Case Ref: 22 007 057 Category: Adult care services Sub Category: Residential care

• The Council should provide evidence the provider has reviewed its policies for housekeeping and inventories for when people move into the care home;provide evidence that staff at the care home have been reminded of its privacy and dignity policy;provide evidence the provider has discussed with nurses and nursing assistants the falls protocol;provide evidence that nurses are aware of the residents that are prescribed blood thinners and the appropriate actions to take in the event of injury; andprovide evidence that relevant staff at the care home have been reminded of the importance of obtaining statements from all witnesses in a timely manner.
• The Council should ensure the care home has reviewed it falls policy and accident reporting procedure and consider whether it should include specific guidance about what action to take if a resident who is taking blood thinning medication falls.
• The Council should through contract monitoring ensure the care home is:correctly applying its fall prevention policy and procedure;accurately completely incident reports and body maps;maintaining robust records that clearly document decisions about seeking medical attention following a fall;communicating with family members where there are significant changes in a residents needs or circumstances; andadhering to its privacy and dignity policy and residents are dressed in their own clothes and that personalisation and dignity are upheld

Case Ref: 22 006 951 Category: Education Sub Category: Special educational needs

• The Council will ensure it has a robust system in place to ensure provision specified in Education, Health and Care plans is in place when it issues a new or substantially different Education, Health and Care plan.
• The Council will review how it commissions private speech and language therapy services, and will implement any changes it identifies as necessary to ensure speech and language therapy can be commissioned without significant delay.

Case Ref: 22 004 335 Category: Education Sub Category: School transport

• The Council will undertake a formal review of Mrs D’s case. The purpose of the review is to identify why the delay occurred and to adopt measures to prevent similar occurrences in the future. The review will also look at whether it is suitable for the Council to be accepting school transport review requests by telephone when its policy outlines this must be by written means. The review outcome will be shared with Council officers involved in school transport decision making to inform any necessary training and guidance.

Case Ref: 22 003 283 Category: Other Categories Sub Category: Other

• Share the outcome of its review with the Ombudsman that it has undertaken regarding its working protocols between education, health and social care. The Ombudsman would like to see that the Council has considered how its working processes can be improved to ensure better sharing of information between services.

Case Ref: 22 000 077 Category: Children's care services Sub Category: Other

• The Council agreed to review its existing liaison arrangements between its complaint service and legal services where it takes legal advice on whether to investigate a complaint. This was to ensure it had procedures in place that would mean it did not lose track of a complaint referred in this way and that it would keep in touch with the complainant while their case was awaiting advice in the event of a delay. Also, to ensure both services knew which one had the responsibility to respond to the complainant.

Case Ref: 21 018 475 Category: Education Sub Category: School transport

• The Council will review its 'home to school transport policy' in relation to children with Special Educational Needs and Disabilitys and/or mobility problems so it is in line with the Education Act 1996. This means:the policy should not apply the 'general criteria' such as 'statutory walking distance' to children who are eligible due to Special Educational Needs and Disabilities and/or mobility problems;the policy should not apply the 'statutory walking distance' to children who use a wheelchair and other mobility aids.
• When the Council has reviewed and amended its 'home to school transport policy', it will provide training and guidance to its school transport staff and appeal panel, so they carefully consider any new transport applications for children with Special Educational Needs Disabilities/mobility issues, to apply the correct criteria.

Case Ref: 21 012 109 Category: Adult care services Sub Category: Residential care

• Within two months of our final decision the Council will remind its officers of the importance of care plan reviews and working with the NHS Trusts to coordinate end of life care plans in a personalised way.

Case Ref: 21 011 359 Category: Adult care services Sub Category: Residential care

• The Council has agreed to eview the safeguarding activity and ensure relevant staff are clear about the Council’s responsibility where other organisations complete the s42 enquiry.
• The Council has agreed to review the commissioning of care home placements for people with complex needs such as Mr Y and ensure the Council has a robust plan to avoid such long delays in future

Case Ref: 21 007 902 Category: Education Sub Category: COVID-19

• The Council should remind staff to keep written records of telephone calls and discussions about individual cases.

Case Ref: 21 003 755 Category: Education Sub Category: Special educational needs

• Remind staff to adhere to the Council’s complaints policy regarding timescales.