Leicestershire County Council at fault for failing to do a risk assessment prior to an essential visit to a care home, and failing to take the appropriate PPE equipment which placed a person at an increased risk of harm

Decision Date: 17th March 2021

What Happened

Mrs X complained on behalf of her adult son, Mr Y, who had been living in a care home. 

In July 2020, a safeguarding concern was raised regarding the care home Mr Y was staying in, which resulted in the police, the Council and the CQC visiting the home at the same time. 

Mr Y was funded by a different authority to the one leading the safeguarding enquiry. 

The Police made enquiries into potential criminal activity and the CQC undertook an inspection which concluded improvements were required.

The Council attended in case the police needed to move people from the accommodation.

After the visits, Mrs X complained to the Council about previous actions taken by a social worker (social worker A). Mr Y had been upset by the visit, and Mrs X complained on his behalf that social worker A had:

  • accessed Mr Y’s notes without his permission and did not tell him how the information gathered would be stored;
  • put Mr Y at risk of contracting COVID-19 by not sanitising her hands, failing to wear a medical face mask, a face shield, gloves or an apron;
  • spoken to Mr Y for 50 minutes and sat less than 1.5 metres away from him; and
  • failed to share the risk assessment (undertaken before visiting the home) with Mr Y.

The Council replied in August, but explained the actions of a social worker manager, rather than social worker A’s actions. It stated that the social worker manager had:

  • visited the care home with her team, the Police and the Care Quality Commission in response to safeguarding concerns;
  • spoken to Mr Y in a smoking shelter and explained they were undertaking an investigation
  • maintained a two-metre distance from Mr Y at all times, wore a cloth mask and gloves provided by the care home, and used hand sanitizer when moving between tasks
  • did not access Mr Y’s notes, only his care plan record; and
  • did not store information on the Council’s system about him.

Mrs X remained unsatisfied with this response. She wrote back to the Council highlighting that she had not been complaining about the social worker manager, but about social worker A. 

She had been told by her son that when the first social worker had been told she could not access his records, she had said “You think you are the boss; you are wrong, I am” and read them without his consent.

She also stated that the Council was incorrect, as the social worker manager had not worn a facemask nor kept two metres away from him, because the smoking shelter was smaller than two metres in size. 

Mrs X also asked that the Council provide the outcome of the risk assessment undertaken before visiting the care home. 

The Council replied in October 2020, stating that it could not share details of the safeguarding concerns or the risk assessment as they contained confidential information. It maintained that the visit followed PPE guidance for frontline care pathway staff undertaking essential visits; the visit was essential, and there was no need for officers to wear PPE as they could remain more than two metres away from people. It still did not provide a risk assessment for the visit. 

The Council stated that it had no concerns over social worker A leading the safeguarding enquiry.

What was found

The LGSCO did not make any specific reference to either of the social workers’ actions. 

The Council was not at fault for the visit in July, as it was a response to safeguarding concerns. However, the Council should have been able to provide a copy of the risk assessment, and there should have been one, amounted to fault. The LGO considered that no risk assessment had been undertaken, even though the council had implied that there was one. 

The LGO said that the council officers would not have known what level of PPE would have been appropriate until they got to the care home, so should have had surgical masks with them. The fact that they did not, was fault. The LGO emphasised that this failure put Mr Y at risk of harm. 

At the time of the visit, the government had no official guidance for social workers in relation to PPE. However, when guidance was introduced, it required the use of surgical face masks but not the use of gloves or aprons. Therefore, the LGO stated that there “would have been no specific need for officers to wear gloves or aprons when visiting Mr Y”. The LGO did however recognise that each establishment would have its own requirements, which is why the Council officers agreed to wear gloves provided by the care home. 

The LGO recommended that the Council:

  • apologise to Mr Y for the distress it caused to him and the failure to do a proper risk assessment before visiting the care home;
  • ensure officers do risk assessments and record them before visiting people in their homes and take appropriate PPE with them to cover all possibilities.

Points for the public

It is difficult to tell what was really going on in this complaint; one can’t be sure whether Mr Y was perceived as a victim or as a perpetrator of the concern being investigated, and that is no doubt because the LGSCO wishes to protect everyone’s right to anonymity here.

When a local authority on the spot has to go and do safeguarding, the staff were absolutely within lockdown law to go and visit – they were acting in the course of a legal duty and doing their jobs. But of course they have to abide by Guidance, and the situation in a care home was acknowledged to require PPE. 

We can’t guess why the LGSCO says nothing about the actual diameter of the smoking shelter, since the council would appear to have been defending itself on the basis of the facts – and the facts could have been nailed. 

Neither can we guess why nothing was said about the allegation that the first social worker used hugely inappropriate language regarding access to records, in the face of lack of consent from a person who was not that safeguarding council’s client. 

The last puzzle is whether or not there was a risk assessment before the visit occurred. A risk assessment in this sort of situation is just posh language for this question: did anyone turn their minds to what they might have to do when they got there, and whether that required them to prepare for any duties that might arise – whether those duties would have been derived from the lockdown regulations, government guidance or the wider law, or simply out of respect for the care home’s staff and residents and any policies that there might have been in place there, for visiting, whatever the purpose. Here, the council implied that it had done one but the family could not have sight of it; but the LGSCO appears to have decided that none had occurred, and that one should have been done. Frustratingly, the LGSCO doesn’t analyse the question as to who should have been entitled to SEE that risk assessment. We would have thought that it was the Home’s management, in the first instance. 

The same principles would have applied to the police and CQC of course, but the LGSCO has no jurisdiction there, so we are not surprised to find nothing about that.

We cannot begin to estimate the number of complaints that there will be about this sort of thing once the LGSCO gets into its stride about incidents driven by the unique circumstances of early lockdown and it is too soon as yet to make any evaluation of the extent to which the legal framework was or was not complied with, in the sector, to our minds.

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The full Local Government Ombudsman report of Leicestershire County Council’s actions can be found here


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