Seashell Trust

3. Mrs A complains about aspects of care and treatment her son received from charity in Stockport (the Charity) while he was in respite. She specifically complains: • her son was placed in a respite house with a peer on 17 August and 28 September 2024 despite her requests for her son not to be placed with them • the Charity failed to raise a safeguarding alert in response to the incidents • because of the complaint her son did not have his regular Saturday respite stays • complaint responses were not factual and did not acknowledge the harm done.

4. She says as a result, her son to isolated himself and he experienced anxiety which resulted in self-harm and increased seizures.

5. She is seeking service improvements and financial remedy.

6. On 20 July 2024 an incident occurred between Mr A and a peer where Mr A was pinched. Mrs A emailed the Charity on 20 July to ask her son to be separated from this peer.

9. The Charity is a learning disability charity providing care and support to children and young adults with learning difficulties. The care was funded and commissioned by Greater Manchester Integrated Card Board (ICB). Extra inpatient stays were authorised by the ICB.

17 August and 28 September 2024

10. Mrs A complains the Charity placed her son, Mr A, in a respite house with a peer on 17 August and 29 September despite her requests the two not to be placed together.

11. An incident occurred on 20 July 2024 between Mr A and a peer at the Charity. Mrs A emailed the Charity on 20 July to ask her son to be separated from this peer. She says this did not happen on 17 August and 29 September.

12. On 23 October, in its first response, the Charity accepted Mrs A had requested her son not be placed with the peer following the incident on 20 July. It said a discussion took place between the Charity manager and Mrs A after this incident. Mrs A’s son’s next few visits were checked. The Charity acknowledged it did not adequately check all of Mr A’s bookings.

13. The Charity accepted Mrs A’s son had been placed with the peer on 17 August and 29 September. The Charity manager said this should not have happened and undertook reflective practice with her line manager. The Charity apologised.

14. We consider there is no disagreement about the failing here. The Charity has accepted there were failings surrounding the bookings. Mrs A explains being placed in a room with the peer caused her son to isolate, it gave him anxiety which manifested in self-harm and increased seizures. We will now consider this if this failing led to the claimed impact and what actions the Charity has taken.

15. We have reviewed the records. We are not considering the event of 20 July here. We are considering the impact of being placed at a respite house at the Charity on 17 August and 28 September with a specific peer.

16. The notes on 17 August acknowledge Mr A was a little anxious on arrival. Staff asked if he wanted time to himself which he accepted and watched TV in his room. The notes say following this he returned to his baseline and seemed more relaxed throughout the night. The notes state he did not want to go down for his tea at first due to the peer being present. It notes once he did want to eat tea, he ate it all. The notes acknowledge he was feeling anxious because of his peer. The records note he had a good night’s sleep with no issues or concerns.

17. The notes on 18 August do not indicate any incidents of isolation, anxiety, self harm or seizures. We have reviewed the seizure sheet provided. There is no noted seizure on 17 or 18 August. The next noted seizure after this stay is dated 27 August.

18. On 28 September the notes set out at 3.55pm Mr A seemed very anxious and wanted to watch TV in his room. At 5.43pm it is recorded he felt happy but anxious. It is noted he responded he was happy when asked by staff but appeared anxious around the peer whom he and incident with on 20 July.

19. An email was sent by the Charity to Mrs A at 8.53pm. It explained Mr A had become unsettled due to his peer. He spent a lot of time in his room but was happy to watch TV. He also did not eat all his tea. It also said he seemed happy, but was anxious around his peer.

20. On 29 September at 6.58am it is noted Mr A slept throughout the night. The notes during this day indicate he was happy. There are no notes of incidents of isolation, anxiety, self harm or seizures. Mr A was picked up by his mother at 12pm.

21. We have reviewed the seizure sheet provided. There is no noted seizure on 28 or 29 September. The next noted seizure after this stay is dated 4 October.

22. In considering the impact, on 17 August and 28 September there is evidence Mr A for some of the time he was at the Charity he chose to remain in his room due to the presence of the peer. It is also recorded Mr A was anxious. We have seen no evidence of seizures or self harm. It appears by the next day Mr A was no longer anxious or isolating. The notes indicate Mr A was happy.

23. Our financial remedy guidance states a case will generally be level one if we consider the person affected has experienced a low impact injustice, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. At this level we do not consider a financial remedy to be appropriate.

24. In line with our financial remedy guidance, we have seen on the second day of respite there were no other adverse effects. The impact was of a short duration and the notes indicate while Mr A was in his room, he was happy watching TV.

25. Mrs A is also seeking service improvements. We can see following the complaint, the individual responsible for informing Mrs A her son would not be placed with a peer undertook reflective practice with their manager. We can see from the complaint records further discussions with Mrs A and her son’s future bookings were discussed.

26. NHS Complaint Standards say:

‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. They are clear about how the learning will be used to improve services and support staff.’

27. In line with the complaint standards, the Charity was accountable and clear with its learning. We consider this action was appropriate.

28. We are sorry to hear of Mr A’s experience. We acknowledge Mrs A’s frustration her son was placed with a peer after she had requested him not to be. The Charity have not disputed the failing. We have considered the Charity have taken appropriate action to put things right. The Charity have apologised and implemented service improvements. We will take no further action on this complaint.

Safeguarding

29. Mrs A complains the Charity should have made a safeguarding referral following the incidents on 20 July, 17 August and 28 September 2024. This was not raised in the initial complaint and was included in an email on 9 October 2024.

30. The Charity responded on 23 October 2024. It explained when there are incidents of suspected, or actual, physical harm it considers whether it is a reportable safeguarding incident. It uses Stockport's Safeguarding Adults Partnership Risk Matrix and Decision-Making Tool. This incident was assessed as low risk and there was no requirement to report it.

31. We have reviewed the records.

32. On 20 July Mr A attended the Charity. At 4.10pm, an incident occurred between Mr A and a peer when Mr A was pinched in the kitchen. Following the incident Mr A began to shout and it is recorded he was not receptive to communication to calm down. It is noted he removed a member of staff’s glasses and threw them. He also threw items off the kitchen table.

33. Staff at the Charity stood outside the kitchen door and observed through the glass. It is noted Mr A then stood in the corner and appeared to be attempting to calm. Staff re-entered the room and Mr A was receptive to their presence. It is noted in total the incident lasted 30 minutes. The Charity did not record any evidence of bruising or red marks.

34. A member of staff has recorded the events in an incident report.

35. The Charity uses Stockport's Safeguarding Adults Partnership Risk Matrix to determine risk. The Risk Matrix is designed for multi-agency professionals to use before making a referral to the local authority. We have reviewed this. It says the level of risk or severity can be considered low if it was:

• ‘Unintended action with no lasting impact • Isolated incident or a ‘one off’ • Little to no impact • No one else affected or impacted • Unintended or unplanned incident • Bad practice but no illegal • Unlikely to reoccur’

36. The Risk Matrix explains if an incident is a low level it should be managed internally and is not a safeguarding concern.

37. We have reviewed what happened against Stockport's Safeguarding Risk Matrix. We acknowledge the incident led to Mr A throwing items in the kitchen. He removed a member of staff’s glasses and shouted. We have seen the incident lasted 30 minutes. We have not seen evidence of a lasting impact. We consider this was an isolated unplanned incident and no one else was affected or impacted.

38. We have also considered the Charity’s Safeguarding Policy, September 2023. It contains the procedures the Charity should follow. The procedures are detailed in appendix four. The Process are separated into sections:

Adults - Immediate danger or risk of harm Adults - Cause for concern (no immediate risk of harm)

39. The Charity did not consider there was an immediate danger or risk of harm. It therefore followed the cause for concern process. This says:

‘Report your concern to a line manager or Head of Service and ensure that your concern is detailed and factual. Depending on what the concern is related to will determine the next course of action and may include taking guidance from the Designated Safeguarding Lead poster and contact formation, Allegation Management procedures, Accident, Incident, Body Map procedure’

40. As noted above, the risk matrix explains a low level incident should be managed internally. We consider it was appropriate for the Charity to follow its adults cause for concern policy. A report of the incident was recorded on 20 July, and no safeguarding referral was made. This is line with the Charity’s own policy and the risk matrix.

41. We have already noted the events of 17 August and 29 September above. We have seen Mr A did show signs of anxiety and there is no evidence to suggest any physical harm occurred on these two days. We have not seen evidence of any events on these two days which would be considered medium or high risk on the risk matrix. The Charity acted in line with the safeguarding guidance and there was no requirement to raise a safeguarding concern on these days.

42. It is understandable the incidents on 20 July, 17 August and 28 September 2024 would give Mrs A reason to be concerned for her son. We have seen the Charity acted appropriately and in line with its own policy and local guidance. We have not seen evidence the events complained about reached the threshold of a safeguarding referral. There is no indication of a failing here.

Saturday

43. Mrs A complains in response to the complaint her son was not booked on his regular Saturday respite stays.

44. The Charity explained following the incidents, and Mrs A’s complaint, it spoke with Mrs A and rescheduled some dates. It acknowledged there were five dates which were cancelled as the peer would also be present at the respite house.

45. We have reviewed the records.

46. Mrs A made her first complaint on 30 September 2024. In this complaint she confirmed in July she did not want her son to be placed at the Charity with the specific peer. On 3 October the Charity emailed Mrs A. It explained there were five dates between 12 October and 7 December in which the peer involved in the incident would be in attendance. The Charity provided 11 alternative dates if Mrs A wished to reschedule.

47. On 3 October at 1.04pm Mrs A responded. She acknowledged the Charity was trying to resolve the issue however she did not see why her son should be impacted. She requested some consideration to changing her son’s peer’s days.

48. The Charity responded on the same day and confirmed the peer’s family had made some alterations. It confirmed the five dates in which both Mr A and peer were due to attend it could not change. The Charity confirmed the next day it had no control of bookings onto its service.

49. We have considered Care Quality Commission (CQC), regulations for service providers and managers. It says:

‘Regulation 9: Person-centred care 1. The care and treatment of service users must: a. be appropriate, b. meet their needs, and c. reflect their preferences.

3. Without limiting paragraph (1), the things which a registered person must do to comply with that paragraph include: h. making reasonable adjustments to enable the service user to receive their care or treatment’

50. In line with CQC regulations point one, we consider the Charity has reflected the needs of Mrs A and her son. Mrs A had requested her son not be placed with a peer. In line with point three, the Charity provided alternative dates so Mrs A’s son could attend the Charity. We acknowledge Mrs A was frustrated as her son usually attended on a Saturday. We would not consider it a reasonable adjustment to ask the Charity to cancel another service user’s booking. The Charity has a responsibility to provide care to all who need it.

51. We can see how important routine is to Mrs A’s son. We do not underestimate the impact not having his regular Saturday routine would have had upon him. We can see the Charity has considered Mrs A’s requests not to place her son with a peer. We consider the Charity’s offer of alternative dates are in line with CQC regulations. We consider it has got nothing wrong here.

Complaint

52. Mrs A complains the Charity’s complaint responses were not factual and did not acknowledge the harm done. She tells us the complaint responses were inadequate, and the Charity has not understood the stress and upset each response caused.

53. As this is about the complaint responses themselves, the Charity has not commented on this aspect. The Charity provided three complaint responses. The first on 23 October 2024 the second on 11 November and the third on 23 December

54. We have reviewed the complaint responses in line with the NHS complaint standards.

55. As already noted above, the Charity has been open and honest when things have gone wrong in line with the complaint standards.

56. The complaint standards say senior staff should make sure appropriate structures are in place to deliver fair and robust complaint investigations.

57. We can see throughout the complaint process the Charity made Mrs A aware of what stage her complaint was at. After the first response, Mrs A requested the complaint move to stage two. After the second response, Mrs A requested stage three. We consider the Charity met this standard.

58. NHS Complaint Standards say:

‘Welcoming complaints in a positive way Staff respond to complaints at the earliest opportunity and consistently meet expected timescales for acknowledging a complaint. They give clear timeframes for how long it will take to look into the issues, taking into account the complexity of the matter.

Being thorough and fair Staff actively listen and demonstrate a clear understanding of what the main issues are for the person who has made the complaint, and the outcomes they seek.

Staff give everyone involved in a complaint the opportunity to give their views and respond to emerging information, where appropriate. They take everyone’s comments into account and act openly and transparently and with empathy when discussing this information.’

59. We can see Mrs A raised her complaint on 1 October 2024. Within three months the Charity issued three responses. We consider it responded at the earliest opportunity to resolve Mrs A’s complaint. We can see in each response the Charity listed clearly the issues Mrs A’s wishes to discuss. This is done before going into each aspect in more detail. As noted above, the Charity issued three responses. We consider the Charity gave Mrs A an opportunity to respond and gave her view. We consider the Charity met these three standards.

60. NHS Complaint Standards say:

‘Giving fair and accountable responses Staff give a clear, balanced account of what happened based on established facts. Each account compares what happened with what should have happened. It clearly references any relevant legislation, standards, policies or guidance, based on objective criteria’

61. We can see in the complaint responses the Charity referred to the records in its explanation. It has provided the guidance and legalisation it relied upon to form its view. We acknowledge Mrs A says the complaint responses are not factual. Disagreeing with a decision made by the Charity does not mean it is not factual. We consider the Charity’s complaint response is a balanced account based on established facts.

62. We can see the Charity acknowledged it had booked Mrs A’s son on the same day as a peer despite Mrs A’s requests. The Charity provided an apology for this. This is in line with NHS Complaint Standards. The Charity has acknowledged what went wrong. We acknowledge Mrs A says the Charity have not acknowledged the impact this has had and the family. This is a subjective view. We have not seen the Charity has failed to acknowledge what went wrong. It apologised for the distress and anxiety caused.

63. We understand how important this complaint is to Mrs A. We do not underestimate the impact these events have had on her and her family. We consider the Charity provided complaint responses in line with the NHS complaint standards. We acknowledge Mrs A does not agree with the responses. We consider there is no failing here. We will take no further action.

1. We have carefully considered Mrs A’s complaint about a charity in Stockport (the Charity). We understand how important it is to feel your child is safe and comfortable at respite care. We recognise how stressful it is when a family member is unsettled and the support you need as a family need is not available as you would like.

2. The Charity have taken appropriate action to put things right regarding Mrs A son’s placement. We have not seen it got anything wrong regarding safeguarding, respite bookings and complaint handling.