Summary: Mr and Mrs X complained about the actions of the Council in relation to their role as foster parents. The Council was at fault when it delayed in sourcing new therapeutic support after stopping the existing support. It was also at fault when it failed to clearly explain to Mr and Mrs X the methods they could use to address the children’s behaviour. It has agreed to apologise to Mr and Mrs X, make a symbolic payment of £300 each to acknowledge the distress this caused them and make service improvements.

The complaint

1. Mr and Mrs X complain about the actions of the Council in relation to their role as foster parents. Specifically, they complain the Council:
1. failed to carry out an assessment with the foster children at the start of the placement to decide whether it was better to place them together or in separate placements (called a ‘together or apart’ assessment);
2. failed to provide Mr and Mrs X with the children’s care plans at the start of the placements;
3. failed to provide necessary support, including therapeutic interventions;
4. knew Mr and Mrs X were using specific methods to control the children’s behaviour but made no criticism of them until much later when carrying out an investigation into the placements;
5. carried out the investigation in such a way that it caused Mr and Mrs X unnecessary distress, which the Council then used against them;
6. failed to include the Independent Fostering Agency Mr and Mrs X were registered with in the investigation, invite it to meetings or send it copies of documents, such as the investigation report;
7. wrongly carried out an emergency removal of the children and failed to provide support to Mr and Mrs X at that time;
8. failed to carry out a together or apart assessment before splitting the children up after their removal; and
9. failed to advise Mr and Mrs X that they could appeal the removal of the children.
2. Mr and Mrs X says that because the Council made no attempts to work with them to ensure the success of the placements, they broke down. They say that as a result the family has suffered financial and emotional distress and their physical health has also been affected.

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The Ombudsman’s role and powers

3. 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)
4. I have not investigated Mr and Mrs X’s complaints in paragraph 1a) and 1b). This is because the children were placed with them in 2018. If they were concerned about whether the Council had carried out a together or apart assessment prior to that placement, or that they had not seen copies of their care plans, they could have complained about that earlier. I have no good reason to exercise my discretion to investigate now.
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 cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
7. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
8. 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)
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Office for Standards in Education, Children’s Services and Skills (Ofsted), we will share this decision with Ofsted.

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How I considered this complaint

10. I spoke to Mrs X and considered her view of her complaint.
11. I made enquiries of the Council and considered the information it provided.
12. I wrote to Mr and Mrs X and the Council with my draft decision and considered their comments before I made my final decision.

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What I found

The law and statutory guidance

13. Children who are looked after by a council may be placed in foster care. Foster care arrangements may be short or long term.
14. Councils have a duty to investigate if there is reasonable cause to suspect that a child in their area is suffering, or is likely to suffer, significant harm. They must decide whether they should take any action to safeguard or promote the child’s welfare. (Children Act 1989, section 47)
15. The National Fostering Minimum Standards says investigations into allegations against carers should be carried out quickly and should provide protection to the child but also support to the person subject to the investigation. Foster carers should be told in writing about any allegations against them and given information about the timescale for completing the investigation.
16. Regulations state that when a council proposes to end a placement it must carry out a review of the child’s case. The council must ensure the views of all the people concerned have been heard, including the child and the Independent Reviewing Officer (the IRO is the officer at the council who is responsible for monitoring the care the child is receiving)

What happened

17. Mr and Mrs X were registered as foster carers with an independent fostering and post adoption support agency (the Agency).
18. In 2018, the Council placed four siblings in a foster placement with Mr and Mrs X. The Council contracted with the Agency to provide support including access to 24/7 telephone support, training and a link worker to visit and provide supervision. An Agency family support worker visited the family weekly (and more often when the family needed additional help) to provide therapeutic parenting strategies. The Council also provided funding for the family to attend an annual holiday organised by the Agency which other fostering families attended.
19. In March 2019, the Council approved Mr and Mrs X as suitable to adopt the siblings.
20. The Council held the first adoption review meeting in April 2019. All agreed one child needed therapeutic support as they were struggling to form an attachment to Mr and Mrs X.
21. The second adoption review meeting took place in August. The Agency attended and stated they were visiting the family twice a week for four hours each time to provide practical support and advice and guidance regarding therapeutic parenting strategies.
22. The Council appointed a Provider to provide specialist therapeutic support based on the Agency’s recommendation. The Provider carried out an initial assessment on 24 September. The Provider recommended therapy for Mrs X as a priority because of previous trauma she had experienced. This therapy took place. Over the next few months, the Provider carried out further assessments with the family and children. These recommended one child required therapy.
23. In September 2019, following a review meeting, the social worker informed their manager that Mr and Mrs X had said they were struggling to manage one of the children’s behaviour which had escalated, and they had fitted a lock to the outside of the child’s bedroom door to use as an emergency. They asked if this was allowed but were told it must be removed.
24. In December, Mr and Mrs X informed the social worker that they had used a shower as a behaviour management method with F. They said the child and Mrs X would have a cool shower, fully clothed, to calm the child down.
25. In February 2020, Mr and Mrs X’s use of ‘safe holds’ was discussed in detail at an adoption review meeting. Mr and Mrs X said they had been told particular safe holds were acceptable by the Provider’s therapist. The Council criticised the Agency for failing to update the children’s risk assessment about this as this would have brought the matter to the Council’s attention earlier. The Agency said this was the Council’s responsibility because the children were on the adoption pathway. It was recommended the social worker and Agency complete an updated risk assessment outlining Mr and Mrs X’s parenting strategies with each child. The notes do not record Mr and Mrs X were told these safe holds must not be used.
26. Also in February, a Council specialist team assessed the family. The notes recorded Mrs X would shut one child out of the living room and hold the door shut and the handle mechanisms had been removed on some doors. Concerns about the stability of the placement were raised.
27. Later in February 2020, the Council identified concerns with the Provider. The Council decided to source another therapeutic agency to undertake work with the family.
28. In March, both Mr and Mrs X and the Agency raised concerns with the Council’s decision to halt the work being carried out by the Provider. The Agency said the Provider had been involved with the family for a considerable time and was at a point where it could begin providing one of the children with therapy. It raised concerns that the decision to terminate the Agency’s involvement had been taken without consultation with the family or the Agency. The Agency also raised concerns about the delays this would create. Mr and Mrs X echoed these concerns.
29. Later in March, the Council social worker emailed Mr and Mrs X regarding upcoming assessments she wished to carry out to ensure the correct therapeutic support, now that the Provider no longer was involved. The assessments would take around three months.
30. Also in March the social worker wrote a report about the placement. This stated the Council had ongoing concerns, including the needs of the siblings being greater than when first placed, Mr and Mrs X’s previous traumas which were impacting on their ability to care for the children, the effect of the placement on Mr and Mrs X’s biological children and the reluctance of the family to submit their adoption application.
31. On 29 June 2020, an adoption review meeting was held. The minutes noted the Council would no longer pursue a together or apart assessment as the family and siblings had coped well during lockdown and their relationship had become more embedded (a together or apart assessment is when siblings are assessed to determine whether they are best kept together within one fostering or adoption placement, or would benefit from being placed separately). Mr and Mrs X raised concerns with the lack of support from the Provider who had not returned their calls for several weeks. Mr and Mrs X said they had identified another provider which might be suitable.
32. The Council case notes record that during a phone call between the social worker and Mr X on 3 September, Mr X stated two of the siblings continued to exhibit difficult behaviour which was escalating. Mr X stated he had been in contact with a friend who worked in a children’s home who had advised on the appropriate safe holds to use and who felt one sibling needed a psychiatric assessment. There is no record that the social worker commented on the information about safe holds but she did say she would follow up the suggestion of a further assessment.
33. On 18 September, a review meeting was held. The minutes recorded that at the February 2020 meeting, Mr and Mrs X had been told by the Council that it did not endorse the use of physical restraint. The notes stated no record of what type of safe holds being used had been received by the Council. The Council said clarity on this was needed. It was agreed the Local Authority Designated Officer (LADO) would be informed if safe holds continued to be used. The LADO is responsible for the management and oversight of allegations against people who work with children.
34. The social worker spoke to Mr and Mrs X that day. They said they were using two types of safe hold where they placed their hands over the child’s to help calm them. Mr and Mrs X said they had been told by a friend who worked in residential care that these were effective.
35. On 28 September, the social worker visited and spoke to each child.
36. On 2 October, the social worker informed their team manager that at a meeting the previous day with Mr and Mrs X and the Agency, Mr and Mrs X had said they had removed one of the children’s bedroom door handle on several occasions but no longer did this.
37. The social worker raised concerns about what they had discussed with Mr and Mrs X. This was because they thought their behaviour might be disproportionate to the behaviour exhibited by the children and punitive. The Council raised concerns over Mr and Mrs X’s lack of insight regarding the children’s previous trauma. It was agreed to refer the matter to the LADO.
38. On 8 October, a meeting was held with the LADO. It was concluded that the siblings had experienced emotional harm from the safe holds and restraints and the Council would investigate this further. The LADO concluded the children were not at risk of immediate harm.
39. The Council wrote to Mr and Mrs X on 16 October. It specified the issues under investigation which were the physical restraints used by them (safe holds, showers and holding or removing door handles to prevent children leaving the bedroom). The letter informed Mr and Mrs X that the report would be sent to a service manager and, if they felt their approval as adopters should be reviewed, the matter would go to a Council panel. Following that, the couple would be informed of the outcome and their appeal rights.
40. The Council started the investigation on 19 October. A review strategy meeting was held on 21 October which the Agency and Mr and Mrs X attended. The restraints used by Mr and Mrs X were considered. Mrs X said she had placed one child in a cool shower on four occasions when their behaviour had been extreme. The Agency said it was aware of only one occasion.
41. In relation to the safe holds, Mr and Mrs X said the Provider had given them advice on the type of safe hold to use and supported this statement with written evidence. The Council stated the Provider had not shared this with it.
42. The meeting concluded Mr and Mrs X were open and apologetic about anything that they had done which was considered inappropriate and were willing to work with the Council. The notes recorded, however, that regardless of this, there was a concern around the emotional harm that had been caused to the siblings.
43. On 29 October, whilst the investigation was underway, a previously arranged professionals meeting was held which was attended by the Agency, the Council and the new therapeutic support provider. A together or apart assessment for the siblings was underway and it was agreed that if the siblings remained in Mr and Mrs X’s case, the nature of the therapeutic work required would be discussed.
44. On the same day, the Council’s placement resource panel agreed to look for an emergency or short-term foster placement for the siblings.
45. The investigation concluded on 30 October. The investigator found the claims of emotional abuse had been substantiated.
46. On 11 November, Mr and Mrs X were informed in writing of the outcome of the panel meeting. It was recommended Mr and Mrs X be returned to the adoption panel with a recommendation that their approval as adopters was terminated and any future fostering assessment would take the findings on the investigation into account. The Council would also review the longer-term plans for the siblings in light of the findings of the investigation.
47. On 4 December, a virtual meeting was held between the Council, Mr and Mrs X and an adoption agency from the area the children were moving to. The Council informed Mr and Mrs X of its plans to remove the children and advised them to seek legal advice. The Council confirmed the discussion in an email.
48. Following discussions with Mr and Mrs X, the Council decided it was in the children’s best interests not to be informed of the move. The children’s schools were informed of the plans in order to assist them in saying goodbye to their friends and teachers. The children left on 10 December.
49. On 11 December Mr and Mrs X resigned as prospective adopters. They subsequently complained to the Council about the matters listed in paragraph 1 of this decision statement. The Council made the following findings:
• it failed to send Mr and Mrs X the children’s care plans. However, these were regularly reviewed and the couple were sent the minutes of these meetings. In addition, all information about the children was shared before the placement started. The Council partly upheld the complaint;
• it apologised for any misunderstandings over the use of showers and safe holds. It said at the meeting in February 2020, it was agreed that risk management plans would be reviewed to ensure there was clarity on what techniques were endorsed. This did not take place. The Council partly upheld the complaint;
• the Council was unaware Mr and Mrs X were removing the children’s bedroom door handles until September 2020. It did not uphold this complaint;
• there was no requirement for the Council to present resignations by adopters to the panel. This was done by the Council as a matter of good practice and not because a decision was needed (in light of Mr and Mrs X’s resignation). There was no appeal process as this would only have arisen if the panel had recommended termination and Mr and Mrs X opposed this. The Council did not uphold the complaint;
• the Council advised them to take independent legal advice over the decision to remove the children which was sufficient to inform them of their rights to challenge that decision; and
• the Council found a placement which kept the children together. However, this broke down and so it made the decision to split the children into two placements.

My findings

Complaint 1c) Council failed to provide necessary support, including therapeutic interventions

50. The Agency provided Mr and Mrs X with regular support during the placement of the children. The family was able to access Council social workers if needed. Mrs X also received therapy following an assessment from the Provider.
51. The Council decided the Provider was not suitable for several reasons and stopped the assessments and provision. Although it would have been best practice if the Council had consulted with the Agency and Mr and Mrs X before making that decision, they did get the opportunity to make their views known and the Council considered these.
52. Prior to stopping support from the Provider, the Council failed to either ensure there was alternative support available or to assess the risk to the family of delaying the therapeutic support identified. This was of particular importance because the Provider had recommended one child required therapeutic support which was due to start. There was fault in the Council’s actions.
53. Although the outcome of that, or any other support cannot be known with certainty, on balance, it is likely this contributed to any difficulties Mr and Mrs X had caring for that child and had an impact on the family as a whole.

Complaint 1d) methods to manage the children’s behaviour and Complaint 1e) October 2020 investigation caused Mr and Mrs X unnecessary distress

54. In September 2019, Mr and Mrs X told the Council they had fitted a lock to the outside of one child’s bedroom. The Council told them to remove it which they did.
55. In December 2019, the notes record Mrs X would stand fully clothed in a cool shower with one child also fully clothed as a behavioural technique. There is no record the Council told them to stop doing this or that the matter was discussed further at the time.
56. In February 2020, the Council told the Council they were using safe holds which they had been told were appropriate by the Provider’s therapist they were working with. Again, the notes do not record the couple were told to stop. The issue arose again in September 2020 at a review meeting. The notes from that meeting said there was a concern that Mr and Mrs X had been told in February that the Council did not endorse the use of physical constraint but had continued to utilise safe holds. The notes from the February meeting do not support this statement. And as a result of this, the October 2020 investigation was started.
57. The lack of a clear message on what the Council considered appropriate techniques and its failure to review the children’s risk management plans were significant faults and contributed to the subsequent events.
58. The outcome of the October 2020 investigation found that the children had experienced emotional abuse because of the techniques used by Mr and Mrs X. There was no fault in how that decision was reached. But the Council’s lack of acknowledgement at that stage that its failure to provide clear messages to Mr and Mrs X contributed to events, meant the couple was left with an enduring sense of frustration and injustice. The faults also mean they were left uncertain whether, had the Council been clear about what was appropriate, the children may not have been removed.
59. At the complaints stage the Council made some reference to the lack of clarity in its messages to the couple but neither fully upheld this aspect of the complaint nor considered the injustice it caused them. This compounded the injustice to Mr and Mrs X and caused them time and trouble in coming to the Ombudsman.

Complaint 1f) involvement of Agency in the investigation

60. The Agency attended the meetings on 21 and 28 October 2020 which considered the methods used by Mr and Mrs X to manage the children’s behaviour. The report was sent to Mr and Mrs X and a virtual meeting was held on 4 December to discuss the recommendations. There was no fault in the Council’s actions.

Complaint 1g) removal of the children and support to Mr and Mrs X at that time

61. The Council arranged a planned removal of the children. It informed Mr and Mrs X of these intentions and after discussing the situation with the couple, acted on their advice not to give the children advanced warning. During that period Mr and Mrs X were able to call on the support of the Agency and also a specialist fostering charity. There was no fault in the Council’s actions.

Complaint 1i) Mr and Mrs X not informed they could appeal the removal of the children

62. The correct course of action if Mr and Mrs X were unhappy with the removal of the children was to complain to the Council and then to us. The Council advised them to seek independent advice and at the end of the complaint process signposted them to us. There was no fault in the Council’s actions.

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Agreed actions

63. Within one month of the date of the final decision, the Council has agreed to:
• apologise to Mr and Mrs X, explain to them what it is doing to prevent future similar faults, and pay them £300 each for the enduring sense of frustration and injustice as well as uncertainty over the removal of the foster children in their care and time and trouble in having to complain to the Ombudsman;
• remind relevant staff that where there are concerns about the actions of foster carers, these and any actions required, are accurately recorded and followed up. Also the Council will remind them to give, and record giving, clear, timely advice when they have concerns including, where relevant, the potential consequences of not following that advice.

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Final decision

64. There was fault leading to injustice. The Council has agreed to my recommendations and so I have completed my investigation.

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Parts of the complaint that I did not investigate

Complaints 1a) and 1b) together or apart assessment and provision of care plans at the beginning of the placement

65. I explain why I have not looked at these complaints in paragraphs 3 and 4 of this decision statement.

Complaint 1g) together or apart assessments at the end of the placement

66. Mr and Mrs X are concerned the Council did not carry out a together or apart assessment at the end of the placement. But they do not have permission to complain on the children’s behalf. This means we cannot consider this part of their complaint.

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Investigator's decision on behalf of the Ombudsman