Summary: Ms X complained the Council’s children’s services placed her children in unsuitable foster care placements and failed to provide enough support to her and her children. These complaints were upheld through the children’s statutory complaints procedure. As this has been properly and thoroughly investigated through the statutory process we have not re-investigated the substantive issues. However we have found fault with the Council for delays in carrying out its complaint investigations and failure to implement all of the recommendations arising from one of the complaint investigations. These faults caused Ms X avoidable frustration and distress at an already difficult time. In recognition of the injustice caused by these faults, the Council has agreed to pay Ms X £300 and carry out service improvements.

The complaint

1. Ms X complained the Council placed her children in unsuitable foster care placements which have caused them distress and ongoing mental health issues.
2. Ms X said the Council failed to provide enough support to her children and said her own experience of dealing with the Council’s children’s social care department had also been poor.

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The Ombudsman’s role and powers

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 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)
5. 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/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
6. In this case there is a good reason for me to look at the complaint investigation which began in September 2021, as it is linked to the later complaint investigation and is one of the reasons that Ms X made two separate complaints. I have therefore decided to look back to events from 13 September 2021.
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)
8. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children's Services and Skills (Ofsted).

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How I considered this complaint

9. I considered the information provided by Ms X and the Council.
10. I considered the relevant law and guidance as set out below.
11. I considered our Guidance on Remedies.
12. I considered all comments made by Ms X and the Council on a draft decision before making a final decision.

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What I found

Law and guidance

Children’s statutory complaints procedure

13. The Children Act 1989 sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. We call this the “children’s statutory complaints procedure”.
14. The accompanying statutory guidance, ‘Getting the Best from Complaints’, sets out the process for considering complaints. We call this, “the Guidance”.
15. The first stage of the procedure is local resolution. The council has a maximum of 20 working days to respond.
16. If a complainant is not happy with a council’s stage one response, they can ask it to consider it at stage two. At stage two, councils appoint an investigator, and an independent person who oversees the investigation. Councils have up to 25 working days to complete stage two of the procedure from the date of request, with a maximum extension to 65 working days.
17. If a complainant is unhappy with the outcome of the stage two investigation, they can ask for a stage three review by an independent panel within 20 working days of receiving the council’s response. The council must hold the panel within 30 working days of the date of request, and then issue a final response within 20 working days of the panel hearing. The purpose of the stage three panel includes:
• considering the adequacy of the stage two investigation;
• obtaining any further information or advice in order to resolve the complaint; and
• identifying injustice and recommending appropriate redress.
18. The Ombudsman would normally expect a council and complainant to follow the full complaints procedure. The guidance sets out the circumstances in which a complaint can be referred to the Ombudsman without completing all three stages. This can only happen when the stage two investigation is robust with all complaints upheld.
19. The Guidance notes that except in circumstances where the person complains about organisations acting on behalf of councils, a council must escalate a complaint to stage two and three of the procedure if the complainant wants it to.
20. If a council has investigated something under the statutory children’s complaint process, the Ombudsman would not normally re-investigate it unless we consider the investigation was flawed. However, we may look at whether a council properly considered the findings and recommendations of the independent investigation.

Children and Family Court Advisory Service (CAFCASS)

21. CAFCASS was set up to represent the needs of children involved in family court proceedings. I refer to them as CAFCASS in this decision statement.

Independent Reviewing Officer (IRO)

22. The law says councils must appoint an IRO to oversee the care planning process for looked after children. I refer to them as IRO in this decision statement.

What happened

Ms X’s first complaint

23. In 2019, two of Ms X’s children were placed in foster care.
24. Ms X raised a stage one complaint to the Council on 13 September 2021. She complained that her children were in an unsuitable foster care placement, the Council had not communicated with her properly regarding steps she needed to take to have her children returned and she was not having regular enough contact with her children.
25. The Council responded on the same day and did not uphold her complaints, other than her complaint that it had failed to send her an important document, which it said it would send to her.
26. Ms X responded on 17 November 2021 to say she wanted her complaint to be escalated to stage two of the children’s statutory complaints procedure.
27. The Council responded at stage two on 14 February 2022.
28. The investigator carried out interviews with social workers, reviewed parenting assessments, CAFCASS reports and spoke to the children’s IRO. It only partially upheld one of Ms X’s complaints, which was that the Council should have been clearer with her regarding the steps she may have been able to take to have her children returned to her care.
29. The stage two report made several recommendations, which the Council agreed to carry out, including:
• a written agreement to be signed by all parties regarding what was expected of Ms X during contact sessions with the children;
• that Ms X be provided with clarity regarding whether the Council has a long-term plan for her children to be returned to her and if so, what changes she would need to make and by when; and
• that contact arrangements be reviewed in line with the best interests of the children.
30. On 22 February 2022 Ms X asked the Council to escalate her complaint to stage three of the children’s statutory complaints procedure.
31. A few days after this, Ms X also raised a new stage one complaint. I begin to deal with this complaints process in more detail at paragraph 38. The Council began investigating her new complaint at stage one, while it escalated her other complaint to stage three.
32. On 1 April 2022, the Council carried out the stage three panel review of Ms X’s original complaint investigation.
33. By this time, events had moved on. The children’s foster care placement had once again broken down, the Council was due to begin a children and family assessment of Ms X and the children and her contact with the children had moved to being unsupervised.
34. The panel said it would not be appropriate to consider the issue of the foster placement as events surrounding this complaint had changed considerably since the stage two investigation and were ongoing. It said the investigation had been carried out properly and did not dispute the findings. However the panel made some recommendations in addition to those agreed to at stage two.
35. Of these recommendations, the Council accepted the following two:
• That the upcoming children and family assessment be sent to Ms X so she could check it for accuracy; and
• That the upcoming children and family assessment be clear about the Council’s expectations of Ms X.
36. However it only partially accepted the following two recommendations:
• That children’s social care services communicate primarily by email with Ms X as she finds it easier to communicate this way – the Council said it would try to do this but sometimes it would need to communicate with her by phone or in person.
• The stage three panel also wanted it to be “noted” that they were concerned about the lack of commitment shown by the children’s foster carers and recommended that the Council should offer the children and Ms X a high level of support in coping with the consequences of this lack of commitment – the Council said it did not feel there was sufficient evidence to form a clear view on this and this recommendation deviated from the stage two panel’s overall findings on this matter, but it said it would provide support to Ms X and the children.
37. The Council apologised to Ms X in its adjudication letter, which was sent on 14 April 2022. It said if she was still unhappy, she could complain to the Ombudsman.

Ms X’s second complaint

38. As already set out, Ms X began a fresh stage one complaint on 28 February 2022. This new complaint contained some of the same issues she had raised before that were ongoing and some new matters.
39. The Council responded at stage one of the complaints procedure on 21 March 2022. It upheld Ms X’s complaint that the foster placement was no longer suitable for her children. It did not respond to her other complaints.
40. On 26 May 2022, Ms X asked the Council to escalate her complaint to the stage two of the complaints procedure.
41. From the date Ms X requested to escalate her complaint to stage two, to the date the stage two investigation was completed, took the Council 24 weeks and 6 days.
42. The investigator had their initial meeting with Ms X six weeks after Ms X first requested her complaint to be investigated at stage two. During this meeting, the investigator offered to try and resolve the issues Ms X had raised informally and Ms X agreed to this initially.
43. However by 4 August 2022 Ms X said she was still unhappy with the service she was experiencing and said there were outstanding issues to be investigated. She asked for the stage two investigation to continue as previously planned. The investigator agreed a statement of complaint with Ms X on 24 August 2022.
44. The stage two investigation was completed by 16 November 2022. By this time, one of Ms X’s children that had been in foster care had now been returned to her care.
45. Ms X said several issues regarding her and her children’s experience of the Council’s children’s services department remained outstanding and she wished to be considered at stage two.
46. The stage two independent investigator interviewed several key professionals including the foster carers’ social worker, the children’s social worker, the children’s IRO and two managers within the fostering service, and also spoke with Ms X via email as this was her preferred form of contact. The investigator also reviewed the case files.
47. The investigator found in their stage two investigation, that most of the stage two and stage three recommendations from the previous investigation were not implemented within the agreed timescale and upheld this part of Ms X’s complaint.
48. The investigator agreed and upheld that her children’s foster carers had shown insufficient commitment to the children and their parenting style may not have been best suited to the needs of the children. They found this had a detrimental impact on the wellbeing of the children.
49. Regarding contact sessions, the investigator upheld that the Council had not carried out sufficient work to maintain family relationships.
50. The investigator partially upheld Ms X’s complaint that the Council’s communication with her had been poor and it had not used her preferred method of contact.
51. Regarding the complaint that key documents were not shared with Ms X, the investigator found that reports and assessments were not shared with Ms X in a timely manner. The Council gave reasons for this including that it had recently committed a data breach and there were now delays in sharing documents due to them going through additional checks. However the investigator still upheld Ms X’s complaint around document sharing.
52. Finally, regarding whether staff absence within the children’s services team had caused issues in dealing with Ms X’s case, the investigator upheld Ms X’s complaint.
53. At stage two, the investigator made seven recommendations to the Council as a way of remedying the complaints it had upheld:
• Children’s services should review how they monitor and respond to recommendations arising from complaint investigations;
• All officers working with Ms X should be reminded that email communication is her preferred option;
• Managers within children’s services should remind all social workers that they must record on their database when they have sent reports and assessments to parents and children;
• Its fostering service should review and consider whether they should be promoting a specific ‘parenting style’ that foster carers are expected to adopt;
• Children’s social care should review how they are promoting the rights of children cared for by the Council and how they record this information;
• The Council’s looked after children service should review where Ms X’s child - who had remained in local authority care - should reside; and
• The Council’s fostering service should review the values, knowledge base and skills of the foster carers involved in this case when considering any future placements.
54. The independent person agreed with the stage two investigation and said it had been carried out thoroughly and with attention to detail. The Council agreed in its adjudication letter of 23 November 2022 to carry out all the service improvements recommended at stage two.
55. On 24 November 2022, Ms X asked the Council to escalate her complaint to stage three of the statutory process. She said she could see that the stage two had been thoroughly investigated but did not feel that an apology was sufficient. She said her remaining child was on course to be returned to her care but at the time of writing there were still problems in the Council responding to her communications and sending her key documents.
56. The Council agreed and a review panel reported on the complaint at stage three on 4 January 2023. By this time, both of Ms X’s children that had been in foster care were now returned to her care.
57. The panel noted that the stage two investigation had upheld all complaints, apart from one which was partially upheld. It also noted that Ms X had raised no concerns regarding the stage two investigation itself.
58. The stage three panel therefore focussed on the Council’s implementation of the most recent stage two recommendations as well as the implementation of the recommendations at stage three in Ms X’s earlier complaint, which concluded in April 2022.
59. The panel found that some recommendations from the earlier complaint at stage three still had not been implemented. From the most recent stage two investigation, it found that all recommendations had been implemented except where events had overtaken the Council’s ability to do so, such as the review into Ms X’s children’s foster placement.
60. Ms X complained to the Ombudsman shortly after receiving the stage three panel’s report. She said the Council’s faults have caused her children to have significant behavioural issues and mental health problems which she is now managing at home. Ms X said her family should have been better supported.

My findings

61. The children’s statutory complaints procedure exists to provide children, young people and those acting on their behalf a way to receive a thorough, prompt and independent response to their concerns.
62. In this case, I am satisfied that both of the Council’s statutory complaint investigations were thorough, detailed and consulted a range of professionals and evidence. There is nothing further that an investigation by the Ombudsman could add to this and I am therefore not re-investigating the substantive matters here.
63. However I have found fault for some delay by the Council in carrying out the investigations and for its failure to implement some of the recommendations arising from Ms X’s initial complaint investigation. These are addressed below.

Delay

64. The Council carried out its investigations at most stages, in both complaints, in line with the statutory timescales. However at stage two of the process in both complaints the investigation took significantly longer than the timescales set out in the statutory guidance.
65. The Council did not address why it took so long to investigate Ms X’s complaint at stage two in her original complaint. However it did in her second complaint.
66. The delay was in part due to the independent investigator being on leave during the investigation period. It is acknowledged that the investigator still worked on the case while on leave.
67. During their initial meeting, the investigator offered to try and resolve the issue informally rather than escalating the complaint to stage two and Ms X agreed they could try. However the records show Ms X then changed her mind in August 2022 and said she still wanted the Council to consider her complaint at stage two.
68. Once Ms X refused the option of resolving the matter formally and raised the further request to escalate to stage two, the investigator conducted the investigation within 73 working days. This was a few days later than the statutory timeframe however I do not consider that this was fault, or caused Ms X a significant injustice.
69. The stage two investigations, when they concluded, were thorough and well investigated. However the delay in progressing the original stage two investigation was fault by the Council and caused Ms X avoidable frustration during an already difficult and distressing time.

Failure to implement recommendations

70. The Council failed to implement all the recommendations put forward in the initial statutory complaint investigation. This was fault.
71. This fault contributed to the reasons Ms X decided to raise another complaint with the Council. On the balance of probabilities, Ms X would have raised another complaint regardless as she was by then raising some new issues following a change in circumstances. Nevertheless, Ms X was put to some avoidable time and trouble due to the Council’s failure to implement the recommendations of the previous investigation.
72. The records show that she was also caused distress and uncertainty by this fault, as the recommendations related to how the Council should communicate with her and its commitment to send her key care planning and assessment documents regarding her and the children. Ms X required sight of these documents in order to have a clear understanding of the steps she could take in order to try and have her children returned to her care. The Council caused Ms X a significant injustice by failing to implement these recommendations in full.

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Agreed action

73. Within one month of the date of the final decision, the Council has agreed to:
1. Pay Ms X £300 as a symbolic payment to recognise the uncertainty and frustration caused by the faults in this case; and
2. Provide the Ombudsman with evidence that it has now implemented all recommendations put forward by its initial complaint investigation, except where the recommendations are no longer relevant.
74. Within three months of the date of the final decision, the Council has agreed to demonstrate that it has:
1. reminded its children’s services and complaint handling staff of the timeframes in the statutory guidance for carrying out investigations at each stage; and
2. improved its processes for monitoring compliance with remedies arising from children’s statutory complaint investigations.
75. The Council should provide us with evidence it has complied with the above actions.

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Final decision

76. I have completed my investigation. I have found fault leading to injustice and recommended a financial remedy and a service improvement.

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Investigator's decision on behalf of the Ombudsman