The Ombudsman's final decision
Summary: Mrs B is the registered manager of an organisation that provides adult social care. The Council received concerns about the organisation and started the adults safeguarding concerns process. Mrs B complained the Council did not follow the process properly. She said the Council did not provide a time frame for its enquiries; did not give her enough support and refused to allow her to take on new clients despite her complying with the safeguarding process. Mrs B said this caused financial loss and damaged her organisation’s reputation. We found no fault with the Council.
The complaint
Mrs B is the registered manager of an organisation that provides adult social care, Organisation C. The Council received concerns about the organisation and started the adults safeguarding concerns process. Mrs B complained the Council did not follow the process properly. She said the Council did not provide a timeframe for its enquiries; did not give her enough support and refused to allow her to take on new clients despite her complying with the safeguarding process. Mrs B said this caused financial loss and damaged her organisation’s reputation.
Mrs B also complained the Council refused to address her concerns through its complaint process.
The Ombudsman’s role and powers
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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended) We consider whether there was fault in the way an organisation made its decisions. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended) 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)
How I considered this complaint
I considered: Mrs B’s complaint and the information she provided; documents supplied by the Council; relevant legislation and guidelines; and the Council’s policies and procedures.
Mrs B and the Council had the opportunity to comment on a draft decision. I considered their comments before making my final decision
What I found
Legislation and guidance The Care Act 2014 and The Department of Health and Social Care’s care and support statutory guidance provides the key legal framework for adult safeguarding. It gives councils the lead responsibility for managing safeguarding concerns, deciding safeguarding duties and undertaking safeguarding enquiries.
Where a council has reasonable cause to suspect that an adult may be experiencing or at risk of abuse or neglect, it is under a duty to make whatever enquiries it thinks necessary to decide what if any action needs to be taken and by whom.
Organisational abuse includes neglect and poor care practice within an institution or specific care setting such as a hospital or care home. This may range from one off incidents to ongoing ill-treatment. It can be through neglect or poor professional practice because of the structure, policies, processes, and practices within an organisation.
London multi-agency adult safeguarding policy and procedures This sets out arrangements for working with providers where safeguarding concerns are identified as serious matters within an organisation.
The provider concern framework is a six-stage process: Decision to initiate provider concerns – the council should tell the provider about the concerns; identify how any risks can be mitigated; and, share concerns with placing councils.
Initial provider concerns meeting – this should happen within five working days of the councils’ decision to start provider concerns. The meeting should identify and clarify concerns; review safeguarding and risk management; listen to the views of the provider; and, set a date for a findings meeting. If possible, actions from this meeting should be completed within 10 working days. Where the concern is about a large organisation or complicated, action may take longer. The provider however should be kept informed.
Findings meeting – the purpose of the meeting is to assess and agree the findings from fact-finding enquiries; draw up a service improvement plan; and, update the risk management plan and agree safeguarding measures. The provider will propose actions, leads, timescales and progress to address the concerns within 48 hours of the meeting.
Quality assurance – agree a quality assurance strategy to test whether improvements have been attained and can be sustained. The target for completing the quality assurance process is 10 working days.
Closure of the provider concern process - following evidence-based improvement, the process will formally come to an end and the relevant parties including the provider will be notified in writing.
Depending on the findings from the investigations undertaken an embargo may be placed on new placements or packages of care being commissioned from the provider in question. Any such embargos are communicated to other London boroughs.
What happened Organisation C leased Property 1 to provide supported living placements. When it leased the property there was a sitting tenant. The tenant had received an eviction notice but remained in the property. The sitting tenant and supported living placements shared facilities. The sitting tenant had mental health difficulties.
In August 2021, concerns were raised with Council 1 about Organisation C. These included its ability to provide services to people with complex needs, the appropriateness of the location of Property 1, and that it was offering a supported living service alongside an independent tenant.
The Council met with placing council’s, the council where Organisation C was registered and the Care Quality Commission (CQC) to discuss the concerns.
The Council visited Property 1 and met with Mrs B in August 2021. They discussed: the appropriateness of an independent tenant living at Property 1 when it was being used for supported living placements; safeguarding risks related to having an independent tenant at Property 1 when it was being used for supported living placements; incidents at Property 1 and risk assessments Organisation C had undertaken before and after these incidents; and, plans for the service.
In September 2021, the Council held a meeting to update CQC and the other London boroughs about its meeting with Organisation C.
The Council decided to start the providers concern process in September 2021. It told Organisation C by letter and outlined its concerns: Organisation C was using Property 1 to provide supported living placements when an independent tenant was living there.
When it met with Mrs B to discuss its concerns, she could not show that she had completed meaningful risk assessments.
It was not clear from its contact with Mrs B that she understood the regulatory requirement placed on her as Registered Manager. Namely, to satisfy herself the service had the necessary skills and abilities to provide safe care to the individuals living at Property 1, both individually and together.
It did not seem suitable to provide a service to individuals with behaviours that challenge in the type and location of Property 1.
It explained it discussed the concerns at two multiagency safeguarding meetings with other London Boroughs and the CQC and the decision to start the provider concern process was supported by all parties. The Council told Organisation C it was temporarily suspended from taking on supported living placements at Property 1. It asked her for her availability for an initial provider concern meeting. The Council contacted her twice more before she responded.
The Council held an initial provider concern meeting with Mrs B in September 2021; seven working days after it started the provider concern process. The Council explained the provider concern process, why it started it and its reasons for suspending placements. The Council and Mrs B discussed its concerns in detail. The Council asked Mrs B to provide documents to support its investigation.
Mrs B sent the Council information it asked for. The Council said it would update her about timescales once it had received information from professionals about the plan for rehousing the independent tenant.
In September 2021, Organisation C withdrew its application to the CQC to register as a supported living scheme.
Mrs B emailed the Council to ask when it would lift the suspension on Organisation C providing supported living placements at Property 1. She explained the sitting tenant would continue to receive support from a mental health team when they returned to live at Property 1 in November 2021.
The Council told Mrs B it would hold a multiagency meeting in October 2021 to decide how the investigation would progress and whether Organisation C’s suspension should continue. It asked her to respond to queries it had about some of the documents she supplied and to send extra information. It said it was concerned she wanted to start to provide supported living placements when the independent tenant was returning to live at Property 1.
In October 2021, the Council held a multiagency meeting and updated attendees on its progress. It advised it was waiting for a response from Mrs B to queries it raised. The Council did not lift the suspension.
Mrs B’s solicitor raised concerns the Council was delaying the provider concern process and not staying in regular contact with Mrs B. It asked the Council to lift the suspension on Organisation C accepting placements at Property 1. It said the concerns about Organisation C did not meet the threshold for suspending placements.
The Council advised Mrs B’s solicitor it had not received a response to its most recent queries and until it did so, it could not progress its investigation or lift the suspension. It explained it had a statutory duty to ensure all services were properly managed and run with the safety of the service user in mind. The Council invited Mrs B to a meeting to discuss the matter.
The Council held a second provider concern meeting with Mrs B and her solicitor in November 2021. After the meeting the Council sent Mrs B a list of questions to answer and asked her to provide Organisation C’s policies and procedures. It said it would tell her whether it would lift the suspension on Organisation C offering placements at Property 1 by the end of the following week and invited her to attend a findings meeting.
Mrs B answered the Council’s questions and provided Organisation C’s policies.
The Council held a findings meeting with Mrs B and her solicitor at the end of November 2021 to discuss the investigation. Following the meeting, the Council sent Mrs B’s solicitor a letter setting out its findings so far, remaining concerns and proposed next steps.
Mrs B’s solicitor said the Council was not adhering to the timescales, purpose, and requirements of the provider concerns process. It claimed the Council had extended the scope of its investigation and had not demonstrated there were enough concerns for it to continue to prevent Organisation C offering placements at Property 1.
The Council wrote to Mrs B’s solicitor in January 2022. It reiterated that it considered it inappropriate and unsafe for the organisation to start providing a supported living service while an independent tenant was living in the property. It said it still had safeguarding concerns around Mrs B’s decision making as the registered manager. It said Mrs B needed to evidence she understood its safeguarding concerns and there were robust decision-making processes in place to prevent unsafe decision making. The Council advised Mrs B had not provided a full response to these concerns and therefore it could not close the provider concern process. The Council offered to meet with Mrs B.
In February 2022, the Council wrote to Mrs B and explained if she did not say by the beginning of March 2022 whether she would provide a respond to the concerns identified in its January 2022 letter, it would consider the provider concerns process closed but unresolved. Mrs B told the Council she had addressed all its concerns.
In March 2022, the Council told Mrs B it did not consider she had addressed its fundamental concern about Organisation C’s decision to offer supported living placements at Property 1 while an independent tenant, who it was aware was vulnerable, was living there. It said it had closed the safeguarding enquiry, but the matters were unresolved and therefore it would not lift the suspension.
In April 2022, Mrs B asked the Council which of its concerns was outstanding. The Council responded that she had not satisfactorily addressed its concerns about the decision to offer supported living placements while an independent tenant was living in the property. The Council told Mrs B it was happy to meet with her to discuss the support it could provide.
Analysis When concerns were raised about Organisation C, the Council took suitable action. It shared its concerns with relevant parties and started the provider concern process. The Council decided the level of concerns required Organisation C to suspend placements. It decided this to safeguard those in supported living placements and the independent tenant. The Council made its decision after discussing the situation with others and considering the information available at the time. I found no fault with the Council’s decision making.
The Council held the initial provider concerns meeting seven days after it started the provider concern process. Although there was a delay of two days, I do not consider this fault by the Council. The Council wrote to Mrs B on the day it started the process asking for her availability for a meeting and chased her twice before she responded. Once Mrs B told the Council her availability, it held the meeting within two working days.
There is no requirement within the provider concern process to give providers a specific timescale for the investigation. From September 2021 to January 2022, the Council progressed the provider concern process. It met with Mrs B to discuss its concerns, asked her for relevant evidence, and responded promptly to correspondence from Mrs B and her solicitor. There was one occasion where the Council could not respond within the timescales it gave Mrs B’s solicitor, however, I do not consider it was so serious to make a formal finding of fault, particularly as the Council responded one working day later. I do not consider the Council delayed the provider concern process or allowed its investigation to drift.
The solicitor and Mrs B questioned the relevance of the information the Council asked for. The Council’s decision about what information it needed was based on the professional judgement of its officers, and they provided Mrs B and her solicitor with justification for their requests. I found no fault with the Council’s decision making about the evidence it needed and therefore I have no grounds to question the professional judgement of the Council’s officers.
Mrs B said the Council did not provide her with support during the provider concern process. The Council met with Mrs B three times to discuss its concerns and following these, confirmed in writing the information it needed to progress its investigation. It was in regular correspondence with either Mrs B or her solicitor and responded to their queries. I found no fault with the support the Council provided. The Council has confirmed it is happy to work with Mrs B to address its outstanding concerns.
The Council tried to work with Mrs B, however, it could not complete the provider concerns process because she disengaged. The Council closed the provider concern with it unresolved and the suspension in place. I found no fault with the Council’s decision. Although Mrs B is unhappy with the Council’s decision, there is no evidence of fault in how the council conducted the providers concerns process.
Final decision
I have completed my investigation and do not uphold Mrs B’s complaint.
Investigator's decision on behalf of the Ombudsman