Summary: Ms B complains about the care her son, Y, received at a residential care home (“the Home”), arranged by the Council. She says the Home neglected his personal care, did not involve family in decisions and reviews and failed to properly investigate safeguarding incidents. Ms B says Y suffered a serious injury due to a lack of proper care. She says the Council did not take the concerns she raised seriously. I have found fault in how the Home’s recording of dental and personal care and in how the Council and Home responded to reports of missing belongings. I have not found fault in the Home’s care leading to the serious injury, or in the Council’s overall response to safeguarding concerns.

The complaint

1. The complainant, who I refer to as Ms B, complains about the care Y received at the Home. She says the Home allowed Y to wear shoes that were too small, left him looking scruffy and uncared for, did not properly look after his dental hygiene and allowed his toenails to overgrow. Ms B says the Home did not provide any explanation when expensive items went missing, or inform her of assaults on Y by other residents. She says the Home did not encourage Y to engage in activities and did not include his family in reviews and decisions about his care.
2. Ms B says that Y suffered a serious, permanent injury due to lack of care by the Home. She says the Council did not take her concerns seriously and did not allow her to remove Y from the Home following the injury.

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The Ombudsman’s role and powers

3. 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)
4. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. If we are satisfied with an organisation’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)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council or care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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How I considered this complaint

7. I considered the information Ms B provided and spoke to her about the complaint, then made enquiries of the Council and Home. I sent a copy of my draft decision to Ms B and the Council for their comments before making a final decision.

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What I found

Law and Guidance

8. Regulations set out what types of incidents care providers must report to the CQC. These include:
• Any abuse or allegation of abuse in relation to a service user
• Any incident which is reported to, or investigated by the police
9. A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
10. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
11. A key principle of the Mental Capacity Act 2005 is that any act done for or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
12. If there is a conflict about what is in a person’s best interests, and all efforts to resolve the dispute have failed, the Court of Protection might need to decide what is in the person’s best interests.
13. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

Background

14. Y is diagnosed with Asperger’s syndrome. He has lived in the Home since October 2015. When he first moved into the Home Ms B attended a meeting about his care plans. Ms B says she was then always invited to annual meetings for several years. However, at some point, she cannot recall exactly when, the Home stopped inviting her to those meetings.
15. Y is assessed as lacking capacity to make decisions about where he should live. He has a Deprivation of Liberty Assessment in place that places restrictions on leaving the Home without support.
16. Ms B has raised concerns about Y’s care at the Home over a long period. These include around dental care, foot care, items going missing and assaults by other residents. Ms B says Y’s behaviour has changed since living at the Home and he now does inappropriate things that he did not used to do. This has made it more difficult for him to be around family.
17. In July 2020 there was an incident in which Y choked on his food. The Home completed a risk assessment. However, it did not report the matter to safeguarding until September 2020. Ms B says the Home did not report the incident to her. The Council’s safeguarding team visited the Home and was satisfied with the risk assessment the Home had completed. It noted there had not been any further choking incidents. It therefore closed the investigation with no further action.
18. In August 2020 Y’s sister sent a letter of concerns to the Council. The concerns included that Y had not had contact with his family since Christmas and staff were allowing him to wear shoes that did not fit. A social worker visited the Home and spoke to Y. The Home manager informed the social worker that Y did wear shoes that fit him. The Home reviewed Y’s care plans, including contact arrangements relating to coronavirus. The social worker did not take further action. Ms B says the Home had allowed Y to wear shoes that were too small for him throughout the time he lived in the Home, from 2015 to 2021.
19. In January 2021 there was an incident in which a dog bit Y on the hand. Staff treated Y for minor injuries and looked to arrange for him to receive an up-to-date tetanus jab. However, there was a delay in arranging the jab due to a miscommunication. The Home submitted a safeguarding referral in early February 2021. The safeguarding team obtained copies of the Home’s risk assessment following the incident. It decided not to progress to an investigation as the Home had taken the necessary actions following the incident. However, the Home agreed it should have made the safeguarding referral sooner.
20. Ms B contacted the Council several times during late 2020 and early 2021 to say she wanted Y to move to a placement closer to where she lived. Ms B was not happy with the level of care Y was receiving at the Home and was concerned about the lack of contact between Y and family.
21. In March 2021 the Council carried out a mental capacity assessment for Y. It found Y did not have capacity to make decisions about his place of residence and care needs. The Council held a best interest meeting in May 2021. Ms B and Y’s sister attended the meeting to give their views. An independent advocate for Y was also present. The Council decided the Home met Y’s needs and that he said he wanted to remain there. It recommended Y remain at the Home. It said staff should liaise with the family around shoes and clothing and encourage Y to visit family more often. Ms B says Y lacks capacity and frequently changes his mind about where he wants to live so this should not have been a deciding factor.
22. In June 2021 there was an incident in which another resident of the Home punched Y. The Home has provided records that it informed Ms B of the incident the following day, as well as the Council. Ms B says the Home did not inform her and she only found out after Y told her. She says staff played the incident down. The Home made a referral of the incident to safeguarding three days later. The safeguarding team decided not to proceed to an investigation as it considered staff dealt effectively with the incident and there was no apparent injury to Y.
23. Ms B says there was another incident in which Y told her a resident strangled him. Ms B says she raised this with staff at the Home who said they were not aware of this incident. Ms B says this happened in January 2018.
24. Ms B also reported that Y’s electronic tablet had gone missing in June 2021. The Home told her it was looking into this. It made a safeguarding referral in early July 2021. The referral said the Home believed the family had taken it home but had no documentation to evidence this. Ms B said no one took it home. The Council informed the police, who did not take further action. The Council asked the Home to replace the tablet and it did so.
25. On a visit to the Home in September 2021, Ms B found Y’s toenails were overgrown. The Home told Ms B that Y missed a routine chiropodist appointment as he was out of the Home at another appointment. The Home rearranged the appointment for the following week. Ms B wrote to the Home as she was concerned it was neglecting Y’s personal care. The Home made a safeguarding referral and the Council progressed this to an investigation.
26. As part of the investigation Ms B raised more general concerns about Y’s footcare, including that staff continued to allow Y to wear the wrong size shoes. She said Y had developed a deformity in his foot because of this. The Home arranged for Y to visit a GP. The GP said Y’s feet did not have a deformity but prescribed cream to treat athlete’s foot. The safeguarding team did not take further action.
27. In November 2021 the Council held a further best interest meeting. It again decided it was in Y’s best interest to remain at the Home. In the same month, the Home took Y to get his feet measured. The measurement found Y had size 11 feet. Ms B said this was not correct and due to the shape of his feet, Y needed size 12. Ms B arranged for an alternative measurement and my understanding is that from this point on Y wore size 12.
28. After the meeting Ms B sent an email to the Council regarding missing items. She listed the items missing as:
• A mobile phone
• A coat
• An electric toothbrush
• A vintage jacket
• A large TV
29. The Council obtained a response from the Home, which said:
• It had no knowledge or record of Y having a mobile phone.
• The coat was replaced due to general wear and tear
• The toothbrush was replaced as it stopped holding charge
• Y outgrew the jacket and staff were not aware of its sentimental value, so it was discarded
• Due to wear and tear Y replaced this with a smaller TV
30. Ms B responded that she bought Y the mobile phone and it was missing. She said she could not see a replacement for the coat and there was no replacement toothbrush in Y’s room. She said Y was the same size now and had not outgrown the coat. The Home should not have thrown this away without speaking to her first. Ms B said the Home should have replaced the TV with a similar size one.
31. The Council directed Ms Y to communicate directly with the Home manager around these concerns.
32. During a visit to Ms B’s home in February 2022, Y indicated that he had experienced some pain in his penis. Y returned to the Home that day and Ms B informed the Home of what Y had said. The Home recorded this in its communication records. The record said the Home would investigate this. The Home decided to contact the GP the following day suspecting a possible urine infection.
33. The following day the daily records say staff assisted Y into the shower. There is no record of Y reporting further pain. The Home sent a urine sample to the GP. The results showed Y did not have a urine infection.
34. The communication record for the next day says at 10:00 Y came downstairs, and it was clear he had an erection. Staff told Y to go back upstairs. The daily records say Y remained in bed during the morning. They say staff supported Y into the shower at around 13:30. The Home’s ‘appointments regarding healthcare’ records say Y mentioned to staff during the day that he had got an erection but it ‘kept going down’. This was handed over to the night shift.
35. At 21:00 the record says Y was displaying inappropriate behaviour and went to his room at 20:00. The healthcare record says Y told the senior carer that the erection would not go down. It says staff checked on him at 20:30 and he said he felt okay and was not in pain. At 21:00 staff checked again. Y said he was in pain, so staff called 111. A clinician called back at around 21:40 and said Y would need to go to A&E as soon as possible. Staff supported Y to A&E.
36. At hospital Y was diagnosed with Priapism. This is described on the NHS website as a painful, long-lasting erection. It says if someone has an erection that lasts more than two hours to call 999 or got to A&E. Prompt treatment is needed to avoid permanent tissue damage that can cause erectile dysfunction.
37. The hospital contacted Ms B in the early morning of the following day. Ms B attended the hospital. She says Y had to undergo surgery and has been left with permanent damage. Ms B says staff at the hospital told her that Y was left for far too long and should not have been left for more than four hours. She says the Home did nothing for four days.
38. The Council carried out a safeguarding investigation. Council officers visited the Home and looked through the care records. Its findings were that staff sought medical intervention in a timely manner and there was no evidence of neglect.
39. Ms B says she was not happy for Y to be discharged back to the Home because of her concerns about the level of care he received there. She wanted Y to come home with her, where she would care for him. The Council said that as Y was subject to a Deprivation of Liberty assessment, he needed to be discharged to the Home. The Council recorded that Y had needs and risks that needed to be managed 24/7 and discharging Y to Ms B’s home without a full assessment as to whether his needs could be met there, would be a risk to Y and others. The Council asked Ms B to identify care homes closer to where she lived, following which the Council would hold a further best interest meeting.
40. Y was discharged back to the Home and continues to live there.

Findings

41. I have separated my findings into the following areas of complaint:
• The Home have not invited family to yearly review meetings or included them in decisions about care
• The Home allowed Y to wear shoes that were too small
• The Home have not properly looked after Y’s dental hygiene
• The Home allowed Y’s toenails and beard to become overgrown and his appearance was uncared for
• The Home have not encouraged Y to engage in activities like music, reading and writing, or using technology Ms B has bought for him
• The Home did not inform the family of incidents where Y was assaulted
• Items of Y’s have gone missing with no explanation
• Y suffered a serious injury because of neglect
• The Council has not properly listened or responded to Ms B’s concerns or allowed Y to move closer to family

Yearly review meetings and decisions

42. The Home’s policy says an initial revision should take place six weeks after admission, then continue every year as a minimum. It says goals within support plans should be monitored and reviewed monthly. It says some actions in the plans may involve others, such as health professionals or family. Their input should always be sought before reviews and they can be invited to attend.
43. The Home has provided two ‘annual reviews’ for Y, dated 2016 and 2017. The reviews covered Y’s overall care needs and show Ms B was present and gave her views. A representative from the Council was also present. The Home says the social work team will hold copies of the reviews for 2018/19. It says no annual reviews took place in 2020 due to the coronavirus pandemic and in 2021 the review process was superseded by the best interest meetings.
44. I have not gone back to further request the reviews for 2018/19 as these would have been more than 12 months before Ms B brought the complaint. Normally we will only investigate concerns that were raised in the 12 months before the person complains to us. In this case, if there were missed reviews in 2018/19 Ms B could have complained to the Council about it at the time, then to the Ombudsman if the response was not satisfactory.
45. It is not clear whether the Home considered if it could conduct an annual review in 2020 and involve family by other methods, such as virtually rather than in person. Also, the best interest meetings in 2021 did not involve a review of Y’s care plans, although it did give Ms B an opportunity to raise the issues she had with Y’s care.
46. While it is not clear the Home properly followed its policy regarding reviews in 2020 or 2021, on balance, I have not found this caused a significant injustice. Throughout this period Ms B was in regular contact with the Home and the Council and had the opportunity to put her views across at best interest meetings. I can see there were changes to care plans based on feedback from Ms B, for instance Y’s dental care plan in July 2021, as outlined later in this statement. The Home carried out regular general reviews of care plans each month, in line with its policy. Therefore, I cannot find care plans were not reviewed, or that Ms B did not have opportunities for input in decisions about Y’s care.
47. However, the Home should consider any requests by Ms B to resume annual reviews going forward.

Shoe sizes

48. I can see that Ms B and other members of the family raised concerns about shoe sizes several times, from August 2020 onwards. Ms B says she raised concerns more historically. On each occasion the Home said he was wearing the right size shoes. There was clearly an impasse between the Home and Ms B. The Home had Y’s feet measured as size 11 whereas Ms B said he had always been a 12 due to the shape of his feet. I cannot make a finding on what the correct shoe size is.
49. It appears the Home does now have size 12 shoes for Y, based on Ms B’s concerns. It might be that it could have reached this position at an earlier point. However, as it had obtained an independent measurement of size 11, and as the GP found there was no injury to Y as a result of wearing size 11, I cannot find there was fault in the delay or that this caused a significant injustice to Y.

Personal care

50. The Home has provided a support plan for personal care dated June 2020 and reviewed in July 2021. I cannot make any findings about Y’s general appearance but have focussed on the two main issues Ms B has raised, regarding shaving and toenail care.

Shaving

51. The plan says Y has a shaver and beard trimmer that needs to be charged. It says it can be documented that after use it has been charged. It says if Y is shaving at home, staff must give full support and ensure he is clean shaven without missing bits. This should be recorded in his journal. He may also go to the barber, which should be recorded in his finance file.
52. I have reviewed a sample of Y’s daily records for the full three months of June to August 2021. I can see one record in June 2021 where Y was supported to shave. There was another record that he attended the barber a week later but for a haircut. I could not see any further records in July or August 2021 of staff supporting Y to shave. I also could not see any records of staff ensuring Y’s shaver was charged. There were occasional general records of ‘attending to personal care’. However, this might only have included showering and it is not possible to know if it included shaving.
53. The support plan does not set out how often Y needs to shave. This may be because it varies slightly, and staff will prompt Y only when it seems to be getting too long. However, I would have expected to see more than one record in the space of three months.
54. Overall, I cannot see evidence that staff regularly supported Y with shaving, in line with the support plan during the period I have reviewed. I cannot say whether this is because Y really did not shave for two and a half months, or whether it was not recorded. However, the support plan says staff should record this support and the lack of records creates uncertainty about how often this happened.

Toenail care

55. The plan says Y can cut his own toenails with support but enjoys someone else doing it. He choses to pay for chiropody but is always given the choice. If supported to cut his nails at home staff should record this. The chiropody should be recorded in his health action plan and daily journal.
56. The Home has provided the health care appointment records for 2020 to 2022. I can see two occasions, in September 2021 and January 2022, in which Y had a chiropody appointment. I also reviewed the daily records for June to August 2021 and could see one other appointment in June 2021.
57. The support plan is not clear on how often Y should be supported to cut his nails or attend a chiropody appointment. This may be because staff monitor this on an ongoing basis. The chiropody appointments I can see were each around three months apart. Mrs B says Y needs his fingernails and toenails trimmed every week.
58. On Balance, I do not find fault. I cannot say for certain how often should normally be left between appointments to cut Y’s toenails. The Home does appear to have a routine of fairly regular chiropody appointments. I understand Y missed on of the appointments in September 2021, but the Council investigated this and the Home arranged for a follow up appointment.

Dental hygiene

59. The Home has provided an oral/dental support plan for Y dated April 2021. It says Y is more likely to have dental problems because of his medication. It says he has an electronic toothbrush and an ordinary one and alternates between them. It says staff should prompt Y to brush his teeth twice daily and record each occurrence in his daily records. In support plan for personal care, it says staff should go with Y when he is retiring at night to instruct and observe oral care.
60. I have looked through two samples of the daily records, one for the four weeks immediately following the date of the care plan, April to May 2021. The other for the first fortnight of February 2022.
61. In the four weeks spanning April to May 2022, I can only see three occasions out of 56 on which staff recorded that Y brushed his teeth. On two other occasions, staff recorded attending to personal care, but it is not clear whether this included brushing teeth. In the first fortnight of February 2022, I can see seven occasions out of 28, on which staff recorded that Y brushed his teeth. Again, there were two occasions when staff recorded supporting with personal care but did not specify if this included teeth cleaning.
62. I also looked generally at the daily records for June to August 2021 while reviewing personal care. There were almost no records of teeth cleaning in June 2021. In July 2021 Ms B appears to have raised concerns about this, following which there are records twice a day, almost every day. In August there is fairly consistent recording twice a day, but not always, suggesting it started to dop off again. And it appears by February 2022 this had dropped further to a point where records were infrequent.
63. I cannot say for certain whether staff consistently did not prompt Y to brush his teeth, or if they simply did not record this. However, I note that in the evening the records often said Y something along the lines of, ‘Y retired to his room and stayed there’. There is no indication staff followed Y to ensure he brushed his teeth, as outlined in his support plans.
64. Y’s support plan was clear that he was at increased risk of tooth decay and gum disease and staff should record support in this area twice a day. The absence of these records means there is no evidence staff regularly supported Y, as set out in the care plan, over several months. This is despite the fact Ms B raised concerns about dental care directly to the Home and to the Council.
65. Ms B says the Home neglected Y’s dental care and this led to him losing a tooth. It is not within the scope of my role to make a definitive link between the lack of records and specific harm to Y. That would be a personal injury matter that only a court could determine. However, the lack of records creates uncertainty about whether staff properly supported Y with his dental care and the impact this might have had.

Activities

66. The Home has provided Y’s support plan for daily activities, dated March 2022. It says Y will have a structured weekly activity plan to suit his needs. It mentions activities such as home skills of cooking, baking and cleaning. It says staff encourage him to have walks and he has a bus pass that allows him to travel with a carer. It says he likes the cinema, supermarket shopping visiting different towns.
67. This is a more recent support plan that was produced after Ms Y’s complaint to the Ombudsman. Therefore, the concerns she raised in the initial complaint related to the 2020 to 2021 period. I have not seen the activities support plan for that period. However, when reviewing the daily records from June to August 2021, I could see frequent records of Y engaging in activities outside the Home, such as walks, shopping, visiting other towns and going to the cinema. I can also see records of him listening to music, watching sporting events and playing games in the Home.
68. Ms B raised concerns the Home did not encourage Y to use an electronic tablet she bought him, for instance for music. I can see a record from the Home saying that Y did not regularly engage with using the tablet. Ms B said he did engage with it when she was with him and questions why staff were not able to get him to engage.
69. I cannot make a finding on whether staff specifically encouraged Y to engage with the electronic tablet. Overall, I cannot see evidence of fault in the way the Home went about engaging Y in activities.

Incidents of assault

70. I can see from the records that staff witnessed an incident in which another resident punched Y. I cannot find fault in the Home’s response to this. Staff reported to safeguarding and updated Y’s risk assessment. There is also a record that staff notified Ms B. Ms B indicates staff did not tell her about the incident. I cannot resolve that conflict in the evidence. There is a record of contact and so on that basis I cannot find fault. The Council carried out a safeguarding investigation and found the Home had taken appropriate action to respond to the incident.
71. Ms B says there was another incident in which a resident strangled Y and the Home did not notify her. I can see a record of Ms B telling the Council this in June 2021. She said the incident happened in January 2018. The Ombudsman normally only investigates concerns brought to us within 12 months of the date they happened. I have not exercised discretion to do so in this case as, due to the passage of time, I would not be able to meaningfully investigate an incident occurring that far back.

Missing belongings

72. The first incident of a missing item being reported was the tablet in June 2021. I do not find fault with the Home or Council’s response to this. The Council initiated a safeguarding investigation and reported the incident to the police, who took no further action. The Home could not evidence how the item went missing and so agreed to replace this.
73. The second occasion was in November 2021, involving several items. I find fault in the way this was managed by the Council and Home.
74. In terms of the Council, there is an element of inconsistency in how it dealt with the matter on the two different occasions. In June 2021 it raised a safeguarding enquiry, reported the matter to the police and ensured the Home replaced the tablet as it had no record of its whereabouts. In November 2021 it does not appear to have looked into the matter and only referred Ms B to resolve it with the Home. This is likely because the Home provided explanations for most of the items. However, the Home said it had no knowledge of the mobile phone and Ms B questioned its responses to the other items. I cannot see any evidence the Council took steps to ensure the Home was properly recording personal property, in particular given the phone was the second electronic device Ms B reported missing, with no clear indication of how it happened, in the space of six months.
75. I cannot see any further correspondence between Ms B and the Home on this matter. The Home has provided a personal property inventory, but this is dated late November 2021, so shortly after Ms B raised concerns on the second occasion. There is no other personal property inventory provided so I cannot see evidence the Home had a clear record of belongings prior to this.
76. The Home was involved in supporting Y with purchasing items. I cannot find fault specifically in relation to how it went about doing so, but items that Y had should have been clearly recorded.

Serious injury

77. It is clear Y has suffered a serious injury. The nature of the condition means there was a short window in which medical intervention was needed to give some chance of avoiding that injury. The question I have considered is whether staff should have recognised the signs of this and sought medical attention sooner. I have approached this on the basis that I am not a clinician and can only conduct a general review of the records and actions taken.
78. I can see Ms B first raised concerns three days before Y’s admission to hospital. The Home did investigate this by contacting the GP and taking a urine sample. I cannot see any record in these days before the admission to hospital that staff were aware of Y displaying symptoms of a permanent erection or ongoing pain.
79. On the day Y went to hospital, staff were aware at 10:00 that Y had an erection. There is no record of whether he continued to have one at 13:30 when staff supported him into the shower. Either way it is possible that staff my not have recognised that it had been continuous. There is a note that Y said he had an erection but that it kept going down. The staff on the night shift recorded that at first, he said he was not in pain. However, he then said he was in pain, so they contacted 111.
80. If staff were aware that Y had a continual erection from 10:00 until 21:00, and that this was causing pain, there is no question medical attention should have been sought far earlier. However, based on the information available I cannot find clear evidence that was the case. Therefore, on balance, I have not found fault in the way the Home dealt with this incident.
81. I also note the Council’s safeguarding team investigated the incident immediately afterwards and did not find evidence of neglect.

Council’s involvement

82. I have found fault with the Council around its response to the report of missing items. However, I do not find fault in the Council’s involvement otherwise.
83. Each time Ms B raised concerns the Council’s safeguarding team decided whether to investigate or take any action and clearly set out its reasons. On some occasions Council officers visited the Home to review care records. The Council has followed its procedures in responding to Ms B’s concerns. I understand Ms B considers some of the conclusions the Council has reached about whether there was neglect by the Home was wrong. However, I cannot question the merits of the Council’s decision as to whether safeguarding concerns remained in each instance.
84. Ms B disagrees with the Council’s decisions not to move Y following best interest meetings. I understand Ms B’s comments that the Council relied on Y’s expression of views, when it had also found he lacked capacity to make decisions about where he lived, and he said different things to her. However, I can see the Council has considered several factors, including whether it believed the Home continued to meet Y’s needs and the opinion of Y’s independent advocate. It followed the correct procedures in holding a best interest meeting and involving all relevant people in the meeting. I therefore have not found fault and cannot criticise the merits of its decision.
85. I understand a further best interest meeting was due to take place to consider Y’s living arrangements following the recent serious injury. Ms B says the Home has now agreed to pursue a move for Y closer to where Ms B lives.

Consideration of Remedy

86. I have found fault on the following points:
• The records do not evidence that staff regularly supported Y with shaving
• The records do not evidence that staff consistently supported Y to brush his teeth
• The Home has not provided evidence it clearly recorded Y’s belongings prior to November 2021 or that it investigated Ms B’s reports of a missing mobile phone
• The Council did not investigate Ms B’s reports of a missing mobile phone in November 2021
87. The fault caused an injustice to Ms B in terms of uncertainty about whether staff provided adequate levels of care in line with Y’s care plans, and regarding what happened to the mobile phone. That uncertainty caused distress and I recommend the Council pay Ms B £200 to recognise the distress caused.
88. At the time of writing my understanding is that Y is still a resident at the Home. I recommend the Home provide evidence it has reminded staff of the need to record support with Y’s dental care and shaving. I also recommend it review its support plan for personal care and consider whether it would be helpful to include some guidance around how often staff should support with shaving.

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Agreed action

89. The Council has agreed to, within a month of this decision:
• Apologise to Ms B for the fault identified
• Pay Ms B £200 to recognise the distress caused
• Provide evidence the Home has reminded care staff of the need to record support with Y’s teeth cleaning twice a day and with when supporting Y with shaving
• Provide evidence the Home has reviewed its support plan for personal care, and considered whether it would be helpful to include guidance around how often staff should prompt Y to shave

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Final decision

90. Subject to further comments by Ms B and the Council, I intend to close this case on the basis there is fault in how the Home’s recording of dental and personal care and in how the Council and Home responded to reports of missing belongings. I have not found fault in the Home’s care leading to the serious injury, or in the Council’s overall response to safeguarding concerns.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman