Summary: Miss Y complains about the Council’s failure to ensure her disabled child, B, received the care and support they needed when living at home. She also complained about the Council’s failure to commission the agreed respite she needed due to carer exhaustion. We find the Council failed to properly deal with Miss Y’s statutory children’s complaint. We have investigated and found fault causing injustice in some parts of Miss Y’s complaint which the Council has agreed to apologise for and make a payment of £1000.

The complaint

1. Miss Y complains the Council’s failures resulted in her child, B, moving into residential care. She said the Council failed to:
• maintain consistent and timely communication with her about B’s case;
• take appropriate action at her home to ensure B’s safety;
• develop a plan to appropriately care and support B at home;
• respond to the concerns she raised about B’s carers being unregistered and inappropriately restraining B; and
• follow its complaints policy, as it took too long to respond and did not fully investigate relevant reports during its stage two review.
2. Miss Y says the fault has caused avoidable distress to both her and B over the past two years, significantly affecting their well-being. She seeks accountability from the Council and essential home adaptations to enable B to safely return home for breaks from residential care.

Back to top

The Ombudsman’s role and powers

3. 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 has done. (Local Government Act 1974, sections 26B and 34D, as amended)
4. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by an organisation to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
6. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).
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)

Back to top

What I have and have not investigated

8. I have exercised discretion to investigate matters from October 2022 when Miss Y and the Council first raised the need for respite provision. This is because some of the concerns were ongoing, and Miss Y was prevented from approaching us sooner due to delay in the Council’s complaint handling. The scope of our investigation ends in January 2025 when Miss Y approached the LGSCO.

Back to top

How I considered this complaint

9. I considered evidence provided by Miss Y and the Council as well as relevant law, policy and guidance.
10. Miss Y and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Complaints under the statutory procedure

11. Section 26(3) of the Children Act (1989) says all functions of the Council under Part 3 of the Act may form the subject of a complaint under the statutory complaints procedure. The statutory guidance explains the process in more detail: (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).
12. Complaint investigations under the statutory procedure consist of three stages.
• Stage 1: Staff within the service area complained about try to resolve the complaint.
• Stage 2: An Investigating Officer (IO) and an Independent Person (IP) investigate the complaint. The IO writes a report with their findings, conclusions and outcomes against each point of complaint and any recommendations to remedy injustice. The regulations say the IO must be independent. They may be an employee of the Council but should have not been involved with the subject matter of the complaint. To ensure impartiality, the process is overseen by the IP, who is neither an elected member nor an employee.
• Once the IO has finished the report, a senior manager acts as adjudicating officer (AO). They will consider the complaints, the IO’s findings, conclusions, and recommendations, as well as any report from the IP, and the desired outcomes. The AO should write to the complainant with their decision on each complaint
• Stage 3: A review panel considers the complaint. The panel must consist of three independent people. Following the panel, the members write a report containing a summary of the representations and their recommendations for resolution of the issues.
• The council must send its response to the panel’s recommendations to the complainant within 15 days of receiving the report. The response should set out how the council will respond to the recommendations and what action it will take. If the council deviates from the panel’s recommendations it should explain its reasoning in the response.
13. The statutory children’s complaints procedure provides children, young people and those involved in their welfare with access to an independent, thorough and prompt response to their concerns. Because of this, the Ombudsman would not normally re-investigate complaints if a council has already investigated under the statutory children’s complaint process.
14. 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.

Handling of Miss Y’s complaint

15. In this case, the Council has already accepted that it failed to follow the published timescales for the statutory complaints procedure. Miss Y escalated her complaint to the second stage of the statutory complaints procedure in March 2024. The Council appointed an IO and IP. The stage two report was finalised on 22 October 2024. This amounts to six months of delay.
16. The delay caused avoidable time and trouble which the Council has already proposed to remedy with a symbolic payment of £500. This is a suitable remedy for the injustice caused by the fault in this part of Miss Y’s complaint.
17. However, we find there is more fault in the handling of Miss Y’s complaint for the following reasons:
• The letter sent to Miss Y at Stage One of the complaints process wrongly signposted her to LGSCO, rather than to the second stage of the process.
• The Stage Two investigation focussed too narrowly on individual events rather than the overarching issues raised by Miss Y. This created dissatisfaction because Miss Y felt the IO had not got to the heart of the issues.
• The IO and IP were not present at the Stage Three panel meeting. The statutory guidance says: “those persons involved with the investigation at Stage 2 (e.g. the Investigating Officer, and the Independent Person) should be invited to attend and contribute as relevant to their roles. Should any of these persons’ unavailability cause an inordinate delay in holding the Panel; the Chair should take a view on proceeding without them”. The Chair of the panel did not properly consider the impact caused by the IO and IP’s absence. While re-arranging the meeting to an agreed date would have created further delay, it would have likely led to a more meaningful discussion for all parties during which panel members could have questioned the IO about their findings.
• The Stage Three panel found the IO failed to consult external third parties and seek interviews with ex staff members.
• Although Miss Y declined the panel’s suggestion to have her complaint re-investigated at Stage Two, and instead opted to escalate to the LGSCO, it should be acknowledged that it is not the Ombudsman’s role to reinvestigate a complaint on behalf of the Council. It is the Council’s responsibility to ensure the statutory complaints procedure is properly completed.
• The final adjudication letter wrongly stated the Stage Three Panel: “were unable to reach any conclusions that differed from the Stage Two report”. This is incorrect; whilst a panel will not reinvestigate the substantive complaints, it can make additional or alternative recommendations or confirm their support of the recommendations already made.
18. Due to the fault in the handling of Miss Y’s complaint, I have reviewed the relevant contemporaneous files to impartially decide whether there is additional fault causing injustice which the Council should remedy. I will set out my findings in the below sections.

Care and support for B

19. Miss Y has a disabled child, who we will call B. Since September 2022, B has been considered a ‘Child in Need’ (CIN) under Section 17 of the Children Act 1989. The ‘Child and Family Assessment’ from October 2022 noted the professional’s view that they, “would support an increase in support/respite for [Miss Y], particularly during the holidays”. The result of that assessment was to create a CIN plan and to assign a social worker for an ongoing review of B’s support. Another recommendation was to reassess the Direct Payments to, “ensure that effective respite is provided to [Miss Y] as the main carer. Emphasis is to be placed on respite availability during school holidays”.
20. The CIN plan dated 24 November 2022 listed the respite arrangements for eight hours a month. The CIN Plan noted that B needed overnight respite, and the allocated social worker would “explore opportunities to provide regular and ongoing overnight respite for [B] to give [Miss Y] a break from her caring role”. The suggested date for completion was 23 February 2023.
21. The Council reviewed B’s CIN plan in April 2023, noting that the previous review scheduled for February was re-scheduled to fit in with the diaries of staff members. During the review, Miss Y expressed the continued difficulties she faced with B’s behaviours, limited family support and the need for additional direct payments and short break provision.
22. The Council recorded: “there was no service to offer [B] short breaks. The resource panel approved [B] to access short-breaks and with a newly developing residential placement [name removed], [B] would access this support”. In addition to overnight short-break provision, the panel also agreed an additional four hours of direct payments each week during term time, and six hours per week for school holidays.
23. The Council reviewed the CIN plan again in July 2023. Miss Y explained that she had searched for a care agency to employ using the direct payments, but due to B displaying physically threatening behaviour, she had been unable to identify a carer. The social worker noted an agreement to put Miss Y’s case back to the panel to approve the use of agency staff for short breaks at the family home, once a fortnight, with a “waking overnight” carer.
24. From August 2023 the Council commissioned a care provider for support workers to help B at home and to provide Miss Y with some respite. However, Miss Y soon reported that the carers were ineffective, and B would continue to seek out Miss Y. Following concerns raised by Miss Y, the Council agreed to have meetings each week with the care provider to review the package and feedback any issues or successes. The Council also arranged a professionals meeting to discuss concerns with the care provider directly.
25. There is fault in the form of unexplainable and avoidable delay. Following the Council’s agreement in September 2022 to fund respite during school holidays, and overnight care from October 2022, the social worker failed to put either long or short-term plans in place until August 2023.
26. Miss Y has explained the commissioned care was not suitable for her or B due to the intrusive nature of carers being present in her home, and that B continued to depend on her. However, the records show this type of support was the only available option. This is because there was no availability for any respite or short-break residential provision in the Council’s area. This is service failure.
27. The Council has also accepted the care provider’s CQC status changed after it commissioned the care package. I understand this limited some tasks that carers could carry out, such as personal care. The presence of carers in the home alongside Miss Y also limited the chance for her to have meaningful respite time. The service failure therefore caused injustice to Miss Y and B because they did not receive the support they would have otherwise received, had there been alternative services available. The Council will make a symbolic payment in recognition of the distress caused by this fault.

Safeguarding concerns

28. Miss Y reported unauthorised use of physical restraint by the carers commissioned by the Council. The first incident happened on 23 February 2023 which was promptly referred to the Local Authority Designated Officer [LADO] on 26 February 2023. Police also submitted a ‘public protection notice’ following their callout to the incident.
29. Two further incidents from August and September 2023 were also referred to the LADO. They related to a support worker restraining B after a physical outburst and secondly when a support worker held B’s wrist when they grabbed the driver during a car journey. The care provider investigated the incidents internally but the support worker left the organisation and it was not investigated further.
30. Following the referral, the LADO reviewed video footage provided by Miss Y and decided that B did not experience harm and an investigation was therefore not justified. The Council acknowledged that B’s care plan did not include use of physical restraint but was based on the use of a ‘Positive Behaviour Support Plan’ including advice from health professionals. The Council contacted the care provider to make suggestions to reduce the necessity for physical restraint.
31. At Stage Two, the IO said there was no fault in the Council’s decision not to start safeguarding procedures following the allegations made by Miss Y. This is because actions were taken to reduce any risk to B and to prevent further incidents. B’s care plan did not include information about restraints but said that providers would need to use “dynamic risk assessments”.
32. It is not for us to question the dynamic decision making undertaken by carers at times of perceived danger and to reach a view on the suitability of the restraint used. Our focus is instead on the procedural steps taken by the Council once it became aware of any concerns. Having reviewed the files, I find no fault in the Council’s response to the incidents raised by Miss Y. The steps it took were appropriate and proportionate.
33. However, we have found that, but for the service failure, B should have been placed in a residential short break or respite setting. Had a placement been available for B, it is more likely than not that the incidents in question would not have occurred. This is evident because the records show B has been settled since moving into their residential placement and has not demonstrated some of their previous physical behaviours. We have already recommended a symbolic remedy in recognition of the distress caused by the service failure.

Funding to adapt Miss Y’s home for B

34. Miss Y moved house via a mutual social housing exchange in June 2023. Before she moved, the OT attended two viewings with Miss Y to help her select the most suitable house. Miss Y opted for a three-bedroomed house which had some issues of disrepair. At the time, only Miss Y and B lived at home.
35. After moving into the house, Miss Y told the social worker that it did not meet B’s needs, and she requested funding for a ground-floor extension to create a downstairs bathroom and “safe space” for B to use when dysregulated.
36. The OT completed a home assessment and wrote a report some days later which concluded that the third bedroom could be used as a breakout space for B, and the existing space on the ground floor would accommodate a level-access bathroom. However, the OT noted that B relied on incontinence aids and did not currently use the toilet, so the necessity for a downstairs toilet was not clear.
37. The OT agreed to put in a grant request for DFG funding. The Council considered the request but refused on the basis that B’s home already had adequate space to be used for a quiet room. The OT discussed other possible options, such as the use of a temporary structure for a ‘safe space’, but Miss Y declined.
38. The ‘DFG Delivery Guidance for Local Authorities in England’ helps councils determine when adaptations, including extensions, are necessary and justified. It emphasises local authority discretion but directs authorities to ensure adaptations are necessary, appropriate, reasonable and practicable, based on an OT assessment alongside property condition and layout.
39. In the event an OT assessment concludes there is a spare bedroom (or other room) that can be adapted to meet identified needs, then the Council must look to adapt that room first. This is because councils are not obliged to fund an extension unless it is clearly necessary, and no existing room can be practically used. Extensions are usually only considered if no appropriate alternative exists within the property, or the applicant’s needs cannot be met within existing layout
40. In Miss Y’s case, the Council was entitled to suggest the use of a spare bedroom to meet B’s needs for a quiet and safe space. From the records I have reviewed, there is no procedural fault in how the Council reached this decision and so I have no grounds to question the merits of that decision.

Car safety

41. Miss Y complained the Council did not support her with the process of identifying and purchasing a suitable car harness for B. Miss Y said the harness was important because B sometimes displayed unsafe behaviours when travelling as a passenger in the car.
42. I have reviewed the relevant records to see what action the Council took when Miss Y raised concerns about B’s safety when travelling. The records show:
• In November 2022 B’s CIN Plan noted the difficulties Miss Y and B’s father experienced when transporting B in the car due to their unpredictability. The OT suggested using a five-point harness in the car, but the plan noted: “Mum not keen and Dad would not use. This is on hold for now as parents aren’t in agreement with use. [Miss Y] prefers to have B sat in the front of the car”. The Plan went on to say that B’s school would “look into” buying a harness.
• On 20 April 2023 the OT raised concerns about transporting B in the front passenger seat of Miss Y’s car using a standard seatbelt. Miss Y told the OT that B’s school had already offered a harness for B to sit in the back of the car.
• In September 2023 further discussion around a harness which Miss Y had reported issues with due to B being able to unfasten it. The OT emailed a safety leaflet to Miss Y on 29 September 2023 with alternative harnesses but said the funding would not come from the Council.
• In November 2023, B’s father wrote to the OT seeking help with sourcing a harness. The OT wrote to a charity supporting a funding request for a magnetic harness as the Council maintained this was not within its remit.
• In March 2024 the Council referred to the use of magnetic harness in a risk assessment form.
43. In response to Miss Y’s complaint, the IO said at Stage Two: “… OT should, if they have not already, consider, view and assess the magnetic harness. Whilst CWAD [Children Who Are Disabled] OT are not able to recommend or provide financial assistance they could provide detailed information to other parents”.
44. This conclusion does not take into account the power of councils to make funding available for CIN. Section 17(1) of the Act defines a “child in need” as a child who is: “unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services by a local authority”.
45. Under Section 17(6) services provided by a local authority may include the provision of accommodation and giving assistance in kind or, in exceptional circumstances, in cash. This could include equipment such as car harnesses if assessed as necessary to meet a child’s needs for safety, mobility, or access to the community.
46. Therefore, the Council was at fault when it automatically refused Miss Y's request for funding without considering B’s individual case. It should have considered whether it was appropriate to fully or partly pay for the equipment using its powers under Section 17. I understand that B now has a suitable harness, so there is no need to recommend an assessment at this stage. However, the Council has agreed to apologise for its mistake and make a symbolic payment in recognition of the uncertainty caused by the fault.

Council’s agreed recommendations

47. Following consideration at Stage Three, the panel made several recommendations which I will summarise below with the Council’s response.
• The Council to consider how to include the views of parents who have children with complex needs when planning services. The Panel suggested Miss Y might feel able to share her experiences to help represent other parents in similar situations. The Council confirmed it has a board in place to ensure there is enough good quality social care services for children. One goal is to help children stay with their families or extended family. To support this, short breaks are available for disabled children and those with complex needs. These are offered through local activities, direct payments, care providers, foster carers, and registered short break homes. The board works in partnership with the ‘Dorset Parent Carer Council’ to make sure parents' voices are heard. Dorset Council would welcome Miss Y’s input, as her experience highlighted the problems caused by delays in arranging overnight short breaks. It is recommended that Miss Y meets with the Council after this process to explore how she can help shape future services.
• Regarding Miss Y’s concerns about safeguarding (as discussed during the hearing), the Head of Service should speak with her to clarify which incidents were reported to the LADO, what evidence was reviewed, and what decisions were made. The final complaint response shows the Council shared this information with Miss Y.
• The Panel heard the Head of Service was already speaking with professionals about lessons learned from the complaint. The Panel recommended an action plan to be produced as soon as possible, and to include a review of quality assurance processes to ensure they are strong and effective. The final complaint response agreed with the recommendation and agreed to create an action plan by January 2025.
• The Panel recommended the verbal apologies (given for the complaints that were upheld in the Stage Two investigation) should also be provided to Miss Y in writing. The Council provided a written apology to Miss Y in January 2025.
• Even though B is now living in a residential placement, he will still spend time at home. The Panel recommended an assessment to make sure the home is safe for B during visits. The Council agreed to undertake a further OT assessment, a copy of which it has shared with us, dated February 2025.

Back to top

Action

48. The Council has made several service improvements which are suitable and proportionate. Whilst we do not recommend any further service improvements, we ask the Council to provide a copy of the following documents within four weeks of our final decision.
• the invitation sent to Miss Y to meet and include her views as part of the Dorset Parent Carer Council and the agreed ‘Action Plan’ dated January 2025.
49. In addition to the £500 already proposed, within four weeks of our final decision the Council will pay a further £500 to make a total remedy payment of £1000. This is a symbolic payment in recognition of the prolonged and significant distress which Miss Y and B experienced from the faults identified in this statement.
50. The Council will provide us with evidence it has complied with the above actions.

Back to top

Decision

51. I find fault causing injustice. The Council will implement the actions we have recommended to remedy injustice.

Back to top

Investigator's decision on behalf of the Ombudsman