Summary: Mrs X complained the Council failed to deal with her safeguarding concerns about her grandchildren. The Council was at fault in delaying statutory visits and delaying or failing to conduct risk assessments. This caused Mrs X significant distress about the safety of her grandchildren. The Council will take action to remedy this injustice.

The complaint

1. Mrs X complained the Council failed to:

• deal with her many safeguarding concerns about her grandchildren’s welfare
• conduct regular statutory home visits to check on the welfare of her grandchildren
• ensure the children’s mother had regular drug tests
• assess the potential risk the mother’s partner posed to her grandchildren
• complete risk assessment on the children’s father after her grandchildren resumed contact with him following his release from custody.

Mrs X says the Council’s failing have caused her significant distress and anxiety about the welfare and safety of her grandchildren.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’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)
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 matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, 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)
6. 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

7. I discussed the complaint with Mrs X and considered the information she provided. I considered the information the Council provided in response to my enquiries and its policies and procedures. I also considered the relevant law and guidelines.
8. I sent Mrs X and the Council a copy of my draft decision and considered all comments received prior to reaching a final decision.

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What I found

9. The Children Act 1989 and statutory guidance Working Together to Safeguard Children (‘Working Together’) sets out a council’s responsibilities to safeguard children.
10. Everyone who works with children has a responsibility for keeping them safe. If children and families are to receive the right help at the right time, everyone who encounters them has a role to play in identifying concerns, sharing information and taking prompt action. (Working Together to Safeguard Children)
11. If a Council accepts a referral for a child, it must carry out a needs assessment. Every assessment should reflect the unique characteristics and needs of the individual child. (Working Together to Safeguard Children)
12. Where a child’s need is relatively low level, individual services and universal services may be able to take swift action. Where there are more complex needs, the Council may offer a service under section 17 (child in need) or section 47 (child protection) of the Children Act 1989.
13. Under the Children Act 1989, local authorities are required to provide services for the children in need for the purposes of safeguarding and promoting their welfare. Where a referral is accepted under section 17 the Council should lead a multi-agency assessment and complete it within 45 working days. Where the local authority children’s social care decides to provide services, it should develop a multiagency child in need plan which sets out which organisations and agencies will provide which services to the child and family. The plan must be reviewed within 3 months of the start of the child in need plan and further reviews should take place at least every 6 months thereafter. (Working Together to Safeguard Children)
14. The Children Act 1989 says that, “where a local authority …have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.” (The Children Act 47(1)). Harm means ill-treatment or the impairment of health or development, including, for example, impairment suffered from seeing or hearing the ill-treatment of another. (The Children Act 1989 31(9))
15. Councils should hold a strategy meeting when they are concerned the threshold for section 47, child protection enquiries is met. If the threshold is met, an initial child protection conference must take place within 15 working days of the strategy meeting. The core group should meet within 10 days of the initial child protection conference and then, at a minimum of every 6 weeks. The Council should hold the first child protection review within 3 months of the initial conference. The Council should hold further reviews at intervals of no more than 6 months for as long as the child remains subject of a child protection plan. (Working Together to Safeguard Children)
16. Where the Council is very concerned about a child’s well-being, it may consider starting a Public Law Outline (PLO) process to address these concerns. The PLO process is the last opportunity for parents to make improvements and protect the child from harm before the Council makes a care proceedings application to the Court.

Background

17. Mrs X is the grandmother of Child 1 and Child 2. They are the young children of her daughter Ms Y and her former partner, Mr Z.
18. The relationship between Ms Y and Mr Z was unstable and there was a report of violence and domestic abuse between the couple some years ago. Mr Z is involved with social care and went to prison for domestic incidents.
19. Ms Y has a new partner, Mr B, who lives with her and Child 1 and Child 2. Mr B is also known to the Police.
20. Mrs X says Ms Y and Mr B are drug addicts and Mr B also deals in drugs. Mrs X says this has led to Child 1 and Child 2 being exposed to substance misuse, neglect and there were serious concerns about the children’s welfare.
21. The family have been known to social care in the past following similar concerns where Child 1 and Child 2 were placed on Child in Need Plan on two occasions.

What happened

22. The family was referred to social services following several concerns raised about Child 1 and Child 2 welfare by school, neighbours, friends and family, particularly Mrs X.
23. In May 2019, Mrs X raised her concerns about her grandchildren’s welfare with the Council. The Council completed a multiagency assessment which identified the needs of Child 1 and Child 2. It decided to put both children on a Child in Need (CIN) Plan in June 2019.
24. The Council says by August 2019, it did not see any considerable improvements from the intervention it had provided for Child 1 and Child 2 so far under the CIN Plan. It also says because of the continuous high level of concerns about the children, the Council decided the case needed to be escalated onto a Child Protection (CP) Plan and subsequently requested a Public Law Outline (PLO). This was to ensure the children’s safety and put in place a contingency plan if the children’s situation deteriorated.
25. Child 1 and Child 2 were put on CP Plans in September 2019 and the PLO was finalised in December 2019. From October 2019 onwards, during statutory home and school visits the Council observed home living conditions and the children’s school attendance were improving. This was feedback in the Core Group Meeting held in November 2019 which demonstrated an improvement in the children’s welfare. The case was de-escalated from CP to CIN and was finally closed in October 2020.
26. The Council have assessed Mrs X and her husband and confirmed it would support the children being placed with them in the event there are future reports of similar safeguarding concerns about the children. The Council also confirms the children are receiving pastoral support from school.

Analysis

Failure to deal with the safeguarding concerns about Child 1 and Child 2’s welfare

27. The Council took account of all the relevant information and based its decisions on the professional judgement of its officers in dealing with the safeguarding concerns of Child 1 and Child 2. During the Child and Family Assessment in June 2019, the Council decided to initially put the children on CIN plans with ongoing and prolonged support until improvements were maintained. This decision was based on the feedback from professionals who confirmed Ms Y was willing to engage with services.
28. Due to increasing levels of concern about the children’s welfare and feedback from other professionals with insufficient evidence of improvements from the CIN interventions, the Council escalated the case to CP and PLO.
29. In May 2020, the Council de-escalated the case from CP to CIN with ongoing support. It eventually closed the case in October 2020. The original decision to escalate matters to CP and PLO was appropriately made given the lack of engagement or progress. The subsequent decisions to de-escalate to CIN and eventual closure were based on feedback from October 2019 onwards. Different professionals recorded Ms Y’s continuous engagement and improvements in protecting the children from harm. The Council is entitled to make the decisions about when additional scrutiny was required via the CP procedures and when sufficient progress had been made to move the children back to support via CIN. I have found no fault in how its decisions were made.
30. However, the evidence confirms there were some delays with the timescales within which some meetings were held. Councils should hold a Strategy Meeting within 24 hours of its decision to consider escalating a case to CP. The Council delayed the Strategy Meeting held in 2019 by a week. Also, once a child is made subject to a Child Protection Plan, councils should hold Core Group Meetings every six weeks. The Council did not hold any core group meeting after it held one in December 2019 until March 2020. This was a delay of over three months. The Council should have held two core group meetings over this period. This is fault which caused Mrs X anxiety and distress about the welfare of Child 1 and Child 2.

Failure to conduct regular statutory home visits to check Child 1 and Child 2’s welfare

31. Mrs X says the Council failed to regularly visit Child 1 and Child 2 under the CP 10-day statutory visits.
32. The children’s CP plan stated the children should be visited every 10 working days. Although the Council conducted several CP visits (announced and unannounced) in different environments (home and school) to monitor the children’s welfare, I found a visit was missed in January 2020. There were also delays with these statutory visits ranging from one day to twenty-four working days between October 2019 and May 2020.
33. The Council has several systems which it uses to monitor statutory visits. It confirms all managers are responsible for ensuring the visits are carried out within specific timescales and will discuss this in supervision with staff. The Council recognises it should have visited the children more frequently than it did. The Council previously indicated there were issues with its case management system but has since clarified on this occasion the delays and infrequent statutory visits were caused by human error and lack of management oversight. The Council has confirmed it is in the process of reviewing the supervision form on its social care recording system to ensure statutory visits are discussed in every supervision.
34. The Council’s error and lack of supervision with monitoring the children’s statutory visits is fault and led to delays in these visits being carried out. This meant the welfare of Child 1 and Child 2 was not monitored as regularly as it should have been. Had there been changes to the children’s situation, these could have been missed due to the delays or failure to carry out the visits. This caused Mrs X distress and uncertainty about the safety of Child 1 and Child 2.

Failure to conduct regular drug tests on Ms Y

35. The children’s CP plan stated Ms Y needed to take regular drug tests. Mrs X says the Council failed to conduct these tests on Ms Y.
36. I have seen evidence to confirm the Council carried out drug tests on Ms Y and it also followed up on any delays caused by its provider.
37. I have found no evidence of fault by Council in conducting random drug tests on Ms Y.

Failure to risk assess Mr B

38. Mrs X says the Council failed to assess the potential risk Mr B posed to Child 1 and Child 2.
39. In the Council’s response to my enquiries, it says Mr B’s involvement with Ms Y and the children was known to the Council in June 2019. In September 2019 Child 1 and Child 2 were put on CP Plan. The Council says it conducted a risk assessment on Mr B in May 2020.
40. The evidence confirms there were several concerns raised about the potential risk Mr B may pose to Child 1 and Child 2. Those concerns were from different professionals including the police and were made over a considerable period, the earliest being June 2019.
41. When the children were placed on CP in September 2019, the CP plan stated Mr B must not be left unsupervised with Child 1 and Child 2 until risk assessment is completed. Evidence shows the Council carried out three unannounced statutory visits between September 2019 and April 2020. More unannounced visits should have been carried out to ensure Mr B was not with the children unsupervised and I find no evidence the Council monitored the situation pending the completion of Mr B’s risk assessment.
42. During the Core Group Meeting held in November 2019, it was agreed a risk assessment would be done on Mr B in January / February 2020. The Council completed Mr B’s risk assessment in May 2020.
43. There was nearly a year delay by Council in completing Mr B’s risk assessment. The Council failed to act in a timely way on the concerns other professionals were raising. It missed opportunities to ensure the risk assessment was completed despite this being flagged as outstanding. Although the Council accepts the Core Group suggested a risk assessment for Mr B, it says that it continuously considered and monitored the risks he posed to the children pending the completion of a risk assessment throughout the safeguarding process. The risks Mr B posed to the children were considered in the Child and Families assessment, the ICPC and during the PLO process. The Council considers these assessments including the CP Review reports are better ways of understanding the risks Mr B posed to the children than a “stand-alone” risk assessment.
44. However, the Council should have made a record of the reasons it did not complete Mr B’s risk assessment as agreed in the Core Group Meeting until May 2020. This is fault. It caused distress to Mrs X and placed Child 1 and Child 2 at potential risk of harm for a prolonged period.

Failure to risk assess Mr Z following his release from prison

45. Mrs X says the Council failed to complete risk assessments on Mr Z following his release from custody and before Child 1 and Child 2 resumed contact with him.
46. The Council accepted it was at fault in its response to my enquiries. The Council says there is no record a risk assessment was completed on Mr Z, following his release from custody or that he was included in an updated Child and Family Assessment.
47. The Council says although Mr Z was included in the Review Child Protection Report in May 2020, this was approximately 5 months after his release from custody. The Council accepts it should have been aware of Mr Z’s involvement with Child 1 and Child 2. A risk assessment should have been completed on his release from custody. The failure to do so left Child 1 and Child 2 at a potential risk of harm.
48. The Council explains between October 2019 and January 2020, there were changes in social workers who were responsible for undertaking this action which led to risk assessment being missed.
49. The Council’s failure to risk assess Mr Z upon his release from prison was fault. This caused distress to Mrs X because she was concerned about the potential risk Mr Z posed to Child 1 and Child 2. Although fortunately there is no evidence the children came to any harm, both they and Mr Z were left in a vulnerable position in the absence of a full and proper consideration of the potential risks and how these should be managed.

Agreed action

50. 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 Mrs X for the emotional distress and anxiety over the welfare of Child 1 and Child 2 caused by the delays and infrequent statutory visits.
• pay Mrs X £300 in recognition of the emotional distress caused.
• action should immediately be taken to remind all child protection staff about the importance of meeting the timescales for risk assessments and child protection visits.
• within three months of the final decision, complete amendments to the supervision form on the Social Care recording system, setting out how statutory records will be checked and monitored during supervision sessions with managers.
• all open cases should be audited as part of the supervision process to ensure statutory visits have not been delayed or missed. Action should immediately be taken on any case where a visit has been missed or delayed to ensure the safety of the child concerned.
• within two months of the final decision, undertake Mr Z’s risk assessment if this is still outstanding. In the event Mr Z cannot be contacted or he is unwilling to engage, undertake a paper exercise assessment of him and address any risks identified.

51. The Council should provide the Ombudsman with evidence that the above actions have been completed.

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Final decision

52. I find evidence of fault by the Council causing injustice to Mrs X. The Council has agreed to take action to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman