SPSO Individual Decisions

C complained about the service provided in respect of their grandchild (A). C complained that A was not being provided with a stable home environment by their parent (B). C was concerned about the condition of B’s home and whether A and their siblings were being adequately supervised and kept safe. C also expressed concerns over other adults in B’s home. C said that the partnership did not take their concerns seriously and had failed to ensure A’s health and wellbeing. This included whether sufficient home visits took place, and the decision not to initiate child protection proceedings, or make a referral to the Scottish Children’s Reporter (SCRA). C also raised concerns about social work documentation and processes relating to Interagency Referral Discussions (IRD) and Child’s Plans. We took independent advice from a social worker. We found that the partnership’s explanations and assurances to C, with respect to the number and nature of home visits, did not match the available records and that there had been a failure to carry out robust and timely assessments of B’s home. Where home visits did take place, there was a lack of evidence that key concerns related to the condition of specific areas of the home were addressed. Regarding the referral to the SCRA, we found that while the IRD stated that ongoing assessment would determine if a SCRA referral was required, there was no indication of the parameters of the ongoing assessment or what timescales were in place. Furthermore, the IRD did not state by whom, or by when, actions should be completed and lacked clarity regarding roles and responsibilities. Similarly, the Child’s Plan lacked clarity and contained significant omissions. Therefore, we upheld C’s complaints.

C complained that the partnership did not provide reasonable care and treatment to their parent (A). A was admitted to hospital on three occasions during one month following falls. After their third admission, A was discharged to C’s home due to the COVID-19 pandemic. A week later, A was admitted to another hospital and was diagnosed with a lumbar (spinal) fracture and incomplete spinal cord damage. C raised a number of complaints with the partnership about the care and treatment A received and about their discharge. The partnership did not indicate any concerns about A’s care and treatment or discharge but noted that discharge planning had been disrupted due to the COVID-19 pandemic. The partnership also undertook a Significant Adverse Event Review (SAER). We took independent advice from an appropriately qualified adviser. We found that the partnership did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of changes in A’s condition. Therefore, we upheld this part of C’s complaint. In relation to A’s discharge, we found no clear evidence that the concerns expressed by the physiotherapist about deterioration were assessed before the decision to discharge A was made. Therefore, we considered A was unreasonably discharged and upheld this part of C’s complaint.

C complained about the care and treatment that their parent (A) received. A had sight and hearing difficulties. Following a fall at home A was admitted to hospital where they stayed as an inpatient for several weeks before being discharged to a care home. A died a few weeks later. C complained that the care and support that A received at home to encourage movement and general wellbeing was not continued while A was in hospital. As such, A’s mobility and mental health deteriorated and they developed pressure sores due to the length of time that they were immobile in bed. C did not consider that A’s blindness and hearing difficulties were taken into account by the hospital staff and complained that A’s calls for assistance were ignored. We took independent advice from a nursing adviser. We found that the lack of a person-centred care plan led to the failure to support A to enjoy activities that would have provided some stimulation. This along with the restricted face-to-face visits due to the COVID-19 pandemic, meant that A was unreasonably isolated and this impacted on their anxiety and mobility. We found that there were a number of issues with documentation and the management of A’s pre-existing pressure ulcer. The lack of clear documentation was concerning and the HSCP failed to have in place documentation and equipment to record, assess, review and treat a pressure ulcer that evidently deteriorated throughout A’s admission. Overall, we found that A was unreasonably isolated throughout their admission due, in part, to a failure to adapt A’s care in recognition of their sensory impairments and that there were clear failures to maintain important documentation. We upheld this complaint.

C complained on behalf of their adult child (A). A has received support for addiction from the partnership for a number of years. However, C complained that the partnership failed to provide evidence of a recovery plan, to explore all possible treatment options, unfairly stated A was difficult to engage with, and failed to reasonably communicate with C. The partnership acknowledged that there had been a gap in the services provided to A due to staff absence and difficulty recruiting, however a recovery plan was in place for A. We took independent advice from an adult psychiatry adviser. We found that the support provided to A was appropriate and reasonable and that there was a clear management plan in place. Despite the difficulties faced by the partnership in terms of staffing, we concluded that appropriate drug addiction support was provided to A and we did not uphold the complaint. Related reading View Decision Report 202100063 as a PDF (24.21 KB) Updated: April 19, 2023

C complained about the partnership’s social work department in relation to their assessment for a Self-Directed Support budget for their child (A). C complained to the partnership that their Children’s Resources Panel (CRP) had failed to adequately consider C’s funding request for after school care for A, and that they failed to adequately considers A's needs, A's carers needs or gather sufficient information to adequately consider the request. The partnership did not identify any failings. We took independent advice from a social worker. We found that the CRP did adequately consider the needs of A and their carers, based on the information and circumstances presented to the panel. Therefore, we did not uphold the complaint. Related reading View Decision Report 202005168 as a PDF (24.13 KB) Updated: February 15, 2023

C complained about the partnership’s handling of a child protection concern relating to their children whereby they were removed from C’s care overnight. The key points to C’s complaint were that the social worker who attended their home did not clearly identify themselves and explain their role, provide adequate information about the options available or their rights, and the children were removed without their consent. The partnership said they were satisfied that they acted appropriately and within their responsibilities under Section 25 of the Children (Scotland) Act 1995 and that C did not object to the children’s removal. We reviewed the relevant case records and sought independent social work advice. Our investigation did not find adequate evidence to show that the social worker properly introduced themselves or inform C of their rights. We identified that there was a failure to contact health and education for further information, to contact C the following day, and to interview the children within a reasonable timescale. As such, we concluded the partnership did not follow reasonable process when responding to the child protection concerns raised. Therefore, we upheld the complaint.

C is a carer for their child and was previously in receipt of direct payments. C raised concerns that the partnership had said that C spent their direct payments inappropriately. C disputed that this was the case. They complained about the length of time taken to complete the Carers Respite Funding assessment and approve the budget and that the partnership overruled decisions made by C's allocated social worker about the use of C's Carers Respite Funding. In particular, C was concerned that they were not permitted to use their Carers Respite Funding to attend particular training courses or towards the purchase of a caravan/campervan. They also complained that the partnership told C that unspent budget could not be carried over into the next financial year; and that the partnership had not paid C Carers Respite Funding. We took independent advice from a social worker. We found that the majority of the partnerships actions regarding C's respite funding were reasonable. However, we also found that there was an unreasonable delay in providing C with a decision regarding their carer's respite budget for short breaks. We upheld C's complaint on this basis.

Mr C's child (Child A) suffered from a rare medical condition. Mr C complained that Child A and their family had not been provided with adequate care and support in the community. In particular, Mr C complained about the failure of the community nurse to visit and the failure by the partnership to provide him with the medical supplies Child A needed. The partnership had accepted that Mr C and his family had not received a reasonable level of support. We took advice from an independent nursing adviser who considered the action plan the partnership had drawn up in response to Mr C's complaint. We found the action plan was a reasonable response to the issues identified in the complaint. We also found the partnership had taken reasonable steps to address the failings of individual members of staff. We asked the partnership to provide further evidence showing the action plan had been completed. We upheld this aspect of Mr C's complaint, but made no further recommendations. Mr C also complained that the board failed to investigate his complaint properly. We noted that the partnership should have made it clear to Mr C that information about staff discipline could not be provided to him. However, we found that the boards investigation of Mr C's complaint was reasonable and did not uphold this aspect of his complaint. Finally, Mr C complained that although the partnership had apologised for failing to provide the appropriate support, they had continued to fail to order medical supplies for Child A. We found the partnership had failed to provide medical supplies as promised following Mr C's complaint. The partnership were, however, able to provide evidence that subsequently they had been able to consistently provide the medical supplies Child A needed. We upheld this aspect of Mr C's complaint but made no further recommendations given the action already taken by the board to fix the problem. Related reading View Decision Report 201804856 as a PDF (24.57 KB) Update

Mr and Mrs C complained about the partnership's management of their adult son's care (Mr A). Mr A's care was managed by the partnership for a number of years. The partnership moved Mr A's care away from his family base when they came to the view that the level of support he required could not be provided at that location. Mr and Mrs C complained that this was unreasonable and appropriate actions were not taken to allow Mr A's care to be provided closer to his family's home. We took independent advice from a social worker. We found that the partnership attempted to provide the support Mr A required close to home, and when this was not possible, appropriate steps were taken to ensure that he received the care he required elsewhere. The partnership reasonably communicated with Mr and Mrs C about the decisions that were being made and listened to their views. The partnership took reasonable steps to ensure Mr A was appropriately placed and received appropriate support. We did not uphold this aspect of the complaint. Mr and Mrs C also complained about the response to their complaint. The complaint was formed as a series of questions. The partnership's complaints handling procedure states that, where appropriate, the partnership should discuss the complaint with the complainant to understand why they are dissatisfied and what outcome they are looking for. As the partnership failed to clarify Mr and Mrs C's complaint, discuss the outcomes they were seeking by pursuing the complaint, and failed to clearly explain their findings, we upheld this aspect of the complaint.

Ms C complained about the failure of the partnership to follow their own complaints process. Ms C raised concerns about the service provided by social work to her child on at least two occasions. We found that the partnership did not recognise that Ms C's concerns were complaints and that the receipt of these complaints should have instigated the documented complaints process. As a result Ms C's concerns were not being formally assessed and responded to under the complaints process. Therefore, there was a delay in Ms C being signposted to our office and we upheld the complaint. However, when the complaint was eventually investigated by the board this was generally handled well.

Mr C complained about a pre-sentence report prepared at the request of the court by the partnership's criminal justice social work service. He considered that the process and the report itself were unreasonable. Mr C also complained about contact the social work service made with two third parties regarding his case. We took independent advice from a social work adviser. We found that the report and the process followed was reasonable and all relevant guidance was appropriately followed. We also found that there was no evidence of unreasonable contact with the two third parties. We did not uphold either of Mr  C's complaints. Related reading View Decision Report 201708286 as a PDF (23.6 KB) Updated: January 23, 2019

Mrs C complained about the partnership's handling of her complaint. In particular, that the person investigating her complaint was located in the same building as the social worker she complained about, that they would not accept further information from Mrs C to support her complaint, that they inaccurately maintained that Mrs C's solicitor was present at a meeting and that they contacted a witness to confirm their statement of facts when Mrs C said that she intended to bring her complaint to us. We found that the partnership had exercised their discretion regarding the person they chose to investigate and respond to the complaint. The partnership's complaints handling procedure does not state that a complaint should be investigated by a member of staff who is located in a different building to the staff complained about. We considered that the partnership demonstrated good practice in having initial discussions with Mrs C about her complaint and seeking her written agreement on the matters she wanted investigated. Whilst we found that the member of staff investigating the complaint should have advised Mrs C that she could raise additional issues as a new complaint, we noted that Mrs C was aware that she could do so. We found that the partnership had no evidence to show that Mrs C's solicitor was present at the meeting and we recommended that they apologise to her for continuing to maintain this. In relation to witness statements, the person investigating the complaint should have received all of the signed statements before issuing their final response to Mrs C's complaint. However, we did not consider that this had any material impact. We considered that the partnership's overall handling of the complaint was of a reasonable standard. Therefore, we did not uphold the complaint.