Decision Date: 11 March 2025
Summary
The Council investigated safeguarding concerns regarding Mr X’s adult son, Mr Y. The Council delayed in completing the investigation, communicated poorly with Mr X and did not keep Mr Y’s wellbeing at the centre of the investigation.
What happened
Mr Y is a gentleman with severe learning disabilities and a diagnosis of ASD. He is non-verbal. He was subject to a DoLS authorisation at his care home (CP1).
In July 2024 CP1 told Mr X it would no longer bring Mr Y to and from his home at the weekends. [This was not on account of the staffing requirement or the cost; it was because the care home had concerns about Mr Y’s home environment, according to the report.]
Mr X raised concerns that this abrupt change in routine would heighten Mr Y’s anxiety.
CP1 said Mr X had made allegations about staff physically abusing Mr Y and had behaved threateningly towards the staff.
CP1 raised safeguarding concerns with the Council in relation to the care provided by Mr X during Mr Y’s home visits including that he was being medicated with a non-prescribed medicine. The Council undertook a safeguarding enquiry.
In late July Mr Y’s social worker emailed Mr X. They asked to arrange a home visit. They also said that it was in Mr X’s best interests to stay at CP11 that weekend because of the ongoing investigation.
In early August, the social worker and team manager visited Mr X’s home to discuss their concerns. They spoke to Mr X about Mr Y’s eating plan and medication. They explored concerns about the storage of Mr Y’s medication and that he had not received enough doses for the duration of his visits home. Mr X disagreed with the eating guidelines for Mr Y but did put a lock on the pantry after this visit.
Six days after the home visit the Council held a multi-disciplinary team (MDT) meeting with relevant staff to discuss the concerns but not inviting Mr X.
The meeting agreed that if professionals explained the importance of Mr Y’s eating plan, home environment and medications, it would be safe for him to continue home visits. They also agreed that Mr Y should stay at the care home over the weekends until they were satisfied that the family home was safe.
In mid-August, Mr X complained to the Council about the social worker’s poor communication, the care provided at CP1 and the safeguarding investigation. He did say he’d added locks to the pantry and the medication cupboards.
The team manager responded to Mr X’s complaint, saying the social worker had been asked to return Mr X’s calls as soon as possible.
The team manager also informed Mr X of the conclusions reached by the MDT meeting adding to concerns about medication, some separate concerns about the storage of food. They explained that Mr Y could not visit his home if Mr X did not adhere to the eating guidelines. They said Mr Y’s visits should be suspended until Mr X:
· Cleared some items from his home.
· Recognised the importance of adhering to Mr Y’s eating guidelines.
· Made a commitment to giving Mr Y his medication as prescribed.
· Met with professionals to discuss what was in Mr Y’s best interests.
Mr X emailed the Council in response and expressed his disagreement with the conclusions of the MDT meeting.
In late August 2024, Mr Y moved to CP2 because CP1 had closed down – having given every client due notice.
Mr X emailed the team manager and said he had received no communication about Mr Y’ settling in, since he had moved into the care home.
Mr X submitted a formal complaint in September 2024 as he had received no updates about Mr Y’s welfare and wellbeing at CP2. Mr X contacted the Council again in late September 2024 as he had still heard nothing further nor about any fresh MDT date. The team manager apologised and advised that Mr Y’s social worker had been asked to arrange an MDT meeting. They said Mr Y would continue to receive care at CP2 until an appropriate placement was identified locally.
In mid-October 2024, Mr X attended an MDT meeting. The meeting agreed:
· It was in Mr Y and his family’s best interests for him to visit home as before. CP2 agreed to transport Mr Y.
· All parties should co-operate to ensure that a plan was in place for the weekends.
· The social worker should complete a risk assessment regarding medication, eating and the home environment.
· A Speech and Language Therapist (SALT) should review Mr Y’s eating plan.
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.
In late October CP2 transported Mr Y home for the weekend. There was a week’s delay because the provider had been given insufficient notice about the visits home.
In late October the Council closed the safeguarding enquiry.
What was found
The Council had acted promptly in investigating safeguarding concerns.
However, the Council took too long to arrange a second MDT meeting. This delay prevented Mr Y from going home for around 6 weeks’ longer than necessary. Following the meeting there was a further week’s delay.
There was no consideration of the impact on Mr Y or whether stopping his visits home was the least restrictive option to Mr X and Mr Y’s right to a family life. The sudden cessation of Mr Y’s visits home was likely to have had a significant impact on him. They also caused Mr X significant frustration and distress.
The Council failed to ensure that Mr X was updated on Mr Y’s wellbeing in CP2. This added to Mr X’s frustration and distress.
The financial remedy due would be £300 for each of Mr X and Mr Y and an apology to Mr X, with all safeguarding staff being reminded of their duties and the legal framework in which they are conducted.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
We find it difficult to credit that the Ombudsman’s investigator does not say anything about the circumstances of the review and revision exercise that would have had to have happened, before the man could be moved. A move of accommodation is a change that affects a care plan and should have triggered a s27 exercise, in which Mr X would have had to have been involved, even if there was a safeguarding investigation going on!
We are surprised that the Investigator did not see fit to comment on the failure to invite Mr X to the first MDT meeting. We think that that was probably in breach of procedural fairness principles which are part and parcel of the public law legal framework which underpins all public body decision-making.
If that review and revision process had been carried out properly, there would of course have been more likelihood of someone appreciating that a best interests decision needed to be taken.
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. 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 and the change in regime would have been likely to have had a significant impact on him.
As it happens, completely preventing contact with a person cannot be done under a best interests decision alone, because it usually involves someone else’s interests as well.
The whole idea of a best interests decision-making exercise involving consultation of others interested in the person’s welfare, and considering whether any less restrictive means can be identified of managing a concern that has arisen, is that if it happens properly, then there is a good chance of agreement, rather than a dispute that needs resolving by the Court of Protection.
In this particular situation CP1 had made it clear that it did not object to Mr X coming to collect Mr Y or visiting him at the home; it had already been decided, possibly in the DoLS authorisation, that it was acceptable for him to leave the home, and it may have even been condition of that authorisation. That aspect of the matter is not mentioned by the Investigator at all, but it may have been the situation that Mr X was not able to mke the journey.
The report recites how the Ombudsman’s remit does not extend to making decisions on whether a body in jurisdiction has positively breached the Human Rights Act because this is a judicial remit. But the Ombudsman can make decisions about whether a council has had due regard to an individual’s human rights in their treatment of them and councils will often be able to show they are compliant with the Human Rights Act if they can show that they did consider the impact their decisions will have on the individuals affected.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Dudley Metropolitan Borough Council (24 009 693) report.
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