Hollybank Trust (19 014 217c)

Category : Health > Care and treatment

Decision : Upheld

Decision date : 31 Aug 2021

The Ombudsman's final decision:

Summary: The Ombudsmen find fault in aspects of the care a Care Home provided to a young man with a severe learning disability. This had an impact on his dignity and likely left him in minor avoidable discomfort at times. The Ombudsmen recommend the Care Home apologises for the impact of these failings. The Ombudsmen have not found fault in the way the Council investigated its own role through the children’s statutory complaints procedure so has no cause to reinvestigate the substantive matters. Further, the Ombudsmen find no fault in the CCG’s attempts to improve the situation.

The complaint

  1. Mr and Mrs A complain about failings, which they describe as neglect and abuse, in their son’s, Mr B’s, care at Hollybank Trust (Hollybank). Further, they complain that neither Kirklees Metropolitan Borough Council (the Council) nor North Kirklees Clinical Commissioning Group (the CCG) took suitable steps to improve the situation or safeguard Mr B – either through their own monitoring, or in response to Mr and Mrs A’s concerns. In addition, Mr and Mrs A complain the Council’s safeguarding investigation was inadequate and reached an unsupportable decision.
  2. Mr and Mrs A said that, as a result, Mr B received undignified care for a prolonged period and was not given enough stimulation.
  3. Mr and Mrs A also complain Hollybank inappropriately evicted Mr B and the CCG failed to prevent it.
  4. In addition, Mr and Mrs A complain Hollybank Trust, the Council and the CCG failed to adequately investigate their complaints.

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What I have investigated

  1. The courts have confirmed we have discretion to limit the scope of an investigation to key areas only, to be selective about the complaints we will address and identify broad categories and investigate only those. I have limited this investigation to the areas listed above. I have detailed at the end of this decision statement notable complaints Mr and Mrs A raised with the Ombudsmen which we decided not to investigate.
  2. I have investigated the Council’s complaint handling. I have not reinvestigated the substantive matters of Mr and Mrs A’s complaints about the Council because the Council considered these under the children’s statutory complaint procedure. The statutory procedure is designed to provide significant independence and detailed analysis of concerns raised. This means reinvestigation is neither necessary nor warranted unless a complainant can point to and evidence serious and fundamental flaws in the way the case was investigated.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
  2. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
  3. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
  4. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
  5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I read the correspondence and supporting evidence Mr and Mrs A sent to the Ombudsmen and spoke to them on the telephone. I wrote to Hollybank, the Council and the CCG to explain what I intended to investigate and to ask for their comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance.
  2. I shared a confidential copy of my draft decision with Mr and Mrs A and the organisations and provided an opportunity to comment on it. I considered the comments and evidence I received in response.

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What I found

Legislation and guidance

Care Home Standards

  1. There are standards for safety and quality children’s homes need to meet, which I will call the Regulations (Children’s Homes (England) Regulations 2015). The Department for Education wrote guidance to help children’s homes meet these standards, known as the Quality Standards (Guide to the Children’s Homes Regulations including the quality standards (April 2015)). As part of these, care homes need to make sure:
  • They provide people with appropriate care, personalised to their needs. This includes taking account of the person’s preferences, and ensuring care and treatment is only provided with their consent. As part of this, children’s homes need to make sure assessments are regularly reviewed (Regulation 7).
  • They help children to take part in and benefit from a variety of activities that meet their needs and benefit them (Regulation 9).
  • They meet the health and wellbeing needs of children in their care (Regulation 10).
  • Children are kept safe from avoidable risk and harm, and from unsafe care and treatment (Regulation 12).

Human Rights

  1. The Human Rights Act 1998 brought the rights in the European Convention on Human Rights into UK law. Public bodies, including councils and NHS Trusts, must act in a way to respect and protect human rights. It is unlawful for a public body to act in a way which is incompatible with a human right. 'Act' includes a failure to act. (Human Rights Act 1998, section 6)
  2. It is not the Ombudsmen’s role to decide whether a person’s human rights have been breached or to say whether an organisation has acted lawfully. Those decisions are for the courts. Our role is to decide whether there has been fault causing injustice. Where relevant, we consider whether an organisation has acted in line with its legal duties in section 6 of the Human Rights Act. We may find fault where the organisation cannot evidence it has had regard to a person’s human rights or if it cannot justify an interference with a qualified right.
  3. We consider that Article 3 of the Human Rights Act is relevant to the part of the complaint about treatment that can be perceived as degrading. Degrading treatment is treatment arousing fear and which is capable of humiliating or debasing a person.

Council Complaint Handling

  1. The handling and consideration of complaints under the Children Act 1989 consists of three stages. (Department of Education, 2006, Statutory guidance for local authority children’s services on representations and complaints procedures)
  2. Stage One: Staff at point of service delivery try to resolve the complaint.
  3. Stage Two: An investigating officer (IO) and an independent person (IP) investigate the complaint. The IO is responsible for the investigation and the IP ensures the process is open, transparent, and fair.
  4. The IO writes a stage two report which includes:
  • details of findings, conclusions and outcomes are against each point of complaint (i.e. “upheld” or “not upheld”); and
  • recommendations on how to remedy any injustice to the complainant as appropriate.
  1. Once the IO has finished the report, the council’s Adjudicating Officer (AO) will prepare a response. (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others)
  2. Stage Three: A review panel considers the adequacy of the stage two investigation and tries to find a resolution for the complainant. 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 Children Act 1989 Representations Procedure (England) Regulations 2006 19(2) and 20(1))

What happened

  1. This chronology includes key events in this case and does not cover everything that happened.
  2. Mr B has a chromosomal disorder, a severe learning disability and epilepsy. He needs support to meet his needs and to keep him safe.
  3. Mr B became a resident of Orchard Court children’s home in spring of 2015 and remained there until December 2017. Hollybank served notice on Mr B at the end of November 2017 and, in early December 2017, he went to live with his parents, supported by carers in their home. He continued to attend Hollybank School – a day-school – until July 2018.
  4. During Mr B’s time at Orchard Court, Mr and Mrs A raised concerns about his care in the residential placement to Hollybank staff on a number of occasions. Generally these were dealt with as day to day issues and were not dealt with under Hollybank’s complaint processes.
  5. Mr and Mrs A also raised concerns about Mr B’s care with the CCG Care Manager and formally with Hollybank in August 2017. Some of Mr and Mrs A’s concerns were also referred to the Council to be considered under its safeguarding procedures.

Analysis

Complaint that Hollybank failed to provide (and the Council failed to commission) adequate and safe care to Mr B during his placement

One-to-one care

  1. When the Council originally placed Mr B at Hollybank the exact details of the support it was commissioning were not as clear as they should be. Documents noted Mr B needed 24-hour care and one-to-one care. However, the documents did not specify whether Mr B needed 24-hour one-to-one care or if he needed to be in a facility which is staffed 24 hours a day.
  2. Hollybank provided one-to-one care for waking hours (it said it considered waking hours to be 15 hours a day; Mr and Mrs A said Hollybank provided it for 14 hours a day). Hollybank advised that, during the night, there were three ‘waking night’ members of staff including a senior support worker. Hollybank also used an alarm on the door plus a listening monitor (although there were some flaws in the monitor system). Mr and Mrs A were under the impression the Council had commissioned one-to-one care for every hour Mr B was awake. It appears from the evidence I have seen that they did not realise this was not the case until mid‑2017.
  3. Mr B’s support remained this way throughout the time the Council oversaw the placement. There were regular LAC reviews which did not raise any significant concerns about Mr B’s care, and Mr and Mrs A regularly noted they were happy with the placement and wanted it to continue. In August 2017 Mr and Mrs A noted concerns about Hollybank leaving Mr B awake alone in his room at night. Around this time it became apparent to Mr and Mrs A, the CCG and Hollybank that the amount of one-to-one support Hollybank provided did not match Mr and Mrs A’s expectations.
  4. Later in the year the CCG arranged 24-hour one-to-one support. At the end of October 2017 the CCG Case Manager noted they agreed to arrange this because of the level of parental anxiety.
  5. The Council said it had not failed to identify any lack of provision in the two‑and‑a‑half years it was responsible for Mr B’s placement. It said there was no evidence of concerns being raised about the lack of support. It also said Hollybank confirmed it could meet Mr B’s needs with the funding provided by the Council and never asked for any extra funding.
  6. In its response to the complaint Hollybank said it had provided an appropriate level of care which kept Mr B safe. However, it acknowledged there had been a lack of detail in the initial care plan which meant it and Mr and Mrs A had different expectations. It also acknowledged that this lack of detail and differing of views was never properly, formally addressed. Hollybank said this initial misunderstanding had a significant impact on the subsequent breakdown of the relationship. I agree that the lack of clarity about the care package was fault on the part of Hollybank, which it has already acknowledged. As it has already set out, better communication at the start would have avoided any confusion.
  7. In terms of the amount of one-to-one care provided, it is not for the Ombudsmen to determine a person’s care package. However, I have considered whether, had there been better communication at the beginning, it is likely the amount of one‑to-one care might have been higher. Mr and Mrs A provided copies of Hollybank daily records from 28 August 2017 to 4 December 2017; a total of 99 days. They highlighted 15 periods where staff did not stay in Mr B’s room with him despite him remaining awake. From my review of these records they do not suggest that Mr B came to any harm because of the lack of supervision. In late October 2017 paramedics had to be called due to seizures Mr B suffered. However, from the evidence available to me this was an isolated incident and, despite the lack of one-to-one care, staff were able to intervene to call for medical help. As noted above, when the CCG agreed additional funding for further one‑to‑one care it did so on the basis of parental anxiety rather than a clinical need.
  8. Taking all of the evidence into account I have not found fault in the content of the care plan in regard to the level of one-to-one care. Professionals had reached a view it offered an adequate level of support and regular reviews had not highlighted any issues arising from a lack of supervision.

Continence care

  1. Mr B had a toileting programme where staff would remind and encourage him to use the toilet regularly. If staff followed this Mr B could remain continent. It was agreed that while he slept Mr B would wear a pad. However, Mr B’s sleep was quite erratic and there were nights when he would wake in the early hours and not go back to sleep. Mr and Mrs A feel that once Mr B was awake staff should have been using the toileting programme. In contrast, Hollybank has concluded it was reasonable for staff to exercise judgement to consider whether Mr B might go back to sleep (and, as such, whether it would be disruptive and unhelpful to remove the pad only to need to put it back on again).
  2. Hollybank has acknowledged there was a lack of clarity in the care plans about waking hours and when the toileting programme should have been used. It said these were never addressed throughout reviews and has noted this meant the differing expectations between it and Mr and Mrs A were never addressed.
  3. I have not undertaken a forensic review of Hollybank’s records to try to establish how many nights Mr B woke in the night or early hours but was not taken to the toilet. However, I have looked closely at the extracts of Hollybank records Mr and Mrs A sent to me. Mr and Mrs A highlighted 24 periods (from the 99 days covered by the records) where staff did not assist Mr B to use the toilet while he was awake. This was made up of:
  • 12 periods between Mr B being put to bed and falling asleep,
  • 8 periods when Mr B had been to sleep and then woke up before 5am, and
  • 4 periods when Mr B had been to sleep and then woke up after 5am.
  1. It seems evident that, once they put him in a pad at bedtime, some staff would not use the toileting routine until the morning regardless of how long it took Mr B to fall asleep. The rationale appears to have been to allow Mr B to relax and encourage sleep, rather than keep getting him out of bed at regular intervals.
  2. In regard to times after staff put Mr B to bed and before he went to sleep, I believe there is some logic to Hollybank’s actions. Staff had no way of knowing when Mr B may fall asleep. In this context it would be unreasonable to criticise Hollybank for failing to take Mr B to the toilet for periods of up to three hours while they were waiting for him to fall asleep. After that it seems it would have been proportionate to have tried assisting Mr B to the toilet to see if it could help his comfort and ability to fall asleep. I accept that this three hour ‘cut off’ is essentially an arbitrary number. However, setting this point allows the issue to be considered transparently. On this basis, in the records Mr and Mrs A shared there were ten occasions when staff did not assist Mr B to the toilet before he got to sleep despite being awake for three hours or more. This represents roughly 10 percent of the days of records Mr and Mrs A sent – although they have noted that during October 2017 the records were limited.
  3. In terms of the periods after Mr B woke, again, I accept that if it was in the early hours (i.e. before 5am) it was reasonable for staff to assume that Mr B may go back to sleep. And, as such, it was reasonable to have held off from taking him to the toilet for up to two hours. Again, this is an arbitrary figure but allows a degree of measurement whilst also recognising that it was reasonable for staff to exercise a degree of judgement and discretion at these times. On this basis there were seven occasions when staff did take Mr B to the toilet after he woke in the early hours but had not fallen back to sleep after two hours.
  4. Last, in regard to times when Mr B woke after 5am, I believe it would be reasonable to expect staff to assist him to the toilet within an hour. There was one occasion when this did not happen, when Mr B woke at 5.40am and staff took him to the toilet at 7.05am.
  5. Overall, there is evidence of fault in regard to the way Hollybank supported Mr B’s toileting needs at night. As Hollybank has already acknowledged, at the very least there should have been an open and transparent dialogue between it and Mr and Mrs A to set out as clearly as possible what the plan would be. Regardless of his needs Mr B had a right to be treated with dignity and this did not always happen, which is not in line with Regulation 7 of the Quality Standards. This is an injustice. It would be proportionate for Hollybank to apologise for the failings in Mr B’s care and to provide a small financial payment to serve solely as a tangible acknowledgement of its acceptance of this failing and the injustice it caused.

Pain relief

  1. In the emails Mr and Mrs A provided (covering 99 days) they highlighted seven days and three nights where Mr B showed behaviour they consider was clearly indicative of him being unwell but where paracetamol was not given.
  2. Due to the nature of Mr B’s needs and the nature of the records there is no way for me to objectively measure whether he was in pain which could (and should) have been lessened through the timely use of painkillers. Mr and Mrs A know their son well and it is reasonable to accept that they are a reasonable judge of signs which could indicate Mr B being unwell.
  3. Overall, on the balance of probabilities, while staff needed to interpret situations in the moment, this evidence suggests staff may have missed opportunities to provide pain relief at times when Mr B showed signs of needing it. This is a failing. This, in turn, means it is probable there were times when Mr B missed out on pain relief which could have benefited him. This is a low level injustice which would be appropriately addressed by an apology from Hollybank.

Offering drinks

  1. In the Hollybank records Mr and Mrs A provided to me they have highlighted 22 periods where staff did not offer Mr B a drink while he was awake.
  • 10 periods between him being put to bed and falling asleep,
  • 7 periods when Mr B had been to sleep and then woke up before 5am, and
  • 5 periods when Mr B had been to sleep and then woke up after 5am.
  1. As with the continence issue, it seems evident that once staff put Mr B to bed some would then try to have as little interaction as possible in order to allow him to relax and encourage sleep.
  2. Again, when staff put Mr B to bed they would not know how long it would take him to fall asleep, and it would be reasonable to allow a period of time before attempting to intervene, including by offering a drink. As such it would be unreasonable to criticise Hollybank for failing to offer a drink for periods of up to three hours while they were waiting for him to fall asleep. After that it seems it would have been proportionate to have tried offering a drink to see if it could help. On this basis there were ten occasions when staff did not offer Mr B a drink before he got to sleep despite being awake for three hours or more. This represents roughly 10 percent of the days of records Mr and Mrs A sent.
  3. In terms of the periods after Mr B woke I accept that if it was in the early hours (i.e. before 5am) it was reasonable for staff to assume that Mr B may go back to sleep and, as such, to have held off from offering a drink for an hour. On this basis there were seven occasions when staff did offer Mr B a drink after he woke in the early hours but had not fallen back to sleep after an hour.
  4. Last, in regard to times when Mr B woke after 5am, I believe it would be reasonable to expect staff to offer a drink within an hour. There were three occasions when this did not happen – twice when Mr B woke at 5.30am and once when he woke at 5.40am.
  5. Overall, there is evidence of failings in regard to the way Hollybank supported Mr B’s hydration needs at night. Due to the nature of Mr B’s needs and the level of his communication there is no way for me to objectively measuring whether he was thirsty or in discomfort because of the lack of a drink. However, I cannot discount the possibility that, because of the fault here, Mr B was left uncomfortable because he was thirsty. This is not in line with Regulation 10 of the Quality Standards. In view of the repetition of this relatively minor impact this constitutes an injustice. As with the issue of pain relief, this would be suitably addressed by an apology from Hollybank.

Two-to-one support

  1. In terms of Mr B’s two-to-one care, there is, again, a distinct lack of clarity about what should have been provided. Hollybank accepted, in its Stage Two complaint response, that there was a lack of clarity at the beginning of Mr B’s placement about the care required to meet his needs safely (in terms of one-to-one, two-to-one and continence care). It accepted that it had not provided the level of care set out in some assessments and plans and which Mr and Mrs A believed was necessary and understood would be provided. However, it concluded that the level of care and support it had provided had been appropriate and adequate for Mr B’s needs.
  2. Hollybank said there should have been better discussions about the proposed levels of care at the outset. It said that because this did not happen all parties had different assumptions about the level of support that had been funded and that would be provided.
  3. There should not be such uncertainty and this is fault. This has led to further uncertainty about whether Mr B missed out on further support which would have been a benefit to him and which may have improved his quality of life. This uncertainty alone is an injustice which Hollybank should apologise for.

Complaint about a failure of the Council to take suitable steps to improve the situation and protect Mr B

  1. The Council noted it would have been for Hollybank to have asked for more money if it had felt it did not have enough to provide safe care for Mr B. The Council said that it did not receive any such request and, as such, was not in a position to provide any further funding. I am satisfied this is a logical conclusion.
  2. In terms of its own monitoring, during the Stage Two complaint investigation the Investigating Officer found the Council could have monitored Mr B’s placement more closely. The Council accepted this and noted it had implemented a relevant quality assurance measure. In addition, in its Stage Two complaint response the Council accepted there was no evidence that the Social Worker made a personal assessment of any of the concerns Mr and Mrs A raised with her. Further, the Council said the Social Worker did not detail any clarifications in future statutory visits and did not follow up “any actualization of the care plan”. In addition, the Council noted the Independent Reviewing Officer did not check whether this had been followed up when they did their quality assurance.
  3. The Stage Three Panel went further in acknowledging that the support provided by Hollybank had not always been consistent with the supported identified in Mr B’s Education, Health and Care Plan. It also found that Hollybank made changes to support arrangements without involving Mr and Mrs A or consulting the Council. It also accepted that the Council had a responsibility to make sure Hollybank was providing the required standard of care but did not do so in this case.
  4. In terms of the impact of this, the Council concluded that, even if the Social Worker had completed a more thorough dip-sampling of records, they may not have highlighted the issues and concerns Mr and Mrs A had subsequently raised.
  5. However, the Council accepted that the Independent Review Process should have been more robust. It said that in Mr B’s case it had not adequately considered the “voice of the child”. The Council said this would be shared during monthly supervision with the Learning and Organisational Development Service. In addition, the Council said the lessons identified in the complaint had been anonymised and shared across Children’s Social Work teams. It also said the line management of the staff involved had received feedback and discussed the lessons learned and how they would deal with matters differently in the future. Further, the Council said the learnings and recommendations had also been shared with Adult Social Care.
  6. Overall, there is evidence to show these concerns were thoroughly and appropriately considered by the statutory complaints process. This process identified failings, considered their impact and led to actions aimed at preventing recurrences. I have not identified any failings in the Council’s investigations of this matter and, as such, have no cause to reinvestigate the substantive issues.

Complaint about a failure of the CCG to take suitable steps to improve the situation and protect Mr B

  1. Although the CCG began paying for Mr B’s care in December 2016 it did not become actively involved in managing the case until July 2017. To my knowledge this was in keeping with local arrangements in place at the time.
  2. From the end of July 2017 to the end of Mr B’s placement (in early-December 2017) there is evidence the CCG Case Manager had regular and active involvement in the case. The records show the Case Manager listened to and considered Mr and Mrs A’s concerns about Mr B’s care. Further, there is evidence to show the Case Manager scrutinised the care plans which were in place, reviewed and monitored care records and discussed the concerns with Hollybank, colleagues at the CCG along with other health professionals.
  3. There is evidence in the records of the Case Manager taking steps to review and renew Mr B’s care plans with the involvement of Mr and Mrs A, Hollybank and other professionals. The Case Manager also sought and obtained additional CCG funding for Mr B’s care. In addition, there is evidence the Case Manager raised concerns with management at Hollybank and asked for explanations and corrective action.
  4. Lastly, there is also evidence that the Case Manager took account of the strained relationship between Mr and Mrs A and Hollybank Trust and considered the implications of this in terms of the provision of safe and effective care for Mr B. The Case Manager also attempted to improve this relationship and create a more collaborative approach.
  5. Overall, I am satisfied there is evidence of regular and appropriate monitoring of Mr B’s placement by the CCG once it took on this role. I have not found evidence of fault in its actions.

Complaint about an inadequate safeguarding investigation which reached an unsupportable decision

  1. This includes concerns about Hollybank providing false information which the overseeing authorities failed to properly scrutinise or challenge.
  2. During the complaints process the Council concluded it followed the adult safeguarding procedures but accepted that a safeguarding meeting was not handled as sensitively as it should have been. It said it would reinforce the importance of listening to families’ feelings and ensuring their concerns are addressed. The Council said it would also review the process of these meetings.
  3. The records show that, following the initial referral, the Council completed a robust initial assessment before deciding to proceed to a safeguarding enquiry. This involved speaking to the CCG Case Manager and management of Hollybank. During the next stage of the process the Council obtained a written response from Hollybank and spoke to the CCG and Police about their involvement. It also held a professionals meeting which was attended by Council, CCG and Hollybank staff in addition to the safeguarding meeting which also involved Mr and Mrs A. All parties were given an opportunity to give their views.
  4. Overall, the Council completed a suitable, evidence-based investigation of this issue and, as such, I have no call to question its conclusions.

Complaint about the way Hollybank ended Mr B’s placement, and that the CCG did not prevent it

  1. When the CCG Case Manager took over responsibility for Mr B’s case in July 2017 the intention was for Mr B to transition to an adult placement at the same site. However, in late August 2017 Hollybank noted its concerns about a difficult relationship with Mr and Mrs A. This led to a suggestion, by a senior manager at the CCG, for work to be done to formalise the relationship between Hollybank and Mr and Mrs A.
  2. By the start of October 2017 the Case Manager was still attempting to help mend the relationship between Mr and Mrs A and Hollybank but also provided details of some alternative placements. Later in October 2017 Hollybank told the Case Manager it had concerns about the placement becoming unsustainable.
  3. In the middle of October 2017 the Case Manager told Mr and Mrs A of her plan to arrange a meeting to discuss whether the placement was sustainable and, if so, to put in place a contractual agreement to promote Mr B’s best interests. The Case Manager noted that if this happened but the agreement was not followed then it would withdraw the placement and look for an alternative.
  4. In the middle of November 2017 Mr and Mrs A told the Case Manager they felt the care provided by Hollybank was inadequate and said they wanted to look for another provider. The Case Manager spoke to a colleague and noted the relationship had irretrievably broken down. She arranged for a new provider to assess Mr B the next day.
  5. By late November 2017 arrangements were being made for another provider to assess Mr B. In addition, in an email to the Case Manager, Mr and Mrs A reiterated their intention – and priority – was to move Mr B from Hollybank as quickly as possible. A few days later Hollybank gave the CCG 28 days’ notice of its intention to end Mr B’s placement.
  6. On 5 December 2017, after Mr and Mrs A had returned from abroad, they advised the Case Manager they would not send Mr B back to Hollybank and would care for him at home. The Case Manager contacted a colleague and noted the need to arrange a temporary Personal Health Budget (PHB). By 11 December 2017 the CCG agreed this was the most appropriate option in the short term. The CCG wrote a PHB Support Plan on 13 December 2017 and agreed this at a panel on 18 December. A Personal Assistant began supporting Mr B on 16 December and the CCG sent the first funds into the PHB account on 29 December 2017.
  7. Overall, there is evidence to show that there had been concerns – from both Hollybank and Mr and Mrs A – about a poor relationship for months before Hollybank served notice. There had been open discussions about this which included a warning that the placement could end if things did not improve. Further, when Hollybank served notice Mr and Mrs A had already noted their intention to end the placement and move Mr B to an alternative.
  8. As such, I have not seen evidence to show Hollybank decided to serve notice without having first considered and attempted less drastic measures. Therefore, I have not found that its decision, or the CCG’s acceptance of that decision, was fault.
  9. The evidence shows that the CCG responded to the notification quickly to arrange alternative support. By the time Mr and Mrs A removed Mr B from Hollybank the CCG had only had eight days (six working days) to respond. However, by 18 December – within the 28 day notice period – the CCG had agreed a PHB package as an interim measure.
  10. While I understand Hollybank decision meant the last six days of Mr and Mrs A’s holiday was more stressful than it otherwise would have been, I have not found fault in relation to the timing of its notice. The notice period still allowed enough time for the CCG to arrange an alternative, regardless of Mr and Mrs A’s whereabouts. Further, the decision and notice period did not place Mr B in any immediate danger.

Complaint handling

  1. My investigation of Mr and Mrs A’s complaints has shown that each of the organisations completed a detailed consideration of Mr and Mrs A’s concerns. There is evidence to show they considered relevant documentations and scrutinised the information they gathered appropriately.
  2. The Council investigated Mr and Mrs A’s complaints under the Statutory Complaints Procedures. The complaint was considered at Stage Two of those procedures by an Investigating Officer and Independent Person. Following a meeting with the Investigating Officer and Independent Person in early March 2018, the Council’s Stage Two terms of reference were agreed at the end of March. It agreed to look at 11 heads of complaint.
  3. The Council sent Mr and Mrs A its response to the Stage Two report at the end of December 2018. It accepted that the issue of its monitoring of the placement should be partly upheld.
  4. Mr and Mrs A subsequently escalated their complaint to a Stage Three Panel. This took place at the end of February 2019. The Panel reiterated the earlier findings of both Hollybank and the Council’s Stage Two report – that Hollybank had not always provided the level of support detailed in Mr B’s plans. It said Hollybank had made changes to Mr B’s care arrangements without proper consultation with Mr and Mrs A or the Council.
  5. The Panel upheld the complaint that the Council failed to identify this, and failed to properly monitor Mr B’s placement including that the Independent Review process had not been as robust as possible.
  6. The Panel noted that new quality assurance measures had now been put in place. It recommended the Council review the supervision arrangements in relation to this case and to provide reassurances to Mr and Mrs A that regular supervision for Social Workers and Social Work Managers took place.
  7. The Council wrote to Mr and Mrs A about the Stage Three Panel’s findings at the end of March 2019. It said it agreed that the Independent Review Process should have been more robust. The Council said this would be shared during monthly supervision with the Learning and Organisational Development Service.
  8. In addition, the Council said the lessons identified in the complaint had been anonymised and shared across Children’s Social Work teams. It also said the line management of the staff involved had received feedback and discussed the lessons learned and how they would deal with matters differently in the future. Further, the Council said the learnings and recommendations had also been shared with Adult Social Care.
  9. The Council also acknowledged that the lack of an allocated social worker during Mr B’s transition from children’s services to adult services, and then to the CCG, meant there was some confusion and uncertainty. It apologised for this. The Council said the Adult Service had been working with the CCG to improve the early identification of young people’s health needs and had increased the number of staff across the whole of the Specialist Adult Pathway Team and within the CCG to ensure young people had a named worker.
  10. Overall, there is evidence to show the Council followed the Statutory Complaints Process appropriately. This allowed a detailed, independent review of the events and I have not found evidence of inappropriate interference. Therefore, I have no reason to criticise the conclusions of the complaints process.
  11. In regard to Hollybank, there is again evidence to show it conducted a detailed complaint investigation at Stage Two. This identified a number of issues which had caused problems throughout the placement. Hollybank also noted a range of actions it intended to take in order to learn from this complaint and to improve its processes to help prevent recurrences.
  12. Owing to Mr and Mrs A’s continued dissatisfaction Hollybank then approached a company an asked it to carry out an independent review of the complaint. Mr and Mrs A met the independent investigators and a member of staff from the CCG toward the end of August 2019. Mr and Mrs A explained their concerns about a range of issues with Mr B’s care which they considered to be unresolved.
  13. In late October 2019 the independent investigators wrote to Mr and Mrs A. It said that following its meeting with them in August 2019 it became concerned that it would be unable to successfully complete the brief Hollybank had given it. The investigators said it shared its concerns with Hollybank which discussed them with the Board of Trustees. It said that this had brought about a change in its terms of reference. The investigators said its review would now examine whether Hollybank’s internal reporting mechanisms were in place and followed appropriately, and whether different action could have prevented the breakdown in the relationship which resulted in the termination of Mr B’s placement.
  14. The independent investigators completed their report in the middle of April 2020. The review recommended Hollybank provide guidance to staff on how to manage conflicts with relatives, and what steps to take before terminating a placement.
  15. The review noted that Hollybank had taken, or was going to take, a number of appropriate steps to address concerns Mr and Mrs A had raised over time. Nevertheless, the review found there were failings in the way Hollybank handled Mr and Mrs A’s complaints. It made a series of recommendations aimed at improving its complaints handling processes and to ensure they were properly embedded.
  16. I have not seen evidence to suggest Hollybank sought to influence or alter the investigation’s terms of reference. The evidence shows it was the independent company’s own decision to alter the terms of reference, and that it provided a rationale for doing so. Further, the evidence shows that, between Hollybank’s own investigation and the independent investigation, there has been a comprehensive review of the breakdown of Mr B’s placement which sought to identify key issues and root causes. The complaints process also led to a range of recommendations aimed to improving its service and helping prevent recurrences.
  17. The CCG conducted its own investigation of Mr and Mrs A’s complaints and identified for the failings it identified. There is evidence to show its investigation was grounded in an appropriate review of the contemporaneous records and in line with relevant policies.
  18. Therefore, I have not found fault in relation to the way Hollybank, the Council or CCG handled these complaints.

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Agreed actions

  1. Failing to provide appropriate continence care at night caused an injustice to Mr B as it impacted on his dignity. Within one month of final decision Hollybank should acknowledge that it did not get this right and apologise for the impact it had on Mr B. In addition, it should pay Mr B £300 as a tangible acknowledgement of its acceptance of the injustice this fault caused.
  2. Failing to provide appropriate pain relief at times caused a likely injustice to Mr B in that he was potentially left in discomfort which could have been eased. Within one month of the final decision Hollybank should acknowledge this and apologise for the impact on Mr B.
  3. Failing to provide adequate drinks at night caused a likely injustice to Mr B in that he may have been left thirsty. Hollybank should acknowledge this and apologise for the impact on Mr B.
  4. Failing to provide clarity about the amount of two-to-one support necessary left uncertainty about whether Mr B missed out. This uncertainty, in itself, is an injustice. Hollybank has already acknowledged the lack of clarity but, within one month of the final decision, it should apologise for the impact of this.
  5. Following its own complaints process and the independent investigation Hollybank committed to enacting a host of actions to improve its service and prevent recurrences. These were appropriate and proportionate and, as such, I have not made any further recommendations aimed at service improvements. However, within three months of the date of the final decision Hollybank should provide the Ombudsmen with an update on its work against all of the recommendations.

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Decision

  1. I have completed my investigation on the basis there was fault on the part of Hollybank which caused Mr B an injustice. I have made recommendations to address the injustice.

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Parts of the complaint that I did not investigate

  1. Mr and Mrs A complained about the theft of Mr B’s money by staff at Hollybank. I did not investigate this issue as the disputed amounts have already been reimbursed by Hollybank. An Ombudsmen investigation would not lead to any further reimbursement. In addition, the police investigated the alleged theft. The Ombudsmen cannot determine whether a crime has been committed or impose punitive or disciplinary measures on people. Further, during the complaints process Hollybank made a number of recommendations aimed at improving its performance in the area of financial record keeping to help prevent recurrences. In view of this, there is nothing an Ombudsmen investigation could add to this issue.
  2. Mr and Mrs A complained about the incorrect use of several medications. These events are not disputed. However, the impact of them was not of a level that we would call a significant injustice as there is no clear indication that Mr B came to any harm. Therefore, there are insufficient grounds for the Ombudsmen to investigate this issue.
  3. Mr and Mrs A complained about the unlawful deprivation of Mr B’s liberty. To my knowledge there was no dispute during this period about where Mr B should live. As such, while it seems clear it was a failing that Deprivation of Liberty Safeguards were not authorised for a long time, this did not alter the day‑to‑day arrangements for Mr B’s care. Therefore, an investigation of this issue is unlikely to be able to link this to a specific injustice.
  4. Mr and Mrs A raised a specific concern about a wipe being found in Mr B’s bed in September 2017. I have not investigated this issue because, while there may have been the potential for harm, Mr B did not come to any harm because of this incident. Further, while Mr and Mrs A had concerns about Hollybank’s response to this incident – in removing wipes from the room – this is also unlikely to lead to a finding of a specific injustice.
  5. Mr and Mrs A asked the Ombudsmen to look into staff having told lies with a view to seeking disciplinary action. This is not an outcome an investigation could achieve. We do not become involved in personnel or disciplinary matters. The Ombudsmen’s role is not to punish or reprimand individuals. For this reason, I did not include these concerns as a specific issue to be investigated.
  6. Mr and Mrs A sent in extracts of Hollybank’s notes and noted concerns about a failure of staff to notice a lump on Mr B’s foot, and about an occasion when Mr B was not showered or when only one member of staff assisted him in the shower. I did not include these as specific heads of complaint as the events are unlikely to represent a significant injustice.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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