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Salford City Council (20 007 305)

Category : Children's care services > Other

Decision : Not upheld

Decision date : 19 Jul 2021

The Ombudsman's final decision:

Summary: Mrs B complained that the care provider acting on behalf the Council failed to properly supervise a child in its care while at an indoor play area. As a result, he bit her grandchild causing injury and distress. The Ombudsman finds no fault on the Council’s part.

The complaint

  1. Mrs B complains that the care provider acting on behalf of the Council failed to properly supervise a child in their care as a result of which he bit her grandchild causing physical injury and distress. In addition, the Council declined to investigate Mrs B’s complaint.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. 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)

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How I considered this complaint

  1. I have spoken to Mrs B and considered all the information she provided including the care provider’s response to her complaint. I have also made enquiries of the Council and considered its comments and the documents it provided.
  2. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What happened

  1. Mrs B was with her daughter, Ms C, and her young grandchildren at an indoor play centre. Whilst playing, her granddaughter was approached by another child, Child X, who bit her causing puncture wounds to her face and bruising around her chin and neck.
  2. Child X was being supported by two support workers from Crossroads Together (‘the care provider’) which was commissioned by the Council to provide the support. Mrs B says the support workers were not supervising Child X closely enough and, if they had been, the incident would not have happened. She says Ms C was first on the scene and pulled Child X off her granddaughter. Mrs B then came to her daughter’s aid followed by one of the support workers. The other support worker was standing by the door at the far end of the room. Mrs B says that, in addition to the physical injury suffered by her granddaughter, the incident was extremely distressing for her and the family.
  3. Mrs B complained to the care provider which completed an investigation. It upheld Mrs B’s complaint that Child X had bitten her granddaughter. The care provider was satisfied the support workers were correctly positioned and were following Child X’s support plan and risk assessment which required one worker to support him and the other to ensure all exits were covered in case he ran to the door. It did not uphold Mrs B’s complaint that Ms C got to her child’s aid before the support workers because there were conflicting reports about this: the support workers said a support worker arrived first and play centre staff said Mrs B arrived first.
  4. The care provider concluded the incident could not have been predicted and said Child X had never done anything like this before while in their care. It apologised for the distress caused and confirmed that, in future, Child X would only attend disability/autism friendly sessions where all children are fully supported to ensure members of the public were not at risk. It also confirmed it had shared the information from its investigation with the Care Quality Commission (CQC) and the Council. It reviewed Child X’s support plan and risk assessment and arranged training for staff on how to respond to such an incident.
  5. Mrs B was dissatisfied with the care provider’s response and complained to the Council. The council declined to investigate the complaint further. So, Mrs B complained to the Ombudsman.



  1. Child X has significant behavioural needs. He has a care and support plan which was updated a few months before the incident. The plan stated, “I need 2:1 support in the community to prevent me running off or hurting myself”. The purpose of the support was therefore to keep Child X safe and prevent the risk of him running away.
  2. The plan stated that Child X had been known to bite support workers and school staff. He also had a behavioural risk assessment in place which stated that staff should be aware he may try to bite them. The risk of biting was assessed to be low.
  3. The Council says it is satisfied appropriate safety measures were in place. Child X was supported to access the play centre by two support workers in accordance with the safety plan. It says the assessment at that time was that this was an effective strategy to manage the risks when Child X was being supported to engage in community-based play with his peers.
  4. Mrs B says Child X should not have been attending a busy play centre. However, I find no grounds to criticise the fact that he was taken to the centre. Crossroads Together had been supporting him for some time and it is documented that he had visited this and other play centres many times previously without incident. Although Child X had bitten support workers, this was being managed by the 2:1 support and neither the Council nor the care provider were aware of him having bitten any children.
  5. There is nothing to suggest the support plan was inadequate. It was up-to-date and the risk of biting was documented. I am satisfied the support workers were following the care plan in that one of them was supporting Child X and the other was positioned by the door to prevent the risk of him running away. I cannot reach a view on whether the support worker was monitoring Child X as closely she should have been because there is conflicting evidence about where she was and who got to the child first. Mrs B, the play centre manager and staff, customers and the support workers all have different versions of events. There is no CCTV footage. In these circumstances, I cannot reach a view on exactly what happened.
  6. In conclusion, I find no grounds to criticise the Council as I am satisfied the incident could not have been predicted. The care provider acting on behalf the Council had properly assessed the risks and put in place an appropriate support plan.

Mrs B’s complaint

  1. The Council says it did not investigate Mrs B’s complaint under its own complaint procedures because Council managers were satisfied the care provider had completed a full investigation and responded appropriately.
  2. I agree the care provider completed a thorough investigation. The complaints manager spoke to Mrs B, the police, Child X’s school and his mother and took statements from the two support workers. She also spoke to the play centre manager and requested CCTV footage. The centre manager took statements from staff members and customers and passed this information to the care provider.
  3. The care provider reported the incident to CQC and made a safeguarding referral. It completed various actions following the investigation including apologising to Mrs B for the distress caused, reviewing Child X’s support plan and risk assessment and providing additional training to staff.
  4. In these circumstances, there are no grounds to criticise the Council for deciding not to investigate the complaint further as there is little more it could have achieved.

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Final decision

  1. I do not uphold Mrs B’s complaint.
  2. I have completed my investigation on the basis I am satisfied with the Council’s actions.

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Investigator's decision on behalf of the Ombudsman

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