Summary: Miss X complains the Council did not safeguard Child Y, and for excluded her from the care process for Child Y. Miss X says this meant Child Y was unsafe at their residential placement, and that she was unaware of what was happening to them. We find fault with the Council for its complaint handling. We do not find fault with the Council for the other parts of the complaint. The Council has agreed to make an apology to Miss X for its complaint handling and review the mistakes that it made during the complaints process.

The complaint

1. Miss X complains the Council has failed to:

• safeguard Child Y while they were not in her care,
• ensure the social worker is working appropriately with Child Y,
• ensure Child Y’s placement safeguarded them,
• keep her updated about Child Y’s care,
• properly consider her complaint,
• carry out the recommendations from the complaints process, and
• consider her requests for reasonable adjustments.

2. Miss X also complains the Council wrongly removed Child Y from her care and lied to professionals and judges about her and Child Y.

Back to top

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 investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
5. 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)
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.

Back to top

What I have and have not investigated

7. Parts of Miss X’s complaint is about the Council’s decision to remove her son from her care and the information that the Council gave in court. I will not be investigating this part of the complaint as we cannot investigate complaints about things that have happened in court.
8. Part of Miss X’s complaint is about issues that have taken place since her complaint. Miss X says the placement continues to not safeguard her child. Miss X has not complained about these issues through the Council’s complaints process.
9. The statutory children’s complaints procedure was set up to provide children, young people and those involved in their welfare with access to an independent, thorough and prompt response to their concerns. Because of this, we expect people to complete the complaints procedure before we will consider whether there were any flaws in how the Council investigated their concerns. I have therefore not investigated Miss X’s new concerns about how the residential placement has not safeguarded Child Y since the Council finished the complaints process.

Back to top

How I considered this complaint

10. I considered:

• Miss X’s complaint to the Council and information she provided,
• information from the Council,
• legal documents that were in place for Child Y, and
• interviews I carried out with Council and third-party officers acting for the Council.

11. I considered comments from Miss X and the Council on a draft of my decision.

Back to top

What I found

Legislation and guidance

Statutory complaints procedures

The three-stage process

12. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. The accompanying statutory guidance, ‘Getting the Best from Complaints’, explains councils’ responsibilities in more detail. We also published practitioner guidance on the procedures, setting out our expectations.
13. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
14. If a complainant is not happy with a council’s stage one response, they can ask that it is considered at stage two. At this stage of the procedure, councils appoint an investigating officer (IO) to investigate the complaint and an independent person (IP) who is responsible for overseeing the investigation and ensuring its independence.
15. Following the investigation, a senior manager (the adjudicating officer) at the council should carry out an adjudication. The officer considers the IO report and any report from the IP. They decide what the council’s response to the complaint will be, including what action it will take. The adjudicating officer should then write to the complainant with a copy of the investigation report, any report from the independent person and the adjudication response.
16. The whole stage two process should be completed within 25 working days but guidance allows an extension for up to 65 working days where required.
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. 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.

No reinvestigation if process complete and not flawed

18. The statutory children’s complaints procedure was set up to provide children, young people and those involved in their welfare with access to an independent, thorough and prompt response to their concerns. Because of this, if a council has investigated something under the statutory children’s complaint process, the Ombudsman would not normally re-investigate it.
19. However, we may look at whether there were any flaws in the stage two investigation or stage three review panel that could call the findings into question. We may also consider whether a council properly considered the findings and recommendations of the independent investigation and review panel, and whether it has completed any recommendations without delay.

What happened

20. Miss X has a child, Child Y, whom the Council placed in foster care. In August 2022, Child Y was placed in a new residential foster placement.

Stage one

21. Miss X complained to the Council in July 2022. In her complaint she said

• the social worker prevented Child Y’s family from attending meetings and speaking with them on the phone,
• the social worker threatened Child Y with a secure placement,
• the social worker did not let Child Y speak to the legal team or police,
• the Council let Child Y see their birth certificate without Miss X’s permission,
• the Council were not communicating with her about the new placement.
• the Council did not invite Miss X to the core group meetings,
• the social worker spoke inappropriately about Miss X,
• the Council have not safeguarded Child Y,
• the foster placement threw away Child Y’s items,
• the foster placement restrained Child Y,
• the foster placement ignores Child Y’s privacy,
• Child Y is always supervised when with family, and
• the foster placement staff allow inappropriate behaviour.

22. Miss X told the Council she would like it to increase family time and clothing allowance. She also wanted the Council to reinstate Child Y’s counselling and return him to her care. She asked the Council to provide Child Y with an advocate and a new social worker.
23. The Council considered Miss X’s complaint through its statutory complaints process. The Council sent Miss X its stage one response in August 2022. The Council agreed that it had not satisfactorily communicated with Miss X about the new placement and that the social worker had spoken about Miss X inappropriately. It did not uphold the rest of Miss X’s complaint.
24. The Council said it would need to see further stability from Miss X, as well as behavioural changes in both Miss X and Child Y before it could consider varying the contact arrangements. It said the social worker would discuss the counselling and clothing allowance with Child Y, and that a legal advocate would be appointed for Child Y if further court proceedings took place.

Stage two

25. Miss X was unhappy with the Council’s response and asked to escalate her complaint to stage two in August 2022.
26. The Council appointed an Investigating Officer (IO) and an Independent Person (IP) for the stage two investigation. The IO discussed the complaint with Miss X in September 2022 and sent Miss X a summary of her complaint to agree in October 2022.
27. The IO report was finished in December. The report agreed the social worker had spoken about Miss X inappropriately. It did not agree with Miss X’s other complaints.
28. The IP report was finished in December 2022. The IP had a slightly different view from the IO and felt the decision about sharing placement updates with Miss X should be changed to partially upheld. They said while the Council did share information, Miss X did not get the weekly updates which were previously agreed at the start of the placement.
29. The IP agreed with the rest of the IO report and recommendations.
30. The Council sent its adjudication of the stage 2 to Miss X in December 2022. In the letter, the Council told Miss X it agreed with the IP’s report. It recognised the IO had a differing view about the complaint for sharing placement updates and accepted it had taken three weeks to set up with the updates, but said the weekly updates were now in place.
31. In its letter, the Council also agreed to the recommendations from the IP report.

Stage three

32. Miss X contacted the Council in January 2023 to say she remained dissatisfied. The Councils complaints manager offered to arrange a home visit to discuss the issues in the complaint. Miss X agreed and the Council visited Miss X to discuss her complaint in February 2023.
33. The Council held its stage three review panel in April 2023.
34. The stage three review panel changed the outcome on several parts of Miss X’s complaint. It changed five points of complaint from not upheld to unable to make a finding. It also changed three points of complaint from not upheld to upheld or not upheld. It agreed with the stage two on not upholding four points of complaint.
35. The panel felt fair conclusions were not always met as there was not enough evidence sought at stage two. It felt there was a lack of detail about processes, procedure and statutory duties. The panel felt the conclusions of the IO were not always logical and there was a lack of evidence from external parties. It highlighted the stage two relied heavily on the views of the social worker and social worker’s manager and had not interviewed other parties that could have provided more information.
36. The panel recommended:

• the Council write an apology letter to Miss X about an incident where the social worker used inappropriate language,
• provide an update to Miss X about how it has sought Child Y’s views in meetings and how they will be supported,
• explore the safeguarding allegations from Miss X about the placement restraining Child Y,
• discuss the concerns raised by the review panel about the reports provided by the IO and IP,
• consider any concerns about lost property through the complaints process, and
• remind staff that care meetings should be held in accordance with statutory timeframes.

37. In its final response to Miss X, the Council said it rejected most of the findings from the stage three panel, and that it agreed with the findings of the stage two investigation. The Council did not agree to the recommendations from the stage three review panel.
38. Miss X remained unhappy with the Councils response and complained to the Ombudsman.

Analysis

39. As previously explained in paragraphs 17 and 18, the Ombudsman does not normally reinvestigate the complaint but instead will review if the process was carried out without flaws.
40. However, in this case, the stage three identified significant flaws in the stage two, and as a result several parts of Miss X’s complaint did not have a finding. The Council then rejected most of the stage three’s findings.
41. There was fault by the Council in its stage two investigation of Miss X’s complaint. I agree with the stage three review panel that the stage two investigation was heavily weighted towards the views of the social worker and social worker’s manager.
42. As a result, the stage three review panel could not reach firm conclusions on most of the complaint. The panel recommended the Council get evidence and information that would give answers to Miss X about these parts of the complaint. The stage three findings were clear and well supported in their views and recommendations. The Council’s decision to reject the review panel’s findings is without clear rationale.
43. As the stage two investigation was not without flaws, I consider it proportionate to reinvestigate the parts of Miss X’s complaint where the stage three could not reach a view. I will not reinvestigate the parts of the complaint which the Stage Three panel drew conclusions on. This is because I am satisfied the Stage three was carried out without flaws and has already decided on these points.
44. As part of my investigation, I interviewed the Independent Reviewing Officer (IRO) for Child Y, Child Y’s advocate, and the manager of their residential placement.

The Council did not allow Child Y’s family to be present during calls or meetings, and prevented him from having access to advocacy

45. Part of Miss X’s complaint is the Council prevented Child Y’s family to be present during calls or meetings.
46. In my interviews I asked all professionals interviewed if they had ever had concerns about this element of the complaint.
47. All professionals felt strongly there were limits in place for whether Child Y’s family were present in meetings and calls, and this was to safeguard Child Y. This was based on evidence and behaviour from previous calls and meetings. As a result, the Council offered an advocate to support him, and all were certain Child Y had shown they could express when and where they would like the advocate present.
48. The IRO felt they had a longstanding relationship with Child Y as they had been involved from the start of their care. They felt the reviews over the years showed that Child Y felt able to express their thoughts and feelings in meetings where their care and wellbeing were discussed. The IRO had split the care review meetings so Miss X and Child Y were never part of the same meeting. They did this to ensure Child Y had the space to voice their own views without influence from family.
49. The advocate for Child Y also commented that he and Child Y had regularly discussed how and when Child Y would like to be supported. Child Y was confident enough in the relationship to say when they would like to be supported in meetings and had remained in contact with them throughout their time in care.
50. It was acknowledged by all professionals that occasionally Child Y did not always wait for their advocacy to be available before having discussions with their social worker and placement manager. This happened when there had been serious incidents with their behaviour that needed immediately addressing, or when they wanted an answer to a question.
51. The complaints process agreed when Child Y did not wait for their advocacy, the reason why should have been recorded. I am satisfied this recommendation suitable recommendation, and I have not seen evidence of further fault by the Council for this part of Miss X’s complaint.

Child Y was prevented from being able to contact legal support and the Police

52. I reviewed the Deprivation of Liberty Safeguards (DOLS) in place for Child Y. This is a legal document ordered by the court. This said the Council should restrict Child Y’s phone use to safeguard them. There was also a period where the police had their phone.
53. All professionals interviewed explained that while Child Y’s personal phone may have been restricted from them, they always had access to an office phone at the residential placement. Child Y had never said to any of them they were kept from contacting the police.
54. There were no case notes from the residential placement that showed Child Y had ever asked to call the police or use the office phone to contact emergency services.
55. There was an occasion when Child Y asked to speak to their court appointed representative, but the Council could not arrange this, as the court case had closed, and the worker was no longer assigned to the case. The Council explained this to Child Y.
56. I am satisfied there is no evidence of fault by the Council for this part of the complaint.

Child Y’s residential placement did not safeguard them

57. As part of my investigation, I reviewed the daily records from the placement where Child Y was living at the time of the complaint.
58. I also asked all three interviewees separately if they had any awareness of the placement not safeguarding Child Y. I did not identify any records which highlighted the placement posed a safeguarding risk to Child Y.
59. Both the independent reviewing officer and Child Y’s advocate told me they had no reason to believe Child Y was not safeguarded during their placement. Child Y had never said to them they felt unsafe.
60. The placement manager said there had been incidents, which he had investigated. However, most of these incidents took place after the complaints process with the Council, and the information would not have been available for the Council to consider at the time of the complaint.
61. I am satisfied there was no evidence of fault by the Council for this part of the complaint.

Staff in the residential placement restrained Child Y

62. Part of Miss X’s complaint is that staff in the placement restrained Child Y. Child Y’s DOLS does allow for restraint to be used to safeguard him.
63. I have reviewed the daily records from the placement, including the days where higher risks and incidents occurred. The records show there were occasions where the Police, not residential home staff restrained Child Y.
64. I also spoke with the placement manager who confirmed it was against their policy to use restraint on Child Y, and no staff had ever done so.
65. I am satisfied there is no evidence of fault by the Council for this part of the complaint.

The Council threatened Child Y with a secure unit

66. Part of Miss X’s complaint is the Council used secure units as a threat to Child Y to manage their behaviour.
67. Child Y’s advocate and the placement manager said they were aware of conversations between the Council and Child Y where secure units were discussed. This was to be clear with Child Y if the current placement did not work out because of Child Y’s behaviour, the Council would have to consider alternatives, which may include secure units.
68. I am satisfied the Council had to have these discussions with Child Y to be transparent with him. It may be that Child Y felt threatened by this, but I find no fault by the Council for this part of the complaint.

Reasonable adjustments

69. Part of Miss X’s complaint to the Ombudsman was the Council had failed to properly consider her request for reasonable adjustments during the complaint process. As part of my investigation, I asked the Council to show how it had considered Miss X’s request for reasonable adjustments.
70. The Council said the Customer Feedback Manager and Head of Service in Social Care visited Miss X at her home address to discuss her Stage 2 complaint and how it may be able to resolve the issues. Miss X requested the home visit and that it take place in the afternoon as part of her request for reasonable adjustments, these were both granted.
71. The Council also said Miss X was supported with her request to have another person to support her on Microsoft Teams during the Stage 3 Panel Meeting in April 2023.
72. All letters and emails to Miss X from the service team have used clear, jargon free language and the team has also considered Ms X’s needs when preparing emails.
73. There is some evidence of the Council using coloured paper to communicate with Miss X, as directed by the stage three panel. However, it is unclear whether Miss X requested this reasonable adjustment from the Council before this, and so I cannot say whether the Council should have considered this reasonable adjustment sooner.
74. I am satisfied I have seen no evidence the Council did not consider Miss X’s requests for reasonable adjustments during the complaints process.

Conclusion

75. I find fault with the Council for how it considered the findings of the review panel.
76. However, if the Council had carried out the recommendations from the review panel, it is likely that it would have reached the view there was not enough evidence to uphold the remaining parts of Miss X’s complaint. I am satisfied that if the Council had properly considered the recommendations, it would not have changed the overall outcomes of the complaint.

Stage 3 recommendations already carried out

77. The Council has shown it reminded staff that care meetings should be held within statutory timeframes.
78. Child Y was supported by their advocate and offered the opportunity report lost belongings and their concerns through the complaint process.
79. The Ombudsman’s investigation has resolved some of the outstanding recommendations to provide further information to Mrs X about her safeguarding and advocacy concerns.

Back to top

Agreed action

80. Within four weeks the Council has agreed to

• apologise to Miss X for failing to properly consider the recommendations from the stage three review panel.
• carry out the stage three recommendation which said “discuss the concerns raised by the review panel about the reports provided by the IO and IP”.

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

Back to top

Final decision

82. I have completed my investigation. I find fault with the Council for its complaint handling process. I do not find fault with the Council for the other elements of Miss X’s complaint.

Investigator’s final decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman