Summary: Mr X complained about the way the Council dealt with a safeguarding report about his mother. We found there was fault in the Council’s actions that warranted a remedy. We also found fault in the way the Council responded to the complaint.

The complaint

1. Mr X complains that the Council failed to properly consider a safeguarding issue raised about his mother’s wellbeing. He complained that if the issue been properly considered, harm his mother came to later may have been avoided.
2. Mr X also complains that a member of the safeguarding team called him late at night without good reason and this was unprofessional. He complained that the standard of some of the Council’s written communication was also poor.

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What I have investigated

3. I have investigated the first part of Mr X’s complaint. I decided I should not investigate the standard of a letter Mr X received. The reasons for this are set out in the last section of this statement.

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The Ombudsman’s role and powers

4. 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)
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 spoke to Mr X and considered the complaint he raised. I asked the Council for information and I considered its response to the complaint.
7. Mr X 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

Safeguarding

8. A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

Assessment

9. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
10. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.

What Happened

11. Mr X’s complaint concerns the welfare of his mother and father. I have referred to them as Mr and Mrs Y in this statement.
12. Mrs Y has a diagnosis of dementia which is in a moderate to advanced stage. She lived with Mr Y, who acts as her main carer.
13. In November 2020, following a telephone call with Mr X, a Community Psychiatric Nurse (CPN) made a safeguarding report, citing concern for both Mr and Mrs Y.
14. The CPN’s report noted that, due to her dementia, Mrs Y could be verbally or physically aggressive towards Mr Y. She stated there had been incidents of Mrs Y hitting Mr Y when he was trying to help her to do something. This caused Mrs Y to sustain bruising as Mr Y, when frustrated, felt he had to push himself away from her. The CPN stated she was concerned that both Mrs Y and Mr Y were causing accidental bruising to one another. She noted the family were adamant that they did not wish Mrs Y to go into a care home for respite. They were fearful of Mrs Y catching the COVID-19 virus and that she may deteriorate significantly in care home environment.
15. In addition to her safeguarding report the CPN stated she had made Mrs Y’s psychiatrist aware of her concern and she had made a referral to the community mental health crisis team.
16. The CPN provided Mr X’s contact details as a person who could speak on Mrs Y’s behalf about the safeguarding report.
17. On 30 November 2020 the Council closed the safeguarding report. It stated the issues raised were case management issues and would need to be followed up under section nine of the Care Act 2014.
18. In response to our enquiries, the Council stated Mr and Mrs Y were both vulnerable and getting bruised as a result of Mrs Y’s dementia, rather than Mrs Y being neglected or Mr Y being a risk to her. Because this was the case, the officers decided not to deal with the matter as a safeguarding report. Rather, it referred Mrs Y to begin an assessment of needs. This would initially involve a telephone call from a social worker to discuss the issues and what support was already in place. If appropriate, it would go on to consider what support could be provided via an assessment of her needs.
19. The Council told us that its Adult Social Care Teams aim to respond to requests for needs assessments within six weeks of the initial contact. The Council stated there was nothing in the report to indicate that urgent safeguarding intervention was required to prevent abuse or neglect.
20. On 20 December 2020 at 4:25pm a member of staff at a hospital (referred to as Nurse A) notified the Council’s out-of-hours social work team that Mrs Y had been admitted via the Accident and Emergency department. Case records show that Mrs Y was admitted with pain to her right wrist and bruising around her left eye, which appeared old. It stated Mr Y had admitted that he pushed Mrs Y over.
21. The note of the call from the hospital stated Mr X had taken Mrs Y into A&E. It noted Mrs Y had a catalogue of bruises. The notes stated Mrs Y would be staying in hospital overnight.
22. Mr X told us he received a call late on 22 December, at around 11:30pm. The call caused concern because his mother was in hospital. It became apparent the call was not urgent, so he asked the caller to call back the next day. Because the call was so late, he could not recall the name of the person who rang him. He did recall that Nurse A’s name was mentioned in the call.
23. When Mrs Y was later discharged from hospital, notes on the Council’s files stated that it was not considered safe for her to return home. It stated it had a duty to place Mrs Y somewhere safe and further enquiries were needed on the safeguarding matter. The Council’s files indicated a long-term care placement was being considered.

Mr X’s complaint

24. Mr X complained to the Council about the failure to properly deal with the original safeguarding report in November and why a call was made to him so late at night. He referred to Nurse A’s name.
25. The Council’s response was muddled and unclear. It partially upheld the complaint about the call. The Council stated Nurse A was employed by the hospital, not the Council. Initially it stated that it was not clear if Nurse A had called Mr X, but its team had called Mr X later in the evening. It stated the call was made to clarify potential risks. It then went on to contradict this. It stated Nurse A had called Mr X and a social worker who contacted Mr X had to complete a call in a timely manner. It also stated it was not possible to comment on which call Mr X was referring to.
26. In respect of the safeguarding matter, the Council stated, based on the information from the referrer, it decided an assessment was the most appropriate response. A referral was sent for an assessment on 1 December.
27. Mr X asked for the complaint to be escalated. In its final response to the complaint, the Head of Service changed the outcome of the complaints relating to the telephone call to ‘not justified’. The response stated the worker identified was an NHS member of staff, so this needed to be referred to the NHS. The Council provided contact details.
28. The Council stated the Head of Safeguarding reviewed the case and agreed with the safeguarding outcome. The Council re-iterated its view that the decision to refer for assessment was the correct one. It stated unfortunately there was a delay identifying someone to assess her, but it was difficult to say whether Mrs Y’s hospitalisation could have been avoided. The Council apologised in any event to Mr X’s family for the delays and the distress caused.

Other Points

29. Following the Council’s response to his complaint Mr X made a complaint to the NHS regarding the call he received late at night on 22 December. The NHS investigated and confirmed that Nurse A had called the Council at around 4:30pm on 20 December to make a safeguarding referral. They confirmed that no-one from the hospital had called Mr X at or around 11:30pm.
30. We asked the Council about the apparent confusion in its complaint response about the telephone call. The Council told us that there had been an error in its ‘initial reporting’.
31. The Council told us a member of the out-of-hours team called Mr X on 20 December 2020 at 11:25pm (not the 22nd) in response to the call they received that afternoon from the hospital. The Council stated the reason for making the call was to establish the concerns Mr X had, and also to determine if there was a likelihood of Mrs Y returning home that night. The Council stated the social worker wanted to establish any immediate risk or interventions that maybe required by the team. It stated the call would have been prioritised according to the workload and the risk to the person at the time.
32. The Council provided us with case notes that suggest the call to Mr X late at night was made on 22 December, not 20 December. Mr X also provided us with a text sent to his family the following day referring to the call the night before (22nd). So, it is most likely the call was made on 22nd December, not 20th. However, it was the lateness of the call rather than the specific date that was the key issue.

Was there fault by the Council

33. We found there was fault in the way the Council dealt with the safeguarding report made in November 2020. I say this because:
• There is no indication that the Council made any enquiries of the requestor, Mr X, or anyone else to assess the urgency of the issue, the frequency of the incidents that were referred to or to gauge the risks to Mr and Mrs Y.
• While a referral for assessment may have been an appropriate action, the Council told us timescales for carrying out an assessment are around 6 weeks. Little or no consideration was given to the extent of the risks that would be present for Mrs Y and Mr Y in the meantime or how these could or would be mitigated.
34. Although, we found fault, I do not consider it is clear that, but for that fault, Mrs Y’s hospitalisation in December would have been avoided. However, it is likely the matter caused Mr X and his family distress.
35. Mr X’s complaint was also that a call to him was unnecessarily late. This worried him given his mother was in hospital. Irrespective of the date of the call, we found this was a justified complaint. The Council gave various different reasons why the call was made in its response to Mr X and to us. It stated the social worker wished to discuss Mr X’s concerns. However, this could have been achieved the following morning. There seems no reason why the call needed to be made this late. While this did not cause significant injustice, the Council could consider whether it is a training need and how procedures allow for other officers to follow up matters in the daytime where this is more appropriate.
36. Furthermore, we found that the Council’s response to Mr X’s complaint about the late‑night telephone call was very poor. This too was fault. This was a simple issue, but the initial response was muddled and confused. When Mr X escalated his complaint, rather than seek to clarify the matter, the Council dismissed this part of the complaint on the basis the complaint was about an NHS employee. This was wrong. It put Mr X to the trouble of raising it with the NHS and the NHS to the trouble of investigating it, when the Council has been able to confirm to us it was the Council who made the call. This additional time and trouble was avoidable.

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Agreed action

37. Within four weeks the Council agreed to:
38. Consider whether the officers who dealt with the safeguarding alert in November 2020, and the late-night telephone call require further coaching or training.
39. Review whether its procedures are sufficient to ensure risk is properly considered and investigated in safeguarding cases such as these.
40. Make a payment to Mr X of £300 to reflect the time and trouble and distress caused by the fault we have identified.

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Final decision

41. There was fault by the Council that warranted a remedy.

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Parts of the complaint that I did not investigate

42. I have not investigated the concerns Mr X raised about a letter he received. This is because I do not consider this caused significant injustice.

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Investigator's decision on behalf of the Ombudsman