not access the upstairs bathroom and instead had a strip wash while sitting on the toilet. The OT recommended the toilet is made into an en suite with the adjoining bedroom, and an over-toilet shower fitted.
16. The Council did not take any more action to progress the adaptation until June 2019, when a technical officer visited Mr B’s home. Mr B had chased the Council in the meantime. The Council suggests it had already sent plans to Mr B for his approval in May 2019, although it does not have a case note of this. Its records also suggest that the Council received the approval on 27 June 2019. The Council sent the recommended design for the adaptation to the OT for its approval on 28 June 2019. The OT did not approve the design until 18 September.
17. The Council obtained and approved quotes from the contractors and then on 10 October, asked for approval from Mr B’s mortgage provider. The Council did not get this approval until sometime between 14 and 19 November 2019.
18. The Council took no further action until Mr B complained to it at the beginning of September 2020. Later that month, Mrs Y slipped off the downstairs toilet and broke her hip. Mr B has explained to me that the toilet room was very small and it was difficult for a carer to mobilise Mrs Y there. He pointed out that this is why the wet room was needed and the Council knew that the toilet was unsuitable for Mrs Y. The wet room adaptation was finished in November and all parts signed off as safe in December 2020. Sadly, Mrs Y died in January 2021.
19. The Council has explained that in December 2019, the relevant technical team ware restricted and two key staff members joined the team. The Council acknowledges that the time it took to train the new staff and handover ongoing cases may have impacted on the time it took to get the work underway. In addition, COVID-19 restrictions from the end of March 2020 meant that contractors stopped working until the August.

Was there fault by the Council in how it dealt with the handrail and adaptations to the home?

20. The Council has acknowledged that it delayed in fixing the stair handrail. The Council should have acted sooner to either reinstall the handrail or to find another solution to allow Mrs Y to use the stairs or access washing facilities while she was waiting for the wet room to be installed. The Council says the failure was due to human error. The Council also missed opportunities to address this when it reviewed her care needs between November 2018 and September 2020 (when progress was made on the wet room).
21. The Council also took too long to progress the DFG and complete the installation of the downstairs wet room. There was no significant progress by the Council between the OT’s recommendation in November 2018 and the first visit by the technical team in June 2019, some seven months. The OT approved the design in September 2019, and it was at this stage that the work could progress.
22. I acknowledge that it took around one month for the mortgage provider to give approval but I do not consider this a significant delay. In total the Council took a year to approve the DFG following the OT’s recommendation and this is at the heart of the avoidable delay.
23. Given that Mrs Y could not access proper washing facilities and that it had already delayed unnecessarily, I would have expected the Council to expedite the work following approval of the DFG. It is unfortunate that COVID-19 and the restrictions on the contractors working in Mr B’s home caused more delay. This was outside of the Council’s control. The Council acted within a reasonable time, once restrictions were lifted, although I acknowledge that this was perhaps due to Mr B complaining to the Council.
24. Overall, the Council delayed significantly and unnecessarily on progressing the DFG between November 2018 and November 2019. It took 12 months to reach a stage that should have been possible in less than six months. Of course, this means that had the Council acted without delay it may well have been able to start the work before March 2020 when COVID-19 restrictions were implemented, and so the wet room would have been completed much sooner. The whole process took around 12 months longer than it should have done had the Council acted without delay.
25. I am also concerned that the delay to the adaptations and any interim measures were not properly considered when the Council met with the family or carers to review how Mrs Y’s needs were being met.
26. During this time of avoidable delay, Mrs Y had no proper access to washing facilities. The Council was aware that Mrs Y could not safely use the stairs, and that movement in the small downstairs toilet was difficult. The delay also caused Mr B distress and frustration, and made his caring responsibilities more difficult and stressful.
27. Mr B has understandably raised a concern that his late mother would not have broken her hip slipping from the toilet before the wet room was installed, and that this made his mother frailer which ultimately shortened her life. I have sympathy with Mr B here, but I cannot conclude there is a link between fault by the Council and his mother’s death. I cannot say the accident in September 2020 caused Mrs Y’s death in January 2021, or that the accident was unlikely to have happened had the Council fitted the wet room sooner. Ultimately, Mr B is saying the Council was negligent and caused his mother’s death. That is for a court to decide.
28. However, I recognise that the delay by the Council has realistically made Mr B uncertain that had it done the work sooner, his mother might not have broken her hip. To be clear, I am not saying that the Council’s delay caused Mrs Y to fall and break her hip, but that the uncertainty that this might be the case, caused Mr B real distress.
29. The Council has explained that it has completed a transformation programme of the service responsible for adaptations. It has made these improvements:
• Improved monitoring so that cases are dealt with in good time;
• All cases are monitored weekly and staff report to the management team;
• Improved staffing levels, staff training and process management across the service; and
• Introduced an improved complaints process so that cases can be escalated and responded to in good time.

Safeguarding

30. In mid-September 2019, the Council was contacted by another family member with concerns that Mr B was not allowing her to see Mrs Y and was mismanaging Mrs Y’s financial affairs. The Council visited Mrs Y in October 2019 to discuss this. The case notes show that Mr B was present and gave information about visits from other family members and about Mrs Y’s finances. The notes say that it was difficult to speak with Mrs Y on her own about this and that the Council needed to assess whether Mrs Y had mental capacity to deal with her finances. The case notes state there are no concerns with Mr B’s care, however. The Council asked Mrs Y’s carer to speak to her about money. The carer reported back that Mrs Y had no concerns about how her son was managing her finances.
31. The family member who had originally raised the safeguarding concern contacted the Council for an update at the end of December. In January 2020, Mrs Y was admitted to hospital. The Council’s case notes say the safeguarding case was still open. The Council liaised with the hospital and on 3 February, its social worker (SW) emailed the hospital setting out the safeguarding concerns, which it says must be investigated before Mrs Y is discharged home. Up until that point, the hospital had been arranging further tests on Mrs Y’s health; she had not been eating and had not opened her bowels.
32. The next day Mr B contacted the Council’s SW. The hospital had told him that a family member had raised a safeguarding concern and his mother could not be discharged to his home until this was resolved. Mr B told the Council that this family member had raised concerns several times. The hospital told the Council that Mrs Y was not medically fit for discharge. The Council said that Mrs Y would need to regain some mobility and open her bowels before she could be cared for at home.
33. The SW liaised with the care provider and with the SW who had been dealing with the safeguarding issues. She said that the safeguarding issues did not need to be resolved before Mrs Y could be discharged and it could be followed up once she was home, although the hospital confirmed she was still not medically fit to go home.
34. On 5 February, the SW spoke to Mr B and discussed the safeguarding issues. The next day, the SW met with Mrs Y and an interpreter. Mrs Y confirmed she has no concerns about Mr B, she said that family could visit her if they wish and she had no concerns about how he managed her finances. The Council’s SW liaised with the safeguarding team that day. The Council decided that Mrs Y could be discharged back to Mr B’s home and there was not enough evidence of abuse.
35. The Council’s case notes show that the hospital did not find Mrs Y medically fit to discharge from hospital until 7 February, as it was at that point she had regained some appetite and had opened her bowels. Once back home, the Council arranged for a carer to again check with Mrs Y whether she had any concerns about Mr B’s care for her. On 13 March, two SWs visited Mrs Y and concluded that there were no safeguarding concerns.
36. Mr B complained to the Council. He said it should have told him sooner that there was an open safeguarding enquiry. He was concerned that the Council had delayed in concluding this and that this in turn, had delayed his mother’s discharge from hospital. He pointed out that his mother contracted a chest infection in hospital and perhaps would not have done so had she been discharged sooner. Mr B was also concerned that the Council interviewed Mrs Y when she has dementia.
37. In response to Mr B’s complaint, the Council said it deeply apologised for its poor communication and unclear information. It said that it did not tell him about the safeguarding enquiry earlier because he was the alleged perpetrator but it does accept that it should have communicated with him better. The Council explained that it had interviewed Mrs Y with an interpreter (as English was not her first language). It had taken into account her dementia but that it did need to establish her wishes. It agreed it would contact the safeguarding team and the hospital social work team to make sure information is properly and effectively communicated.
38. The Council’s records also show that it addressed the issue of serial allegations from the family member, acting on subsequent actions sooner and working with the family member to stop repeat allegations due to the impact on Mrs Y.

Was there fault in how the Council dealt with the safeguarding investigation?

39. Councils should generally inform the alleged perpetrator of allegations made against them and give them an opportunity to give their side of the events before any decision is made. The involvement of the alleged perpetrator may be limited depending on the circumstances.
40. In this case, the Council did not make Mr B aware of the safeguarding concerns and it was the hospital that did so, over four months after the Council received the original allegations. Mr B says the Council has failed to do this with more recent allegations. However, I have not investigated how the Council dealt with more recent allegations, and there would no longer be a safeguarding role.
41. In response to my investigation, the Council has acknowledged that it should have told Mr B about the allegations sooner. This was fault by the Council. It has raised this as a serious concern at a senior level and has committed to a review to improve staff practice.
42. The Council has also acknowledged that it delayed unnecessarily in concluding the safeguarding enquiry, and had it not done so it might have completed the enquiry before Mrs Y’s admission to hospital. The safeguarding enquiry took nearly five months to complete, with no action to progress this between October 2019 and February 2020. Again, this is fault by the Council.
43. Mr B says that the safeguarding investigation delayed his mother’s discharge from hospital and as a result she contracted a chest infection. There is not sufficient evidence for me to conclude this. There were a number of reasons why the hospital did not discharge Mrs Y sooner. She was discharged from hospital as soon as she was medically fit.
44. The delay in concluding the safeguarding enquiry, did cause Mr B distress and frustration, with his mother already in hospital and led to his concerns about her discharge home. The lack of communication with Mr B compounded the impact on him.

Agreed action

45. There was fault by the Council causing injustice to Mrs Y and Mr B. Sadly, Mrs Y has now died. In terms of a remedy, we will not normally seek a remedy for distress or another unfair impact where the person has died. We would not expect a public body to make a payment that would enrich a person’s estate. However, I have considered how the Council should remedy the injustice its shortcomings caused Mr B, and how it might prevent these from recurring.
46. The Council has already apologised to Mr B for its poor communication with him about the safeguarding enquiry and its delay. It has raised the issue at a senior level.
47. The Council has explained that it has completed a transformation programme of its adaptations service.
48. The Council should also within one month of the date of this decision show the Ombudsman it has:
• Apologised to Mr B for the distress it caused him when it took too long to address the stair handrail and progress the adaptations to make a wet room; and
• Paid Mr B £500 in respect of the prolonged distress, uncertainty, inconvenience, and frustration the Council’s delays caused him.
49. Lastly, the Council should within three months of the date of this decision show the Ombudsman the outcome of its review into its practices around safeguarding enquiries, and any intended actions to improve the service, including how it deals with serial allegations, and its communications with alleged perpetrators.

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Final decision

50. I have completed my investigation. There was fault by the Council causing injustice to Mr B and Mrs Y.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman