Summary: Miss X complained about the Council’s failure to carry out a proper safeguarding enquiry about neglect she suffered while living in a supported living unit arranged by the Council. We have found the Council to be at fault. The safeguarding enquiry was inadequate, and the Council failed to properly remedy the significant distress and uncertainty suffered by Miss X and her father, Mr Y. The Council has agreed with our recommendations to remedy this injustice.

The complaint

1. Miss X complains the Council failed to carry out an adequate safeguarding investigation into neglect she experienced in a supported living placement.
2. The Council has already accepted several areas of fault during its internal investigation.
3. Miss X says the Council has failed to acknowledge the significant personal injustice and its remedy payment of £250 is inadequate.
4. Miss X is represented by her advocate, Ms P, in making this complaint. Miss X’s father, Mr Y, had also made complaints on her behalf to the Council about what happened.

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What I have and have not investigated

5. Miss X’s complaint includes matters which occurred since October 2020. Her complaint is therefore late. However, I have found it appropriate to exercise my discretion to consider her complaint as Mr Y first complained about what happened at Home B in March 2021 and the Council did not issue its final response until July 2022. Miss X complained to the Ombudsman soon after.
6. I have not investigated what happened after Miss X left Home B. This is because these later events have not been considered by the Council under its complaints procedure.

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The Ombudsman’s role and powers

7. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by an organisation to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
8. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
9. Where a council arranges or commissions care services from a social care provider we can treat the actions of the care provider as if they were the actions of the council.
10. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
11. If we are satisfied with an organisation’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

12. As part of my investigation, I have:

• considered Ms P’s and Mr Y’s complaints (made on behalf of Miss X) and the Council’s responses;
• considered the information the Council provided in response to our enquiries. This included several letters of complaint from Mr Y and the Council’s case records; and
• considered the law and guidance relevant to the complaint.

13. Miss X and Council had an opportunity to comment on my draft decision. I considered all comments received before making a final decision.

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What I found

Relevant law and policy

Adult safeguarding

14. 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)

The Council’s adult safeguarding policy

15. The Council works to the Sussex Adults Safeguarding Policy and Procedures (2019). This reflects the law and statutory guidance and says that an officer should be appointed to make proportionate enquiries and produce a report and decide whether action is needed to keep the adult safe.

Mental capacity

16. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity.
17. To assess someone’s capacity, they must have an impairment of the mind or brain, or some disturbance affecting the way their mind or brain works. The impairment or disturbance must also mean the person is unable to make the decision when it needs to be made.

Brief summary of what happened

18. This chronology includes key events in this case and does not cover everything that happened.
19. Miss X has autism, mental health issues and learning difficulties. She also has issues with alcohol and substance misuse.
20. In September 2020, Miss X was accommodated at Home B, a supported living placement. This was an emergency placement following the breakdown of an abusive relationship. A support plan was put in place that set out the areas of daily living that Home B would assist with. This included help with meal preparation, keeping her room tidy and prompting with personal care. In October 2020, Home B raised concerns with the Council about Miss X’s conduct and asked the Council to provide “more structured guidance”.
21. In January 2021, Home B again asked the Council for support in managing Miss X, in part because her unwillingness to comply with rules around Covid-19 that impacted on the safety of staff and other residents.
22. Home B also told the Council it could no longer accommodate Miss X and wanted her to leave as soon as possible. The Council tried to find an alternative placement. This proved problematic because of lack of local resources and Miss X’s complex needs, particularly her substance misuse.
23. In February 2021, Home B raised concerns about headlice that were affecting Miss X. Home B was not allowed to provide personal care and so was only able to prompt Miss X to use the medication to treat the condition. In response, the Council arranged for a registered care agency (“the Agency”) to administer the treatment.
24. This proved unsuccessful, in part because Miss X’s hair was too matted, and the infestation was too severe. She also developed scabies that was causing Miss X significant pain and discomfort. Concerned about her welfare, Miss X’s father took her to hospital on 29 March 2021. The hospital advised the Council it was not prepared to discharge Miss X back to Home B. Mr Y then made his first complaint to the Council about what he considered to be neglect by Home B. He has explained the significant trauma experienced when he took Miss X home to take action to treat her infections. He described her head as “a huge oozing infection, accompanied by a smell that cannot be described”.
25. Miss X was discharged to a different supported living unit two weeks later.

The safeguarding enquiry

26. The Council opened a safeguarding enquiry in March 2021. This was completed in November 2021 when the Council held what it described as a “Safeguarding Conclusion Meeting”. Although Miss X and her advocate were invited to attend, it was not possible for the advocate to join the meeting remotely to join the meeting remotely. Miss X did not attend either.
27. The minutes from this meeting were brief. They stated:

• the safeguarding concern related to self-neglect;
• there was a query about Home B being negligent for not spotting the head lice problem soon enough;
• lots of enquiries were made about the concerns;
• Home B was not an inappropriate placement; and
• as Miss X was no longer at Home B, there were no outstanding actions.

28. Dissatisfied with this outcome of the safeguarding enquiry, Miss X’s advocate made a complaint. She specified several concerns about the safeguarding enquiry. I have summarised her concerns below.

• The safeguarding investigation was not “person centred”. Miss X was not supported to allow her voice to be heard.
• The advocate was not consulted and her written submissions were not referenced within the minutes.
• The report failed to include important information, including the fact the hospital refused to allow Miss X to return to Home B due to the level of concern about her welfare.
• No responsibility was taken for the neglect of Miss X. The report referred to “self-neglect”, a term that sought to apportion blame on Miss X rather than the Council or Home B. The purpose of the placement should have been to prevent such self-neglect from occurring.
• The Safeguarding Conclusion Meeting was “a farce”. Only 30 minutes was allocated and neither Miss X nor the advocate were able to participate.

The complaint investigation

29. In March 2021, Mr Y first complained to the Council about the lack of suitable support his daughter had received at Home B and the Council’s failure to take appropriate action. The Council said it would postpone responding to his complaint until the safeguarding enquiry had been completed.
30. In February 2022, Mr Y also complained about the inadequacy the safeguarding enquiry. He raised similar concerns to those highlighted by Miss X’s advocate, including its failure to properly investigate the actions of Home B.
31. The Council completed its complaint investigation in July 2022. The 13 page report identified several areas of, what the Council described as, “shortcomings in our practice”:

• Delay in allocating a social worker to Miss X.
• Failure to complete a mental capacity assessment.
• Poor communication from both the Council and Home B.
• Failure to properly manage the safeguarding enquiry.

32. In response to these findings, the Council set out actions it would take to improve its service. These included the following:

• Being more alert to cases that are escalating and require allocation of a dedicated social worker.
• Being more aware of the need to prioritise mental capacity assessments.
• Having a discussion with the manager of Home B.

33. As part of the complaint investigation, the Council carried out an audit of the safeguarding enquiry. A number of improvements to practice were needed, including the following:

• Better consideration as to who participated in the enquiry, including the advocate.
• Improved timeliness.
• Ensuring all areas of concern were addressed.
• Not proceeding with a meeting if the person affected and/their family cannot attend.
• Better partnership working with health services.

34. Specific to Miss X’s case, the Council says it should consider use of its self-neglect policy.
35. The Council apologised to Miss X and Mr Y and offered a payment of £250 each to acknowledge their avoidable distress. This remedy also sought to acknowledge the delay in completing its complaint investigation.
36. Disappointed by this outcome, My Y and later, Miss X via her advocate, brought a complaint to the Ombudsman. They were particularly unhappy that neither the Council, nor Home B had been held properly accountable for the harm and neglect suffered by Miss X.

Analysis

37. The Ombudsman is not an appeal body, and it is not our role to decide whether neglect or abuse has taken place; that is the council’s responsibility. We investigate the processes the council followed in making its safeguarding enquiries, to assess whether it made its decision properly.
38. Nor does the Ombudsman reinvestigate complaints where the Council has already accepted it acted with fault. For this reason, I will not reinvestigate the Council’s:
1. failure to conduct a capacity assessment;
2. failure to appoint an advocate for Miss X, and failure to involve her as much as possible in decisions affecting her;
3. failure to appoint a named social worker;
4. failure to carry out a robust, timely person-centred safeguarding enquiry;
5. poor communication; and
6. delay in its complaint handling.
39. Instead, my analysis will focus on the main areas of complaint where the Council did not accept it acted with fault. I note there were many aspects about the actions of the Council and Home B that Mr Y was aggrieved about. But I do not propose to examine all of these matters here. Our role is not to provide answers to each and every criticism a complainant may have about a council. I will address the significant areas of concern below:

Placement at Home B

40. Mr Y is of the view Miss X should not have been placed at Home B in the first place because her level of support was too low for her complex needs. In its complaint investigation response, the Council has explained that the initial assessment, carried out in August 2020 identified her as needing support to become more independent. Home B carried out its own assessment and confirmed it was able to meet her needs. I have found no fault in the way these assessments were carried out, or that Miss X required more intensive support such as personal care at that time. The case records show there was a swift change in Miss X’s circumstances when she moved to Home B, but I do not have the evidence to say this was either foreseeable or preventable. For this reason, I do not find the was fault Council’s decision to place Miss X at Home B.

Failure to accept responsibility for the neglect experienced by Miss X and for Home B to be properly investigated and held accountable

41. This lies at the heart of Miss X and Mr Y’s complaints. They say the failure (by both the Council and Home B) to act on the self-neglect by a vulnerable person is, in itself, neglect.
42. It is not in dispute that Miss X’s complex needs, including her alcohol and substance misuse, were a significant challenge to all parties. I accept that Home B was limited in the interventions it could make because it was not registered to provide personal care. Its role, as evidenced by the support plan that was put in place when she moved there, was to encourage Miss X to increase her independence and to provide prompting and support with shopping, meal preparation and accessing other specialist services. From the information that was available at this time, I do not find fault with this approach.
43. In early October 2020, Home B told the Council it needed more structured support to manage Miss X. It gave notice to the Council that it could no longer accommodate Miss X in January 2021. It took the Council approximately three months to source an alternative. The Council has explained there were no local options that could cater for Miss X’s complex needs. The case records show the Council made its best efforts to find an alternative to Home B as soon as it was known the placement was no longer sustainable. But this proved unsuccessful, and Miss X remained living somewhere unsuitable for longer than necessary.
44. Failure to be able to move Miss X sooner is evidence of service failure and is therefore fault.
45. Unfortunately, in this three months, Miss X contracted the headlice and scabies that caused significant pain and suffering. Mr Y says Home B should not have allowed both conditions to deteriorate as they did, and this clear is evidence of fault.
46. It is not clear from the records I have seen, exactly when Miss X contracted the headlice, but it was sometime in January 2021. The first case record about the issue was on 5 February 2021. Home B reported it was unsure whether she was using the prescribed lotion although staff were prompting her to do so. Six days later, Home B advised the Council additional support was needed to physically administer the lotion. The Council made the necessary arrangements with the Agency the following day. Unfortunately, this did not prove successful. The Agency contacted the Council on 4 March 2021 to say Miss X’s infection had deteriorated significantly, causing significant pain and unpleasant odour. The Agency said all the residents of Home B appeared to be infected and that “housing support from the care workers [at Home B] has been poor”.
47. I have found no record of this significant concern being acted upon either at the time or during the safeguarding enquiry. This recorded comment provides evidence that others at Home B may have been similarly affected and that an independent third party had identified possible poor practice at the home. Failure to respond to this was a serious oversight by the Council. I cannot say whether there was any substance to what the Agency had disclosed, but it should have been investigated, particularly as the Agency seems to suggest here was a link between the support being provided at Home B and the scale of the infestation. Failure to do so was fault.
48. Despite the strong view held by Mr Y, I am unable to say there was a direct causal link between the actions of Home B and the deterioration in Miss X’s health. I do not have evidence to support a finding on this. There were several contributory factors, including Miss X’s non-compliance and lifestyle (that I reference here as a statement of fact, without any attachment of blame) and the restrictions placed on Home B about how far it could intervene. For this reason, I do not find further fault here.

Inadequacy of remedy

49. Mr Y had described the Council’s remedy payment of £250 as “an insult”. This has not been paid to either Miss X or Mr Y.
50. It is positive the Council acknowledged the many shortcomings in this matter and taken action to address the findings of fault contained within the investigation report.
51. While I welcome this, in my view the Council failed to properly consider the injustice caused as a result of the several areas of fault that occurred during both the placement at Home B and its safeguarding enquiry.
52. The Ombudsman’s Guidance on Remedies says that councils are expected to treat people fairly and with respect and not expose the public to unnecessary distress, harm or risk as a result of their actions. Such injustice cannot generally be remedied by a payment so we usually seek a symbolic amount to acknowledge the fault on the complainant. A remedy payment for distress (which covers undue significant stress, inconvenience and frustration) is often a modest sum between £100 and £300. In cases where the distress is severe or prolonged, up to £1000 may be justified. In exceptional cases we can increase this further.
53. In reaching my decision about this, I have considered what injustice arose from the numerous faults and service failure identified by the Council’s investigation and this decision statement. What was already a distressing experience was made much worse by the actions of the Council. Miss X should have been moved from Home B at the start of January 2021 when she was first given notice. She remained at an unsuitable placement for approximately three months longer that she should have.
54. It is not possible for me to speculate about what would have happened had a suitable local resource been available, but this uncertainty as to whether the outcome could have been different is an injustice that requires an improved remedy.
55. Taking this into account, together with the faults already identified by the Council, I consider it entirely appropriate and proportionate for both Miss X and Mr Y to receive an additional payment, that recognises the significant distress caused to them both. I consider the distress caused to Miss X to be significant enough to justify a payment at the highest end of the Ombudsman’s guidelines. The Council should also set out the service improvements it has taken and intends to take as a result of what happened in this case.

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Agreed action

56. The Council has agreed to take the following action within four weeks from the date of my final decision:
1. Apologise in writing to Miss X and Mr Y.
2. Pay Miss X £1000 and Mr X £250. This is in addition to the £250 already offered to them both (but not yet paid) to reflect the delay in the progression of the complaint and safeguarding enquiries. I understand Mr Y is appointed to manage Miss X’s finances. Miss X’s total payment of £1250 should be paid to Mr Y to be used for her benefit.
3. Provide the Ombudsman with a short report setting out the service improvements that have now taken place as a result of the investigation report completed in February 2022. This should include action taken to increase the supply of supported living placements in the Council’s area.
4. Reflect on the issues raised in this decision statement and identify any additional areas of service improvement. The Council should prepare a short report setting out what the Council intends to do to ensure similar problems do not reoccur. This should include action taken in respect of the concerns raised by the Agency about Home B. This report should be sent to the Ombudsman.
57. The Council should provide us with evidence it has complied with the above actions.

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Final decision

58. I have completed my investigation. I have upheld the complaint the Council has agreed to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman