Summary: Mr X complained about the Council’s investigation into safeguarding concerns regarding his adult son Mr Y. The Council was at fault for the delay in completing the safeguarding investigation, for poor communication with Mr X and for not keeping Mr Y at the centre of the investigation. This meant Mr Y was stopped from visiting Mr X for longer than necessary and caused Mr X distress and frustration. The Council has agreed to apologise to Mr X and make payments to Mr X and Mr Y. It has agreed to remind officers of the importance of effective communication in safeguarding investigations.

The complaint

1. Mr X complained about the Council’s decision to initiate a safeguarding investigation about his care of his adult son Mr Y, which resulted in Mr Y’s weekend visits home being stopped. Mr X also complained the Council:
1. failed to communicate effectively with him and provided Mr X with no updates about Mr Y whilst the safeguarding was ongoing.
2. delayed finding alternative accommodation for Mr Y and failed to involve him when his current accommodation closed so Mr Y is now living a significant distance away.
3. Has delayed finding Mr Y alternative accommodation closer to his home.
2. Mr X says this has caused him great stress and anxiety. Mr X also says his human rights to a family life have been breached.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused 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)
4. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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What I have and have not investigated

6. I have investigated what happened from July 2024 until the end of October 2024 when Mr Y moved accommodation, and the Council closed the safeguarding investigation. I have not investigated 1 b) and 1c) above. This is because, before we can consider complaint, a council must have had a reasonable opportunity to consider the complaint and to respond to it. The Council has not had an opportunity to consider a complaint about these issues. It is open to Mr X to complain to the Council and then approach us again if he remains unhappy with the response.

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How I considered this complaint

7. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
8. Mr X and the Council have had an opportunity to comment on my draft decision. I considered any comments I received before making a final decision.

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What I found

Relevant law and guidance

9. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
10. The Deprivation of Liberty Safeguards (DoLS) provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative.
11. The Human Rights Act 1998 sets out the fundamental rights and freedoms that everyone in the UK is entitled to. This includes the right to life, freedom from torture and inhuman or degrading treatment or punishment, liberty and security of person, a fair hearing, respect for private and family life, freedom of expression, freedom of religion, freedom from forced labour, and education. The Act requires all local authorities - and other bodies carrying out public functions - to respect and protect individuals’ rights.
12. The Ombudsman’s remit does not extend to making decisions on whether a body in jurisdiction has breached the Human Rights Act – this can only be done by the courts. But the Ombudsman can make decisions about whether a body in jurisdiction has had due regard to an individual’s human rights in their treatment of them, as part of our consideration of a complaint.
13. In practical terms, councils will often be able to show they are compliant with the Human Rights Act if they consider the impact their decisions will have on the individuals affected and that there is a process for decisions to be challenged by way of review or appeal.

Background

14. Mr Y is an adult with diagnoses of an autism spectrum condition and a severe learning disability. He does not communicate verbally. Mr Y lived at care home 1 and visited his father, Mr X, most weekends. Care home 1 would drop Mr Y off and pick him up after the weekend. Mr Y takes regular medication, receives two to one support in the community and one to one support in the care home. Mr Y was subject to a DoLS order at care home 1 which showed he lacked the mental capacity to make decisions about his care. Care home 1 was closing down and earlier in 2024 gave Mr Y notice to leave by late August 2024.

What happened

15. In July 2024 care home 1 told Mr X it would not drop off or pick up Mr Y. If Mr X wanted Mr Y to go home at weekends it said he could pick him up. It said Mr X had made allegations about staff bruising Mr Y and had used threatening language against the team. Mr X responded that care home 1 was paid to deliver services and an abrupt change in Mr Y’s routine would heighten his anxiety.
16. That same month the Council received safeguarding concerns from care home 1. This related to Mr Y’s home visits and Mr Y having access to medication not prescribed to him, eating unhealthy food, eating food which had not been prepared in line with Mr Y’s eating guidelines and concerns about the condition of Mr X’s home. The Council decided to undertake a safeguarding enquiry.
17. Mr Y’s social worker emailed Mr X in late July. They said there were concerns about Mr Y’s eating guideline compliance, medication and environmental concerns about the family home. They asked to arrange a home visit and said with the ongoing investigation it was in Mr Y’s best interests to stay at care home 1 that weekend. Mr X responded and listed reasons he had concerns about the care provided at care home 1 and the significant impact on Mr Y if he was not allowed home.
18. The social worker and their team manager arranged to visit Mr X’s home in early August to discuss the concerns. Mr X emailed beforehand to advise he was currently decorating the upper floor of the property. At the visit the social worker noted it was homely but cluttered. They noted they spoke with Mr X about ensuring Mr Y adhered to his eating plan and advised Mr X to get a lock for his pantry to prevent Mr Y accessing food without supervision. They noted Mr X ordered Mr Y’s medication separately from care home 1 and stored this at home. They noted Mr Y’s medication was stored in two different cabinets, one of which was not lockable. They noted the medication was dated to earlier in the year but only two doses had been dispensed when Mr Y had been home several times since then.
19. The team manager noted Mr X wanted to see Mr Y every weekend but was choosing not to follow the given instructions to keep Mr Y safe. They noted Mr X did not agree with the eating guidelines in place and said he had looked after Mr Y for many years without his health being affected. Mr X emailed the Council following the visit asking whether the weekend visit could go ahead. He said he had added a lock to the pantry and medicine cabinet.
20.  
21. Six days after the home visit the Council held a multi-disciplinary team (MDT) meeting with relevant staff to discuss the concerns. Mr X was not invited. At the meeting a third-party professional said staff observed Mr Y was unsettled with heightened anxiety after visits home. Care home staff reported concerns about the food Mr Y ate at home, the cluttered environment and issues regarding medication arrangements. The notes record a visit would be arranged with Mr X to discuss the concerns and the home environment. The meeting agreed to hold a further MDT meeting the following month when Mr Y’s GP could attend. It agreed if professionals met with Mr X and explained the importance of Mr Y’s eating plan, home environment and medications, it would be safe for him to continue home visits. At the meeting all agreed Mr Y should stay at care home 1 over the weekends until they considered the family home was safe for Mr Y.
22. Mr X complained to the Council in mid-August that he had tried to ring the social worker several times and they had not called him back. Mr X was also unhappy the social worker had asked for Mr Y’s GP details when these should be on his records, with the care provided at care home 1, and with the safeguarding investigation.
23. The records show the team manager called Mr X on two occasions to discuss the outcome of the MDT meeting and left a message. They then emailed Mr X and asked if he would attend a meeting with health colleagues to discuss the outcome of the recent MDT meeting and how to progress Mr Y visiting home. Mr X telephoned the team manager. The notes record Mr X was unhappy about the medication concerns and said he always gave Mr Y his medication. The team manager said they had invited Mr Y’s GP to the next meeting to discuss the importance of ensuring Mr Y stuck to his dietary plan and eating guidelines.
24. The team manager responded to Mr X’s complaint. They said they had advised the social worker to return Mr X’s calls as soon as possible to maintain communication with him. They said the social worker asked for Mr Y’s GP details as they thought Mr Y was getting medication from a different GP at home than when at care home 1.
25. They said following the home visit they had no concerns about the home environment which although cluttered had space to walk around and was not unhygienic. They had concerns around the storage of medication and some of it being stored in an unlocked cupboard and that the medication administered did not match up to the times Mr Y had been home. Food in the kitchen was not stored away and the pantry was not lockable. They explained they could not guarantee Mr Y could visit if Mr X did not adhere to his eating guidelines. In relation to the MDT meeting, they said the meeting concluded that:
• Mr Y’s visits should continue to be suspended until the Council was satisfied Mr X had taken efforts to clear some items from home.
• Mr X recognise the importance of adhering to Mr Y’s eating guidelines.
• Mr X make a commitment to giving Mr Y his medication as prescribed
• A meeting be arranged for professionals and Mr X to discuss what was in Mr Y’s best interests.
26. Mr X emailed the Council expressing his unhappiness at the MDT meeting and the decision not to let Mr Y come home.
27. Mr Y moved to care home 2 in late August 2024. Mr X emailed the team manager. He said he had no idea how Mr Y was settling in and had not received any daily reports about how Mr Y had spent his time at the new care home. He asked for confirmation as to when the MDT meeting would be held.
28. Mr X contacted the team manager again in mid-September as he had not heard when the MDT meeting may be and had received no update on Mr Y’s welfare and wellbeing.
29. Mr X submitted a formal complaint in September 2024 that he had been kept in the dark and had no updates about Mr Y’s welfare and wellbeing at care home 2. The Council told Mr X the team manager was off work and would be in touch on their return.
30. Mr X contacted the Council again in late September 2024 as he had heard nothing further. The team manager apologised and advised they had asked Mr Y’s social worker to arrange an MDT meeting. They said Mr Y was continuing to be cared for at care home 2 whilst efforts were made to identify an appropriate placement locally. Mr X responded in early October expressing his frustration at the delay.
31. In early October 2024 the team manager spoke with the social worker and advised them to arrange a multi-disciplinary meeting urgently. Mr X attended the meeting which was held in mid October 2024. Care home 2 explained the eating guidelines it had put in place for Mr Y and that it had requested a speech and language therapy (SALT) review. The meeting proposed Mr Y took his medication in a blister pack to Mr X’s to enable Mr X to administer it during the weekend. The meeting agreed:
• it was in Mr Y’s best interests, and that of his family, for him to visit home as before. Care home 2 agreed to transport Mr Y.
• all parties should work together to ensure a plan was in place for weekends.
• The social worker should complete a risk assessment regarding medication, eating and the environment at home.
• The social worker to visit Mr X and confirm the changes he had agreed to had taken place.
• A review of Mr Y’s eating plan by a Speech and Language Therapist (SALT).
32. The social worker visited Mr X the next day. Mr X read and agreed to the risk assessment which included Mr Y’s medication being in a blister pack, food being cut to bite size and Mr Y to be supervised at all times at home. The social worker emailed care home 2 so that Mr Y could be supported home for the weekend. Care home 2 advised it was too short notice to arrange transport. It agreed to transport Mr Y home the following weekend.
33. Care home 2 transported Mr Y home for the weekend in late October 2024.
34. The team manager wrote to Mr X in late October 2024 regarding his complaints about Mr Y’s welfare and Mr Y not being allowed home. The letter confirmed that at the MDT meeting they agreed a plan to allow Mr Y home. They acknowledged there was a significant amount of time since Mr Y had visited home. They said the delay was trying to arrange a suitable time for an MDT meeting. They reiterated what the MDT meeting agreed.
35. The Council closed the safeguarding in late October 2024 as Mr Y had moved to a new placement, it had completed a risk assessment, checked Mr X’s home and Mr X had agreed to care home 2’s eating and drinking guidelines.

Findings

36. The Ombudsman’s role is not to reach a view on whether the Council’s decisions on safeguarding concerns are correct. Our role is to consider whether the Council followed the Care and Support Statutory Guidance process and considered all relevant information to reach its view.
37. The Council has a statutory duty to make enquiries if it believes an adult is experiencing or is at risk of abuse or neglect. It has to make enquiries to establish whether action needs to be taken to prevent abuse or neglect.
38. The Council received safeguarding concerns and decided to investigate them. It acted promptly when it received the concerns. It made Mr X aware of the concerns, carried out a home visit and held an MDT meeting to discuss the concerns. This was appropriate and was not fault.
39. However, following the MDT meeting there is no evidence the Council took any further action to address the concerns before it arranged a second meeting for mid-October 2024. It is acknowledged that staff absence contributed to the delay. However, the Council took too long to arrange a second MDT meeting and this was fault.
40. When an MDT meeting was arranged, Mr X attended and agreed to the actions, including his agreement to the risk assessment. The meeting concluded Mr Y’s home visits could resume. Following the meeting it took a further week before a visit home could be arranged. The delay in arranging the MDT meeting meant Mr Y was prevented from going home for around 6 weeks longer than necessary
41. Mr Y should have been at the centre of the safeguarding process and in the minutes of neither of the MDT meetings is there any consideration of the impact on Mr Y, or of whether stopping the visits home was the least restrictive option. The Council failed to give due regard to Mr X and Mr Y’s rights to a family life. This is fault. It is acknowledged Mr Y does not communicate verbally so it is more difficult to assess the impact on him. However, Mr Y’s visits to Mr X’s home have been a regular occurrence for a number of years and part of his regular routine. On balance, it is likely the sudden cessation of these will have had a significant impact on Mr Y. These faults also caused Mr X significant frustration and distress.
42. The records also show Mr X requested an update on progress with arranging the MDT meeting and his frustration at calls to the social worker not being answered or returned. Given Mr Y moved care homes and was prevented from visiting home, the Council failed to ensure care home 2 kept Mr X updated on Mr Y’s progress. The poor communication with Mr X was also fault which added to Mr X’s frustration.

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Agreed action

43. Within one month of my final decision the Council has agreed to:
1. Apologise to Mr X and pay him £300 to acknowledge the distress, frustration and missed home visits caused by the Council’s faults. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
2. Pay Mr Y £300 to acknowledge the impact of the missed home visits on him.
3. Remind officers involved in safeguarding of the importance of keeping those subject to a safeguarding investigation updated with its progress and of responding to reasonable communication without delay.
4. Discuss this complaint with staff involved in ASC safeguarding to remind them of the importance of keeping the adult who is the subject of the safeguarding enquiry at the centre of the enquiry.
44. The Council should provide us with evidence it has complied with the above actions.

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Decision

45. I find fault causing injustice which the Council has agreed to remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman