Norfolk County Council (21 010 937)

Category : Children's care services > Other

Decision : Upheld

Decision date : 11 Aug 2022

The Ombudsman's final decision:

Summary: The Council was at fault for unfairly alleging that Ms X prevented staff members from leaving her home during a visit, and for requiring that she sign a ‘safety plan’ which implied the same. It has agreed to correct its records, apologise to Ms X and make a small, symbolic payment to recognise her injustice.

The complaint

  1. The complainant, whom I refer to as Ms X, complains about an incident which took place in the family home she shares with her partner, Mr Y, and her son, Z.
  2. In mid-2021 Z was receiving education at home as, for medical reasons, he was unable to attend school. Ms X complains that:
    • A failure of supervision by the members of staff running the educational session led to Z running off down the street. This incident caused severe distress to Ms X and Z, both of whom are autistic.
    • Following Z’s escape (and subsequent return) the members of staff failed to recognise that Ms X was in distress. They ignored Ms X’s request for privacy and failed to give her the time and space to recover, thus making the situation worse. This, in Ms X’s view, amounted to disability discrimination.
    • The Council subsequently arranged a meeting to discuss the incident at Ms X’s home, but only gave her 40 minutes’ notice, so she could not attend. It held the meeting instead with Mr Y, who had not been present during the incident.
    • The Council then insisted that Ms X sign a ‘safety plan’ and refused to provide therapy to Z until she signed it. The wording of the plan strongly implied that she had refused to let the members of staff leave her home, which, she says, is untrue. She believes the plan also amounts to disability discrimination.
    • The Council failed to properly investigate Ms X’s complaint. In its complaint response, it reiterated that Ms X had locked the members of staff in her home and told them they could not leave. She says that this, again, is untrue.
    • The Council refused to agree Ms X’s request for a new social worker, despite clear evidence that Z’s existing social worker had been discriminatory.

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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. 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)
  2. 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)
  3. 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

  1. I considered information from Ms X and the Council. Both 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

The incident

  1. In July 2021 a tutor from Z’s school visited his home to deliver an educational session. She was assisted by a social care worker from the Council. Ms X and Z were present.
  2. During the session Z ran out of the room and did not return. He was then seen running past the living room window (on the outside). The members of staff saw that the front door was open, with the keys in the lock.
  3. The members of staff and Ms X went to look for Z. Ms X found him at a nearby supermarket and brought him home. On the way into the house Ms X told the members of staff that it was their fault Z had escaped.
  4. The conversation continued inside the house. The social care worker told Ms X that it was, in fact, Ms X’s responsibility that Z had escaped. She suggested that Z opened the door because Ms X had left the keys in it.
  5. Ms X asked the staff members to leave, which they agreed to. But then she changed her mind. She locked the front door, removed the keys, and said she now wanted the members of staff to finish their session. She walked away with the keys.
  6. At this point, Z’s behaviour became challenging towards the members of staff and he began hitting and kicking them. They went into the kitchen to find Ms X, who was holding a knife. Ms X had been cutting bread for sandwiches and was not holding the knife in a threatening or aggressive way. Nonetheless, the members of staff reported that they felt intimidated.
  7. The social care worker told Ms X that she was ending the visit because Z was too distressed to continue. She asked Ms X to unlock to front door and let them leave. Ms X did so, and they left the house.

The aftermath

  1. The following day, the Council called Mr Y and arranged a visit to discuss what had happened. This visit took place the day after.
  2. Ms X was not present, but the Council spoke to Mr Y about the incident and said a ‘safety plan’ should be put in place for future visits.
  3. The Council sent the plan to Ms X and Mr Y for comments in early August. Among other things, the plan included the following provisions:
    • Staff members must know where the front door key is before and during any visit.
    • Neither parent should prevent a member of staff leaving the home.
  4. Mr Y told the Council he was unhappy with the part of the safety plan which said he and Ms X should not prevent staff members from leaving. He said it was ‘ludicrous’ to imply they would do this. However, the Council told him the plan “does not interpret that you have held anyone captive, it only prescribes what must not happen”.
  5. Mr Y remained unhappy with the safety plan, and asked the Council to reword it so as not to imply anyone had been held captive. The Council refused. The social care team manager, when later justifying the decision, noted:

On the 20th of July 2021, [Ms X] kept the house key in her pocket and refused to allow workers to leave when the home situation was not safe and she insisted they stay one more hour. This presented a safety issue and we need to ensure that it never happens again through an agreement to a safety plan.

  1. The Council also told Ms X that Z would not receive occupational therapy until the plan had been signed. The team manager recorded that he was “not prepared to send a worker out to a home where they cannot be sure whether they can get out or not in an emergency”.
  2. Ms X and Mr Y refused to sign the plan, and no further support was delivered to Z. The Council tried several times to meet with them to discuss their objections, but they refused. At the end of September, they withdrew their consent for the Council to work with Z, and the case was closed.

Ms X’s complaints

  1. Ms X submitted two complaints to the Council.
  2. The first, in July 2021, was about Z’s escape during the educational session (for which she blamed the Council). She did not mention that she felt she had been treated unfairly because of her disability.
  3. The Council did not uphold this complaint, saying Z was Ms X’s responsibility while he was in the family home.
  4. Ms X’s second complaint, in September, was about the safety plan. She said the plan was “unreasonable, offensive, discriminatory (see Equality Act 2010)”. However, she did not clarify how she felt the plan amounted to discrimination and did not explain why she thought she had been treated unfairly because of her disability.
  5. The Council, again, did not uphold Ms X’s complaint. The Director of Children's Services, who responded to Ms X, said, “I understand the Safety Plan was put in place following an incident where you locked two members of staff in your house and told them they had to stay”.
  6. Ms X remained dissatisfied and approached the Ombudsman.

Further relevant information

  1. The Council conducted a further assessment of Z’s needs in May 2022. The assessment document says:

[Ms X] briefly ended our work with the family … when she refused to sign a safety plan for professionals to work with the family at home following an incident at home which compromised professionals safety and violated health and safety regulations because the workers could not leave the home when faced with risk of harm.

My findings

  1. The records I have seen, including Ms X’s complaints, suggest that the incident in question was clearly very stressful for everyone present. I have no reason to doubt the three accounts given by Ms X and the two members of staff, which are all largely consistent about what happened.
  2. The Ombudsman is an administrative review body which makes decisions drawn from documentary evidence. When the documents provide enough information for me to make a decision on the balance of probabilities, I will do so. But I cannot do this for everything Ms X has complained about. The final section of this decision statement sets out matters I did not investigate.
  3. There is also an aspect of Ms X’s complaint which warrants little further consideration: namely, that the Council only gave her 40 minutes’ warning of a meeting, which meant she could not get out of work.
  4. The Council’s records show clearly that the Council arranged the meeting with
    Mr Y the day before. Whatever the reason for Ms X’s non-attendance, the Council gave the family reasonable notice and therefore was not at fault.
  5. I have set out my findings for the remaining parts of Ms X’s complaint, in turn, below.

The safety plan

  1. Although the Council has claimed otherwise, the wording of the safety plan clearly implies that its staff were prevented from leaving Ms X’s home. If this were not the case, the plan would not be necessary. Z’s social care notes confirm that this was the Council’s view.
  2. Although there are, understandably, some small differences between the accounts of those who were there on the day, I am satisfied that the following things happened:
    • The Council’s social care worker told Ms X that she should not leave the door unlocked or leave the keys in the door.
    • Ms X then locked the door and removed the keys.
    • Ms X asked the members of staff to leave – to which they agreed – but then changed her mind and told them she wanted them to stay and finish their session. At that point, they had not actually asked to leave or told her they felt unsafe in the house.
    • When they asked to leave, Ms X unlocked the front door and let them out.
  3. This means the Council’s view, as either implied or specifically stated in its safety plan, case records and complaint response – that Ms X prevented members of staff from leaving her home – is not supported by the accounts of those who were there on the day, including a member of the Council’s own staff.
  4. The Council also failed to acknowledge that Ms X locked the front door and removed the key immediately after direct criticism of her, by a member of the Council’s staff, for having previously not done so.
  5. Because of this, I consider the wording of the safety plan – and, consequently, the Council’s insistence that no social care provision would be delivered until Ms X signed it – to be fault. This extends to the wording of the Council’s second complaint response and any other case records which refer to Ms X refusing to allow staff members to leave her home.
  6. It feels particularly unnecessary that this complaint has reached the Ombudsman without prior resolution given that the safety plan already contained a point – uncontested by Ms X – that staff members must know where the front door key is before and during any visit. This would mean they could access the key and leave the house at any time, without the need for any separate agreement that Ms X would allow them to leave.
  7. However, I cannot change what has already happened. The question now is what should happen next.
  8. Ms X has confirmed that she does not want any continued social work involvement with Y, so it would not be proportionate to recommend that the Council review either the safety plan or its social work provision. But, as the Council’s recent records continue to imply that Ms X prevented staff leaving her home, it is likely that this is still affecting her.
  9. I am also confident, from speaking to Ms X and reviewing what she has sent me, that this matter caused her distress – as it would anyone who felt they had been unfairly accused of something this serious.
  10. The Council should take action to remedy Ms X’s injustice.
  11. I have also considered whether Z was also caused an injustice, as – without Ms X signing the safety plan – he did not receive the occupational therapy the Council was due to deliver.
  12. Although I can understand Ms X’s reluctance to sign the agreement, the decision to refuse to meet with the Council to overcome the dispute and, subsequently, to withdraw from the Council’s support services completely, was hers.
  13. So, although the Council was at fault, there was enough parental involvement in the decision to refuse support that I do not consider it appropriate to recommend that the Council provide a retrospective remedy to Z.


  1. Ms X believes that the Council has been discriminatory in both how it has provided a service (the behaviour of a member of its staff during a home visit) and in its denial of a service (the refusal to allow staff to visit until Ms X signed the safety plan).
  2. The Ombudsman has no power make a ruling on whether a council has breached the Equality Act 2010, so I will not comment on whether the Council’s actions amounted to disability discrimination.
  3. However, I have considered whether, when Ms X complained both about staff behaviour and about the safety plan, the Council properly considered if it had met its duties under the Act.
  4. Having reviewed Ms X’s complaints to the Council, I am not satisfied that they clearly set out her belief that she had been treated differently because of her disability. They certainly do not explain why she felt that was the case. Because of this, the Council was not at fault for explaining its actions without reference to its duties under the Equality Act.

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Agreed actions

  1. Within four weeks of this decision, the Council has agreed to:
    • write a note on Z’s social care file, flagged for prominence, which summarises the findings in this decision statement and sets out the remedial actions the Council is taking.
    • write a letter of apology to Ms X for alleging on a number of occasions, without supporting evidence, that she prevented staff members from leaving her home.
  2. Within six weeks of this decision, the Council has agreed to make a payment of £300 to Ms X to recognise her avoidable distress and the time and trouble she went to in pursuing this matter.

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Final decision

  1. The Council was at fault for unfairly alleging that Ms X prevented staff members from leaving her home during a visit, and for requiring that she sign a safety plan which implied the same. The agreed actions remedy Ms X’s injustice.

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Parts of the complaint that I did not investigate

  1. I cannot make a finding on Ms X’s complaint that the Council was at fault for allowing Z to escape from the family home. The Council disagrees, and there is no evidence which tells me decisively who should have been held responsible.
  2. I also did not consider Ms X’s complaint about not being allowed a new social worker. It is not for me to tell the Council how it must allocate staff resources.

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Investigator's decision on behalf of the Ombudsman

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