Summary: Mrs X complained about how the Council dealt with a safeguarding investigation about the care and support provided to her adult child, Ms Y. There were some faults with the Council’s safeguarding enquiry process. This caused injustice to Ms Y and Mrs X. The Council will take action to remedy the injustice caused.

The complaint

1. Mrs X complained on behalf of her adult child, Ms Y.
2. Mrs X complained about the Council’s:

• failure to adequately conduct a safeguarding investigation about the care and support provided to Ms Y by the Care Provider
• failure to provide Ms Y with an advocate to represent her views during the safeguarding investigation
• failure to consider the views and evidence submitted by Ms Y’s family in support of the safeguarding investigation
• lack of transparency and poor communication with Ms Y’s family in relation to the safeguarding process.

3. Mrs X said the Council’s failings caused significant distress to her and Ms Y. She said as a result of the standard of care and support provided by the Care Provider, Ms Y had to leave her placement and moved in with her parents which has affected her independence.
4. Mrs X said Ms Y and the family’s views were not represented and the safeguarding report contained incorrect information. She said the matter caused frustration and time and trouble for the family and that Ms Y’s mental health has been affected.

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The Ombudsman’s role and powers

5. 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)
6. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
7. 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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What I have and have not investigated

8. I have investigated matters relating to how the Council conducted a safeguarding enquiry about the care and support provided to Ms Y. This investigation covers the period, June 2022 – May 2023.

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How I considered this complaint

9. I have discussed the complaint with Mrs X and considered the information she provided. I also considered the information the Council provided in response to my enquiries.
10. I sent Mrs X and the Council a copy of my draft decision and considered all comments received before reaching a final decision.

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What I found

Legislation and Guidance

11. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
12. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help and protect the adult.
13. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement.
14. The Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively.
15. The Council’s safeguarding adults policy and procedures under the section “Involving a person in an enquiry” states “the person should always be involved from the beginning of the enquiry, unless there are exceptional circumstances that would increase the risk of abuse.”
16. Under section 68 of the Care Act 2014, councils must arrange for an independent advocate to support and represent an adult’s views in an enquiry or review unless the council is satisfied that there is a person:
1. who would be an appropriate person to represent and support the adult for the purpose of facilitating the adult’s involvement, and
2. who is not engaged in providing care or treatment for the adult in a professional capacity or for money.

Key events

17. Ms Y has some health conditions. She lived in a supported living accommodation provided by the Care Provider (CP).
18. Prior to June 2022, the CP informed the Council about changes to Ms Y’s behaviour and needs. The CP said there was a potential placement breakdown and confirmed it was struggling to support Ms Y’s needs. The CP asked to discuss the matter with the Council.
19. In June 2022, Ms Y moved in with her parents due to ongoing concerns about the care at her placement.
20. Mrs X informed the police and the Council about her concerns. The safeguarding issues Mrs X raised included neglect, medication abuse, personal care, nutrition, missing items, male staff providing personal care for Ms Y despite the family’s request for female staff.
21. The Council agreed to make safeguarding enquiries into Ms Y’s case. Mrs X said she requested an advocate to represent Ms Y’s views during the safeguarding investigation process. The Council sent Mrs X an email with details of the available advocacy service. It said Ms Y could have an independent advocate and advised that Mrs X or Ms Y could contact the service directly to request an advocate to represent Ms Y.
22. Mrs X contacted the advocacy service the Council signposted her to. Mrs X was told the service was in a transition process. It advised Mrs X to get back in touch in early July 2022 when a new advocacy service would be in operation. Mrs X informed the Council she was in the process of applying for an advocate for Ms Y through the advocacy service it signposted her to. Mrs X maintained she was unable to represent Ms Y.
23. The Council arranged and invited Mrs X to attend a strategy meeting. The meeting was to discuss the safeguarding concerns she raised.
24. The police conducted an unannounced visit to the CP’s property to investigate Mrs X’s concerns. The police closed the case after its investigation with a ‘no further action’ outcome.
25. At the end of June 2022, the Council held a strategy meeting with the police and the CP. The outcome of the meeting was for the Council to conduct a safeguarding enquiry into Mrs X’s concerns. Mrs X did not attend the meeting. The Council contacted Mrs X with an update and the outcome of the strategy meeting.
26. In early July 2022, Mrs X contacted the new advocacy service and another service which was also commissioned by the Council. Both services told Mrs X she could not self-refer Ms Y and said only the Council could refer Ms Y for safeguarding advocacy. Mrs X informed the Council about the difficulty she was experiencing with self-referring Ms Y for an advocate. The Council provided Mrs X with the new advocacy service details and advised her to contact the service to self-refer Ms Y. Mrs X was still unable to secure advocacy for Ms Y.
27. In July 2022, the Council conducted its safeguarding enquiry. Based on the safeguarding concerns Mrs X raised, the Council gathered information from various sources such as the police, CP and the Council’s quality assurance team. It considered all the available information provided. The Council said it appeared there was a significant breakdown in the relationship and trust between the CP and Mrs X, but it identified no safeguarding concerns. The Council decided there was no further safeguarding action required and it closed the case.
28. In August 2022, Mrs X called the Council and asked for an update on the safeguarding enquiry. The Council informed Mrs X it had completed the safeguarding enquiry and closed the case. Mrs X questioned why she was not informed of the process and why she was not provided with a copy of the enquiry report. The Council apologised to Mrs X and sent her a copy of the report.
29. Mrs X disputed the contents of the safeguarding enquiry report. She said there were many factual errors and false allegations against her in the report.
30. Mrs X made a formal complaint to the Council. She complained about the lack of adequate care and support provided to Ms Y by the CP and the Council’s failure to properly address her safeguarding concerns. Mrs X complained the Council failed to consider the family’s views and failed to provide Ms Y with an advocate to represent her views during the enquiry process. She also complained about the Council’s lack of transparency and its poor communication with her during the safeguarding enquiry process. Mrs X said the report was misleading and contained several factual inaccuracies.
31. The Council in its responses to Mrs X’s complaint said its records showed advocacy was requested for Ms Y but was not progressed. It said this was because the Council was of the view Mrs X was advocating for Ms Y. The Council said it gathered and considered views from various sources which included Mrs X’s safeguarding concerns before it made its decision. The Council said it considered its enquiry process was robust and said it would not be undertaking another enquiry into the same concerns it had dealt with.
32. Mrs X remained dissatisfied with how the Council had dealt with the safeguarding enquiry and its complaint response. She made a complaint to the Ombudsman.

Analysis

33. The Ombudsman’s role is not to reach a view on whether the Council’s decisions on safeguarding concerns are correct. Our role is to consider whether the Council followed the Care and Support Statutory Guidance process and considered all relevant information to reach its view.
34. In this case, I find the Council carried out its safeguarding enquiry process in line with statutory guidance. The Council acted promptly when it received safeguarding concerns from Mrs X. It held a strategy meeting and then a safeguarding enquiry into the concerns raised. The Council took account of Mrs X’s concerns, it gathered, and properly considered the information it received from various sources before it reached its safeguarding enquiry outcome. The Council identified no safeguarding concerns and decided there was no further action to be taken. This was not fault. This is a decision the Council is entitled to make, and the Ombudsman cannot question the merits of its decision.
35. I find fault by the Council for its poor communication with Mrs X. Communication with the person involved and/or their representative is part of the Council’s safeguarding policy. There was no evidence to show the Council informed Mrs X about its safeguarding enquiry process and timelines. The Council also failed to share the outcome of its safeguarding enquiry with Mrs X until she contacted it for an update on Ms Y’s case. These were faults. They caused Mrs X distress, worry and uncertainty.
36. The law states councils must arrange for an independent advocate to support and represent an adult’s views in an enquiry. But it further states this duty does not apply where the council is satisfied that there is an appropriate person to represent and support the adult for the purpose of facilitating the adult’s involvement.
37. I note the Council said it believed Mrs X was representing Ms Y and therefore she was her advocate. But evidence shows Mrs X asked the Council to provide Ms Y with an advocate during the safeguarding enquiry process because she was unable to represent Ms Y. There was no evidence to show the Council provided Ms Y with an independent advocate.
38. Mrs X contacted the Council’s commissioned services it signposted her to but she experienced difficulties with self-referring Ms Y. She informed the Council about this, but the Council failed to make any referral and/or arranged an advocate for Ms Y. This was fault and not in line with the provisions of the Care Act 2014. This caused Mrs X distress, uncertainty, and frustration. It also meant Ms Y missed out on the opportunity to have been represented by an independent advocate during the safeguarding enquiry process.
39. I cannot however say that if the Council had arranged an advocate to represent Ms Y, the safeguarding enquiry outcome would have been different. This is because as earlier stated above, I consider the Council gathered and properly considered the information it received including Mrs X’s concerns before it reached its safeguarding enquiry outcome.

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Agreed action

40. To remedy the injustice caused by the faults identified, the Council has agreed to complete the following within one month of the final decision:

• apologise in writing to Ms Y and Mrs X to acknowledge the injustice caused to them by the Council’s failings as identified above. The apology should be in accordance with our new guidance, Making an effective apology
• pay Ms Y a symbolic payment of £200 to acknowledge the injustice caused to her by the Council’s failure to provide her with an independent advocate during the safeguarding enquiry process
• pay Mrs X a symbolic payment of £150 in recognition of the distress, worry, uncertainty and frustration caused by the Council’s poor communication with her and its failure to provide Ms Y with an independent advocate
• by training or other means remind staff of the Council’s referral processes to its commissioned advocacy services. This is to ensure people are appropriately referred to and have access to independent advocacy in line with the provisions of the Care Act 2014
• by training or other means remind staff of the importance of providing information about its safeguarding enquiry process and communicating outcomes to the service user and/or representative(s) in a timely manner.

41. The Council should provide us with evidence it has complied with the above actions.

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Final decision

42. I find evidence of some faults by the Council leading to injustice. The Council has agreed to take action to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman