Summary: Ms X complains the Council was at fault as it failed to ensure the safety of her mother Mrs Y, while resident in a care home as she was attacked by another resident. We found no fault by the Council in the way it ensured Mrs Y’s safety and carried out a safeguarding referral. We found fault by the Council as it delayed responding to Ms X’s complaints about the matter. The Council has accepted it was at fault. It has already apologised which is suitable action for it to take so we have completed our investigation.

The complaint

1. I have called the complainant Ms X. She complains the Council failed to ensure the safety of her mother, Mrs Y while resident in a care home. Ms X says;
• The Council failed to properly investigate an incident in March 2021 when another care home resident caused Mrs Y harm.
• The Council allowed the offender to remain at the care home rather than move them to more suitable accommodation for their needs.
• The Council delayed telling the Police about the incident until she made a formal complaint.
• The coroner was not told of Mrs Y’s head injury on the day she died and there was no post-mortem. And no record of Mrs Y’s dementia or heard injury on the death certificate.
• The Council overlooked and delayed dealing with her complaints about the matter.
2. Ms X says this has caused her and Mrs Y’s family considerable distress.

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What I have investigated

3. I have investigated Ms X’s complaints about Mrs Y’s safety at the care home and the Council’s response to the incident in March 2021 and Ms X’s complaints. The final section of this statement explains why I have not investigated Ms X’s concerns about the coroner’s actions or decision on Mrs Y’s cause of death.

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The Ombudsman’s role and powers

4. The Ombudsman investigates complaints about the administrative actions of councils and certain other bodies. She cannot investigate the actions of independent judicial office holders. (Local Government Act 1974, sections 25 and 34(1))
5. A Coroner is an independent judicial office holder. The Ombudsman cannot investigate complaints about the conduct of Coroners.
6. 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)
7. If we are satisfied with a council’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)

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How I considered this complaint

8. I have read the papers submitted by Ms X and spoken to her about the complaint. I considered the Council’s comments on the complaint and the supporting documents it provided.
9. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

Law, guidance, and policies

Section 42 Care Act 2014

11. The Care Act 2014 and the Care and Support Statutory (CASS) Guidance set out the council’s safeguarding duties.
12. Section 42 of the Care Act 2014 says safeguarding duties apply to an adult who:
• has needs for care and support
• is experiencing, or at risk of, abuse or neglect
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect
13. If the section 42 threshold is met, then the local authority must carry out a safeguarding enquiry or ask another agency to do so.
14. A council must make enquiries if it has reason to think a person may be at risk of
15. The Council follows its CSAB Safeguarding Adults Procedure March 2021 to help support and protect adults at risk to live their lives free from abuse or neglect.
16. The Council uses the Safeguarding Adults Thresholds Tool and Guidance February 2021 to define harm and impact. Once a concern is reported to ASC it will decide how it will be logged based on the information provided and perceived level of risk. And whether it meets the statutory threshold for a S42 safeguarding inquiry. Once the Council decides the matter meets the statutory requirement to investigate further it will notify the Police.

Quality Care Governance

17. The Council’s Quality and Care Governance Framework sets out the approach the Council and its health partners take to secure high quality provision across all community, health, and social care provision. The Council’s quality care governance officers oversee quality monitoring and improvement in its area. They carry out proactive visits, reactive visits, and intervention either remotely or in person in response to concerns. The Council’s last visit to the care home focused on training records and found no issues.
18. The officers largely rely on intelligence gathering, information sharing and multi-agency working. It uses information from complaints and safeguarding concerns to decide if any extra support is needed. So, the Council can target resources where extra monitoring or support to improve quality is needed.
19. The Council uses reports from the Care Quality Commission (CQC) who last visited and rated the care home as good in 2018. In addition, the Council uses the safeguarding procedure, carries out ad hoc remote and telephone audits and refers the outcomes of safeguarding referrals to Quality and Care Governance.

Pre-admission assessments

20. The Council confirms it has measures and arrangements in place to assess each resident when they enter a care home. A social worker carries out a CSAB Safeguarding Care Act assessment of need which usually includes a multi-disciplinary assessment. If the Council considered a person a particular risk to themselves or others there would be a detailed risk assessment which is regularly reviewed. The care home manager also carries out a pre-admission assessment.

What happened in this case

21. This section sets out the key events in the case and is not intended to be a detailed chronology.
22. Mrs Y was frail and elderly with advanced dementia when she moved into the care home in 2015. In March 2021 Mrs Y suffered an unprovoked attack by another resident. The offender entered Mrs Y’s room during the night and hit her over the head with a plant pot. Mrs Y’s care records note her as being ‘fine’ after the incident, but Ms X says she suffered bruising to her head.
23. The care home referred the incident to the Council’s adult care services (ASC). ASC assessed the referral according to the Cumbria Safeguarding procedures. ASC decided the matter did not meet the criteria for a formal Section 42 safeguarding enquiry using the Cumbria Safeguarding Adults Board Multi- Agency threshold tool. This was because there was no allegation of abuse having taken place, no harm caused to Mrs Y and appropriate measures put in place by the care home. The Council also had measures in place to support a safe environment within the home for residents through its Quality Care Governance.
24. The social worker for the offender reviewed the situation with the care home and ensured it made the appropriate health referrals.
25. Ms X complained to the Council about the incident. Ms X said she and her sister were concerned about the incident but reassured it was being discussed at a meeting. Ms X assumed the Council would consider the welfare and safety of Mrs Y and other residents with the offender moved to more suitable accommodation. Ms X was disappointed at the decision not to investigate further. Ms X said the Council failed to consider Mrs Y’s safety and gave priority to the offender.
26. An ASC manager reviewed Mrs Y’s case and referred the incident to a safeguarding investigation. The Council says it took the decision on the same day it received Ms X’s concerns but was not prompted by her complaint. The Council progressed the case to a S42 enquiry and notified the Police of the incident as required. A social worker contacted the care home and updated Mrs Y’s family.
27. The social worker completed a risk assessment and noted action taken by the care home to ensure Mrs Y’s safety. This included putting a door sensor on her room in case anyone tried to enter during the night, staff increasing monitoring and actions about the offender.
28. The Council arranged a safeguarding meeting for April 2021 and responded to Ms X’s complaint. It noted Ms X’s concerns about Mrs Y’s care, and said it was holding a safeguarding investigation. This took precedent over a complaint investigation. So, the Council would consider her complaint once the safeguarding ended and they had an outcome.
29. Sadly, Mrs Y passed away a week later in April 2021 before the meeting was held. The Council cancelled the safeguarding meeting. A safeguarding officer spoke to family members to explain why it had stopped the safeguarding process as this normally happened when a person died. The officer offered to reconvene the safeguarding meeting if the family wanted this. The Council’s records note it was left with family members including Ms X to discuss matters with the care home manager.
30. The Council records note officers continued to be in contact with the care home about the offender. The care home manager reported staff were being vigilant and the offender’s social worker doing all they could to resolve the situation.

The Council’s response to Ms X’s complaints

31. Ms X contacted the Council in June 2021 as it had not responded to her complaint in March 2021. Ms X said this caused her distress. This was because she did not know if Mrs Y suffered any pain caused by her injury during her last few days as she could not communicate due to advanced dementia. Ms X felt the Council disregarded her concerns and its actions caused suffering to Mrs Y.
32. The Council apologised to Ms X for the breakdown in the way it managed her complaint. The Council confirmed it had addressed the error so it would not happen to anyone else. The Council said it would implement changes so other customers did not experience delays and frustration when trying to resolve a difficult situation. The Council said it was investigating Ms X’s complaint and would reply.
33. The Council responded to Ms X’s complaint and apologised for the delay in the complaints procedure. The Council told Ms X it could only provide limited information on her concerns about the offender.
34. The Council confirmed it carried out a safeguarding review when an adult died, and it knew or suspected the cause of death was abuse or neglect. This was a multi-agency process which considered whether the serious harm experienced by an adult could have been predicted or prevented. The coroner In Mrs Y’s case recorded the cause of death as dementia and did not request a post-mortem due to Mrs Y’s age at the time of death. The Council concluded from the coroner’s decision there was no correlation between the cause of death and any incident leading up to it. So did not consider it appropriate to carry out a safeguarding enquiry due to the coroner’s decision. The Council also considered it inappropriate to carry out other lines of enquiry where it was prevented from sharing or detailing information about another resident.
35. The Council reassured Ms X that when ASC decide to place an adult in a care home its officers work with the home. This was to understand whether a placement was suitable and able to meet the needs of the person being referred. In addition, care home providers carry out their own assessment to review the needs of the person before accepting the placement. Once a resident had a placement there are support plans and risk assessments in place to ensure the persons’ needs were understood and met. The Council said its officers also regularly review the arrangement to ensure it remained fit for purpose.
36. The Council says it holds no information to suggest the care home was not a suitable placement for the offender when they first became a resident at the home. It also does not hold any information in its records on any information requested by the coroner about Mrs Y. Ms X gave the Council information about the coroner’s actions when she advised the coroner did not carry out a post-mortem and the cause of death was dementia.
37. Ms X remains unhappy with the Council’s response to her complaints.
38. In commenting on the draft decision Ms X says the coroner stated Mrs Y’s death was from dementia, but the death certificate cited natural causes.

My assessment

39. Ms X considers the Council has failed to keep Mrs Y safe at her placement. The evidence shows the Council uses its Quality Care Governance framework and information gathering in place to ensure it provides high quality social care provision. It uses the safeguarding procedures and carries out risk assessments and draws up support plans for each resident when they enter a care home. The Council has provided a copy of Mrs Y’s support plan with the measures put in place for her. It also provided a copy of Mrs Y’s care records which show no concerns or incidents regarding her safety until the event in March 2021.
40. The Council confirms it holds no information to suggest the care home was not a suitable placement for the offender when they first became resident there. It is unfortunate that the offender acted in the way they did. But the evidence shows the Council dealt with the incident through the measures it has in place. These included the safeguarding process, ensuring the home carried out a risk assessment for Mrs Y and putting measures in place for her. There is no evidence of fault by the Council as it used the quality care governance procedures it has in place.
41. The Council’s documents show it received the safeguarding referral in March 2021 for Mrs Y and considered the incident. The Council decided it did not meet the threshold for a referral at first. While Ms X may disagree with the Council’s decision it is one it is entitled to make. The Council has recorded and explained the reasons for its decision as we would expect. There is no evidence of fault in the way the Council reached its decision .
42. The Council reviewed the decision as its procedures allow and decided to make a referral. The Council arranged a safeguarding strategy meeting to discuss the incident but cancelled it after Mrs Y passed away. This is again a decision for the Council as the risk to Mrs Y had ended. It was also supported by the coroner’s decision the head injury was not the cause of Mrs Y’s death.
43. Ms X remains unhappy the Council allowed the offender to remain at the care home rather than move them to more suitable accommodation for their needs. The evidence shows that this was an issue the Council looked to address with the offender’s social worker to resolve the situation. The documents show the Council continued to deal with the issue of the offender even though it cancelled the safeguarding meeting about the incident.
44. The Council confirms it did not delay notifying the Police or that it took the action due to Ms X’s complaint. The Council records show the review of the decision on a safeguarding referral took place on the same day the Council received Mrs X’s complaint. But it did not prompt the safeguarding decision. Once an alert moves to a Section 42 investigation the Council tells the Police. Because of this I am satisfied the Council followed its procedures and told the Police on the day it decided the incident met the requirements of the section 42 investigation. So, the Council did not delay telling the Police about the incident.
45. The Council accepts it overlooked and delayed dealing with Ms X’s March 2021 complaint about the incident after the safeguarding investigation was cancelled. This is fault by the Council and caused an injustice to Ms X as she was waiting for a response from the Council to her concerns. However, the Council apologised to Ms X when it responded to her complaint which I consider is suitable action for it to take and remedies the injustice caused to Ms X. The Council has also taken action to ensure there are no delays in dealing with similar cases in the future when a complaint is on hold due to a safeguarding investigation.

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Final decision

46. I am completing my investigation. There is no fault by the Council in the way it ensured Mrs Y’s safety while resident at a care home and carried out a safeguarding referral. But there was fault by the Council as it delayed in responding to Ms X’s complaint about the matter. The Council has accepted it was at fault. It has apologised already which is suitable action for it to take.

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Parts of the complaint that I did not investigate

47. Ms X has raised concerns the coroner did not request a post-mortem into Mrs Y’s cause of death or record Mrs Y’s dementia or head injury on the death certificate. Ms X raised concerns about the lack of information given to the coroner about Mrs Y’s head injury. These and the information given to the coroner are not matters we have any power to investigate. This is because Coroners are judicial office holders, and their decision can only be challenged in the courts by judicial review. Ms X will need to raise any concerns she may have directly with the coroner.

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Investigator's decision on behalf of the Ombudsman