Summary: The Council failed to ensure a safeguarding investigation carried out by another Council into the care the late Mrs Y received at a care home, was completed properly. It failed to take adequate action to chase the progress and outcome of the investigation. Consequently, any poor care may have gone unchallenged. This may have had implications for Mrs Y and other residents. The Council also failed to communicate with Mrs Y’s daughter and failed to deal with her complaints properly.

The complaint

1. Ms X complains the Council failed to deal with her complaints about the quality of care her late mother received at a care home.
2. Ms X has pursued the complaint for some time, despite this she has not received a response from the Council.

What I investigated

3. I am only investigating the actions of London Borough of Haringey Council (Council 1), not the actions of a neighboring Council (Council 2). The final section of my statement explains why.

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The Ombudsman’s role and powers

4. 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)
5. 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

6. I have:

• considered the complaint and discussed it with Ms X;
• considered the correspondence between Ms X and the Council, including the Council’s response to the complaint;
• made enquiries of the Council and considered the responses;
• taken account of relevant legislation;
• offered Ms X and the Council an opportunity to comment on a draft of this statement, and considered the comments made.

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What I found

7. If a council funds a person’s care in a care home, it remains responsible for the care. This was the case for Mrs Y.
8. Adult safeguarding means protecting a person’s right to live in safety, free from abuse and neglect. The Care Act 2014, requires that each local authority must:

• Make enquiries, or ensure others do so, if it believes an adult is, or is at risk of abuse or neglect. An enquiry should establish whether any action needs to be taken to stop or prevent abuse and neglect, and if so, by whom.

9. Government guidance states that early sharing of information is key to providing effective help where there are emerging concerns. Fears of sharing information must not stand in the way of protecting the well-being of adults at risk of abuse and neglect.

Background

10. Mrs Y lived at Lennox House Care Home, (owned and operated by Care UK) from November 2015. She had vascular dementia, diabetes and some mobility issues. The home is in the borough of Council 2.
11. Mrs Y was admitted to hospital in July 2017 and sadly passed away on 21 August 2017.
12. Mrs Y’s family first raised concerns with Council 1 in December 2016. Issues included poor hygiene, food quality, personal care, staff attitude, medication, and the existence of a DNR (do not resuscitate) to which neither Mrs Y nor Ms X had agreed but was communicated to the hospital and may have affected the treatment Mrs Y received.
13. As Mrs Y passed away in 2017, I do not propose to investigate the allegations listed above. However, I do intend to investigate how the Council responded to the concerns/complaints raised.

What happened

14. Ms X began raising concerns with Council 1 about the quality of care provided at the care home in 2016. Council 1 raised a safeguarding alert on 15 December 2016. It closed the alert the following day, saying ‘risk reduced’. The reason for this decision was recorded “An email has been sent to [Council 2] Access Team asking them to advise who the allocated worker is and for the allocated social worker to inform Haringey Adults Safeguarding Team of the steps taken to safeguard [Mrs Y]”.
15. An inspection of the care home by the Care Quality Commission (CQC) in 2016 raised concerns about the overall care provision and management of the care home. Council 1 held a multi-disciplinary meeting in March 2017, following this, an action plan was devised. The CQC had a separate plan.
16. In July 2017, Ms X, and other family members contacted Council 1 again to express concerns about the care Mrs Y was receiving. They were particularly concerned she had developed a grade 4 pressure sore and was not being turned regularly. Council 1 raised a safeguarding alert on 27 July 2017. A ‘Safeguarding Concern’ form was completed. The social worker recorded she had arranged to visit the care home to review Mrs Y’s care, meet with her family, and raise the concerns with the care home.
17. Mrs Y was admitted to hospital on 15 July 2017.
18. On 27 July 2017 Council 1 completed a safeguarding triage form. The section on the form asks, if the person is an ‘out of borough placement’, it is marked, ‘yes’, and records Council 2 had made the placement within Council 1. This is incorrect it was Council 1 who placed Mrs Y in Council 2’s area.
19. On 9 August 2017, Council 1 alerted Council 2 to the safeguarding concerns.
20. The records show a social worker in Council 1 was unclear about which Council was responsible for undertaking the safeguarding investigation. The officer sought advice from another officer in the safeguarding team, who responded on 11 August 2017 saying, “It is the responsibility of the Local Authority where client is placed i.e [Council 1] Social Services) We have to be careful not to merge the two. This is a Care home under an embargo with serious high risks. I suggest that you ask the LA when/if they have commenced their investigation and any information you have obtained to pass to them”.
21. Council 1 asked the care home for the care records relating to Mrs Y’s pressure area care and asked it send copies to Council 2.
22. In August 2017 Council 1 closed the ‘Safeguarding Triage’. It recorded “Mrs Y] is currently placed at Lennox House Care Home in [Council 2] so [Council 2] will have to lead with this alleged enquiries”.
23. Council 1 decided to carry out an unannounced inspection of the care home on 23 August 2017. This highlighted numerous concerns. It suspended any new placements, saying, “Our primary concerns are around high turnover of management staff, use of agency staff, poor communication and the impact this is having on clinical aspects of care particularly”.
24. A social worker from Council 2 sent an email to Council 1 on 23 August 2017 saying she had been unable to visit Mrs Y in the care home due to work pressures, and she had been informed Mrs Y had been admitted to hospital. She said she intended to visit the care home on 24 August 2017 to look at the care home’s records and would commence initial safeguarding enquiries and inform Council 1 of the outcome.
25. On 5 September 2017 Council 1 received an update from Council 2 about an action plan to address the general concerns about the care home. Council 2 made no reference to safeguarding investigation into Mrs Y’s care.
26. Council 1 did not receive any further information relating to the safeguarding investigation. It sent chaser email to Council 2 on 12 September 2017.
27. Ms X says despite contacting Council 1, and Care UK numerous times she received no response.
28. In October 2018 Ms X made a complaint to this office. We decided the complaint was premature and passed it back to Council 1 to deal with. Council 1 sent another email to Council 2 on 12 November 2018 chasing a response to earlier emails requesting copies of the safeguarding documents.
29. Council 1 received a response from Council 2 on 14 November 2018 saying, “The safeguarding enquiry was closed on the 17th of November 2017. The outcome concluded “neglect and acts of omission - was substantiated”. It did not inform Ms X. Council 1 requested a copy of the safeguarding minutes the same day. It received no response.
30. Ms X contacted this office again in February 2019 to say she had not heard from Council 1 so we contacted Council 1 again on 18 February 2019 for an update. It sent chaser emails to Council 2 on 19 & 20 February 2019. It received no response. It did not inform Ms X.
31. In response to my enquiries Council 1 said it has not been able to obtain the safeguarding documentation from Council 1 and “[Ms X] is being written to today explaining the delay and will be provided with a point of contact in the service until the matter is resolved”.
32. A CQC inspection report of the care home dated January 2019 shows the care home still requires improvement and found “…concerns relating to regulation 11, 12 and 17 of the Health and Social Care act 2008 (Regulated Activities) Regulations 2014. We found that the provider had not effectively operated systems and processes to monitor and improve the quality and safety of the service. The provider was not following the requirements of the Mental Capacity Act 2005 (MCA). We also found that people at risk of falls were not properly assessed and monitored”.
33. Council 1 says it is, along with Council 2 …” working closely with Care UK to keep track of improvements made as per their improvement plan”.
34. Council 1 says, “unfortunately there continues to be ongoing delays due to lack of information returned by [Council 2] despite numerous emails to multiple individuals. We have received no minutes of any safeguarding meetings in relation to [Mrs Y]…”When our officers visited Lennox House on 06 March 2019, we were informed that Lennox House also were not given any minutes to safeguarding meetings in relation to [Mrs Y]”.
35. Council 1 says it no longer places people at the care home. However, it has two people still placed at the care home and says it reviews them on an annual basis.
36. In response to my enquiries Council said “We have approached Lennox House and asked that they comment on the complaint, as requested. However, we have received no response to this request”.

Analysis

37. There are a number of elements in this complaint which require consideration. Did Council 1 respond adequality when concerns were raised in 2017, did it do enough to chase up the progress/outcome of the safeguarding investigation, and did it communicate effectively with Ms X.
38. Council 1 was not responsible for undertaking the safeguarding investigation, Council 2 was. However, Council 1 remained responsible for Mrs Y’s well-being.
39. On Council 1’s safeguarding triage form it wrongly recorded that Council 2 had made an ‘out of borough placement in Council 1’s area. This was incorrect. Council 1 made the placement in Council 2’s area. It is essential that the facts are recorded accurately, however I have seen no evidence that any injustice arose from this error.
40. Council 1 passed the safeguarding alert to Council 2 on 9 August 2017. I have not seen any evidence which shows it informed Ms X about this. It should have done so. Mrs X had a right to be kept informed about the progress of the investigation.
41. Council 1 received an email from a social worker at Council 2 in August 2017 to saying she had not been able to visit Mrs Y due workload pressures but intended to do so on 24 August 2017. This should have been a cause for concern for Council 1. It should have addressed the delay with Council 2.
42. Council 1 received an update from Council 2 on 5 September 2017, but this information related to general concerns about the care home, not about Mrs Y. Council 1 sent an email to Council 2 on 12 September 2017 asking for an update on the safeguarding investigation. It received no response. Council 1 took no further action to chase Council 2 until November 2018, after Mrs X complained to this office, and we contacted Council1.This is unacceptable. Council 1 had been aware of concerns about the overall quality of care provided by the care home since late 2016, it also commissions care for other residents at the home. It should have taken robust action to ensure it was kept informed about the progress of the safeguarding investigation, and closely monitored the wellbeing of other residents it was responsible for. It failed to do so.
43. In November 2018 Council 1 was informed by Council 2 the safeguarding investigation concluded neglect/act of omission. Council 1 requested the safegaurding notes. It received no response. It took no further action until Ms X contacted this office again in February 2019, after which we contacted Council 1 to ask for an update. This delay in unacceptable. Council 1’s actions have been reactive, not proactive. It acted only in response to prompts from this office and appears to accept the lack of response from Council 2 without robust challenge.
44. Council 1 says it could not obtain the safeguarding documents from Council 2. This is not good enough. Officers from Council 1 should have escalated the matter to senior officers to deal with.
45. The Care and Support Statutory Guidance - 14.43 says “Early sharing of information is the key to providing an effective response where there are emerging concerns…To ensure effective safeguarding arrangements:

• All organisations must have arrangements in place which set out clearly the processes and the principles for sharing information between each other, with other professionals and the SAB; this could be via an Information Sharing Agreement to formalise the arrangements”.

46. The Guidance also sets out Council’s responsibility to hold other safeguarding adult boards to account. Council 1 failed to ensure the safeguarding investigation by Council 2 was completed in a timely manner and failed to act when relevant documents were not received. Consequently, any poor care could have continued. This may have had implications for Mrs Y and other vulnerable residents.
47. I note the 2019 CQC inspection report of the care home found improvements were needed. The issues identified correlate with the concerns Ms X raised in 2017. Although Council 1 no longer commissions new placements at the care home, it is responsible for two residents living there. It says it undertakes annual reviews unless circumstances change. Under the circumstances this is not adequate. Given the historical and ongoing concerns about the care home Council 1 should have closely monitored the resident’s welfare.
48. Council 1 failed to communicate effectively with Ms X. It failed to keep her informed about the difficulties in communication with Council 2 and failed to inform her of the outcome of the safeguarding investigation. Ms X has been denied a timely and fair investigation into the concerns she raised. This caused her prolonged distress and uncertainty. This has been compounded by the way the Council handled her complaints about this. Since 2017, Ms X made numerous verbal and written complaints to the Council, and to Care UK, neither of which has been dealt with properly.

Agreed action

49. The Ombudsman’s guidance on remedies recommends a symbolic payment for avoidable distress. A remedy payment for distress is often a moderate sum between £100 and £300. The Ombudsman can also make symbolic payments for uncertainty and time and trouble.
50. In this case the upper distress payment for Ms X is appropriate because Ms X has suffered ongoing distress and uncertainty since 2017.
51. Therefore, in recognition for the faults identified above Council 1 will within four weeks of the final decision:

• provide Ms X with a written apology from a senior officer and make a payment to her of £300 for the distress and uncertainty she experienced because of a lack of information about the safeguarding investigation
• pay Ms X £250 to acknowledge the time and trouble she has been put to pursuing this matter since 2017
• Council 1 should provide Council 2 with a copy of the final decision statement
• Council 1 should provide Care UK with a copy of the final decision statement
• Council 1 should escalate issues of communication and collaborative working around safeguarding with Council 2 to director level to address. It should develop an action plan of how to improve its communication and continue to work with Council 2. It should share this information with the Ombudsman
• Council 1 should take steps to ensure the wellbeing of the remaining residents at the care home for whom it commissions care and continue to review on a regular basis - no less than every six months.

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Final decision

52. Council 1 failed to ensure a safeguarding investigation by Council 2 was completed in a timely manner. Consequently, any poor care may have gone unchallenged. This may have had implications for Mrs Y and other vulnerable residents. It also failed to communicate with Ms X and failed to deal with her complaints properly.
53. The above recommendations are a suitable way to settle the complaint. It is on this basis the complaint will be closed.
54. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I intend to send it a copy of the final decision statement.

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Parts of the complaint I did not investigate

I have not investigated the actions of Council 2 because Ms X has not complained to it. We usually expect councils to have had the opportunity to comment on and investigate the complaint, before it is brought to the Ombudsman.

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Investigator's decision on behalf of the Ombudsman