Summary: Mrs X complained about the care provided to her mother, Mrs Y, by a Council-funded care home. These concerns were investigated by the Council during two safeguarding enquiries. We found the Council took too long to complete the first enquiry, leaving Mrs Y exposed to risk for longer than necessary. Many of Mrs X’s concerns were substantiated by both enquiries, and so we found fault with the Council for delivering poor care. We also criticised the Council’s complaint handling. We made recommendations to address the faults we found.

The complaint

1. Mrs X complained about the care provided to her mother, Mrs Y, by Westerley Christian Care Home (the care home). Mrs X raised a range of safeguarding concerns, including:
• Staff not meeting Mrs Y’s needs safely, or sometimes at all, amounting to neglect
• Low staffing levels
• Poor nutrition that did not meet her diabetic needs.
• Poor continence care
• Poor communication from staff, including a staff member shouting at Mrs Y
• Poor moving and handling
• Lack of adequate food during meals
2. Mrs X said that witnessing her mother’s suffering caused her distress. She considered that additional staff were needed to remedy the situation.

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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 significant injustice, or that could cause injustice to others in the future, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
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)

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How I considered this complaint

6. I considered the information provided by Mrs X and discussed the complaint with her on the telephone.
7. I considered the Council’s response to our enquiries and the relevant law and guidance.
8. Mrs X and the Council had the opportunity to comment on my draft decision. I considered their comments before reaching my final decision.

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What I found

Safeguarding

9. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. 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 Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively.

The Council’s safeguarding policy

11. The Council’s policy is set out in the Southend, Essex & Thurrock (SET) Safeguarding Adults Guidelines, Version 10 (May 2024). This provides timescales for taking action during an enquiry and sets out the steps the Council should take.

What happened

12. Mrs Y moved into the care home in May 2023. Mrs X said that the care provided was generally good until that Christmas, after which it deteriorated.
13. There was an instance of missed medication in early 2024 which meant a safeguarding concern was raised. The medication error itself was investigated and resolved without the need for a safeguarding enquiry. However, that incident led to Mrs X raising further concerns, which trigged a safeguarding enquiry. This enquiry was planned to address issues of personal care and hygiene, toileting and continence care, communication, diet and nutrition, and visiting times and accessibility. The Council officer who was leading the safeguarding enquiry then went on sick leave.
14. In early May 2024, Mrs X complained to the Council that no action had been taken to address her concerns about her mother’s care. Mrs X emphasised that the family wanted to have input into choosing a new home for their mother.
15. Mrs Y’s case was reallocated to a second Council officer, who met with Mrs X in early June. Additional concerns were raised, a second safeguarding enquiry was initiated, and the move to a new care home was discussed.
16. The Council responded to Mrs X’s complaint in mid-June. It explained that the delay in completing agreed actions had been caused by staff absence. The Council apologised for any distress caused, acknowledged that Mrs Y’s “situation was urgent”, which was why it had reallocated her case. The letter did not explain how to escalate the complaint to the Ombudsman, instead saying that Mrs X should contact the Council again if she remained dissatisfied.
17. The second Council officer carried out a Care Act Assessment in June which captured the family’s concerns, and concluded:

“It is apparent from [Mrs Y’s] reports about neglect in her care in Westerley care home that she feels unsafe due to unmet needs. I agreed with her view to move to a different placement whilst safeguarding investigations are taking place.”

18. The Care Plan resulting from that assessment included the actions that were being taken to address Mrs X’s concerns about Mrs Y’s care:
• “The concerns are still being investigated,
• CQC was notified about these concerns.
• Contracts Team was notified.
• Liaising with other professionals to obtain their views.
• [Mrs Y] to be moved to a different placement.
• Liaise with other residents and families to obtain their views about their care in Westerley care home.”
19. Mrs Y expressed a preference to move to a specific care home that was close to her family and in a location of which she had happy memories. Unfortunately, a single room was not available in that care home. Another placement – the second care home – was identified by the second Council officer. Mrs X viewed it and agreed it was suitable. Mrs Y moved to the second care home in early July.
20. Mrs X complained to the Ombudsman in mid-July. We asked the Council for copies of the complaints correspondence. The Council sent the stage 1 complaint and its response to us, but said it hadn’t been asked to escalate the complaint to stage 2 of the complaints process.
21. A case conference (part of the safeguarding enquiry) took place in September. Mrs X and several other family members attended this. Matters could not be concluded within the time available for the first case conference and so a second meeting was held in October.
22. The Council sent the safeguarding closure report to the Ombudsman in late October, and a separate outcome document to Mrs X in late November. The Council also sent the Ombudsman a copy of the closure report of the first safeguarding enquiry that had been initiated in February.
23. The first safeguarding enquiry concluded that:
• Allegations of neglect in the areas of continence care, hair care, and personal care were substantiated.
• An allegation regarding poor nutrition and lack of choice at mealtimes was partially substantiated.
• An allegation regarding a lack of activities offered to Mrs Y was substantiated.
• An inconclusive finding was reached in relation to allegations regarding visiting times and accessibility, and poor manual handling practices.
24. The second safeguarding enquiry concluded that:
• Allegations regarding a specific care worker being rough with Mrs Y, shouting at her, and being “too busy” to help her, were substantiated.
• An allegation of low staffing levels was substantiated.
• An allegation of inadequate monitoring of prescriptions, including misuse of medication, was unsubstantiated, as was a concern about a lack of weight monitoring.
• An allegation of passive neglect was partially substantiated.
• Additional allegations of significant delays in continence care were substantiated.
• More specific moving and handling allegations, including that Mrs Y was left in bed all day when she asked to sit in her chair, and on another occasion was left in an uncomfortable and unsafe position in bed, were substantiated.
• Nutritional allegations, including breakfast being served late (in the context of Mrs Y being diabetic), and a lack of diabetic diet, were substantiated.
• An inconclusive finding was reached in relation to oral care concerns.
25. The care home later sent a letter of apology for its failings to Mrs Y, care of Mrs X. Mrs Y was not well enough to be informed of the outcome of the safeguarding enquiry, or to hear the care home’s apology, before she died at the end of November.

Analysis

26. The Ombudsman’s role is not to reach a view on whether the Council’s decisions on safeguarding concerns are correct. Our role is to consider whether the Council followed the Care and Support Statutory Guidance process and considered all relevant information to reach its view.

The first safeguarding enquiry

27. When the Council was made aware of concerns about Mrs Y’s care, in late February 2024, it promptly initiated a safeguarding enquiry. Given the nature of the concerns I am satisfied this was the correct process for the Council to follow.
28. The Council commenced the enquiry by meeting with Mrs X and Mrs Y in mid-March to discuss their concerns in more detail. I have seen evidence that it put these concerns to the care home. The Council officer met with Mrs X and Mrs Y again in late April to discuss some additional concerns, and again in early May to discuss the outcome of its enquiries to the care home. It was then documented that the Council would look for a different placement for Mrs Y as a matter of urgency. The safeguarding closure document includes that no safeguarding strategy meeting was held as the Council officer then went on sick leave until September. The enquiry was closed in early October on the basis of the information that had been gathered during the Spring.
29. I find that there was fault on the part of the Council in the way the first safeguarding enquiry was managed.
30. The adult safeguarding procedures, and the Council’s own policy, do not set definitive timescales for how long a safeguarding enquiry should take to conclude. However, target timescales are indicated in the Council’s policy, which states that once it has been agreed that an enquiry is needed, the enquiry should be completed within 90 working days. This would have been in early July. This may be extended if there are exceptional circumstances, for example if the case is particularly complex and/or requires the involvement of multiple agencies.
31. However, the Council has not argued there were exceptional circumstances to warrant the 150 days it took to complete the investigation, and notes that staffing issues caused the delay. While I appreciate these may have been outside the Council’s control, the delay in completing the enquiry was, nevertheless, fault.
32. I also find that a safeguarding strategy meeting should have been held within the first few weeks of the enquiry, so the Council could consider the need for an interim protection plan to be put in place. It was fault that this was did not occur, and meant that Ms Y was exposed to risk for a longer period.
33. The impact of the Council’s faults on Mrs Y was that she suffered from the effects of continuing inadequate and neglectful care whilst the enquiry was ongoing, until Mrs X felt forced to insist upon a move to a different care home. Had the first safeguarding enquiry been progressed without fault, it is possible that the concerns it addressed could have been resolved without the move being required. Even if the move was required, this could have happened sooner than it did. In the meantime, Mrs X and Mrs Y suffered the distress, worry, uncertainty and frustration of not knowing when the move might occur.
34. Finally, had the first safeguarding enquiry been concluded without delay, Mrs Y would have been aware of the outcome before she died. The fact that she was not is a further injustice.

The second safeguarding enquiry

35. Once the case was allocated to the second Council officer, matters proceeded in line with statutory guidance. The second Council officer met with Mrs X and Mrs Y, and Mrs Y’s son, in early June. Following this meeting, the Council initiated a second safeguarding enquiry. I have not seen evidence of an interim protection plan being put in place, but Mrs Y was appropriately safeguarded by being transferred to the second care home. This move took place within four weeks of the second Council officer’s first meeting with the family. I consider this to be a reasonable timescale, particularly in light of the fact that a suitable placement was not available within Mrs Y’s preferred setting.
36. There was a short delay before the second Council officer was able to investigate Mrs Y’s case fully, caused by the fact that Mrs X and Mrs Y refused permission for her to discuss their concerns with the care home before she moved. This delay was not, in itself, fault, but rather was indicative of the extent to which the relationship between Mrs Y and the care home had broken down by that time, exacerbated by the delays I found in relation to the first safeguarding enquiry.
37. Once the second Council officer was able to progress the second safeguarding enquiry, it proceeded in line with the Council’s own target timescales. It was good administrative practice that the closure report addressed each concern individually, and the investigating officer took account of relevant information from the records and from key individuals. The report provided clear and balanced outcomes on each aspect of the enquiry.
38. The closure report indicated that “misuse of medication” was investigated as part of the safeguarding enquiry and deemed to be “unsubstantiated”. There is no dispute that a medication error occurred in early 2024, but it was found to be a one-off incident which had not caused Mrs Y harm, and there was no potential for future harm in this respect. And so, it did not meet the threshold for a safeguarding enquiry and the concern was closed at the alert stage. The closure report would have been clearer if it had explained this correctly.
39. Many of Mrs X’s concerns were substantiated by the safeguarding enquiry. It follows that there was fault by the care home in the way it provided Mrs Y’s care. The care home has now apologised to Mrs X and Mrs Y for its failings. Sadly, this apology came too late for Mrs Y to be aware of it.
40. I understand that the Council’s contracts team and the Care Quality Commission (CQC) are both involved in overseeing improvements within the care home. I welcome this, but nevertheless will make a recommendation to ensure that the outcomes of the second safeguarding enquiry are fully realised. I will also share a copy of this decision statement with the CQC.

Complaint handling

41. The statutory adult social care complaints process consists of a single stage. After the council has issued a decision complainants can come to the Ombudsman without having to escalate their complaint further though a council’s processes. I find the Council was at fault in advising Mrs X to return to it if she was unhappy with the stage 1 response. Instead, it should have advised her to escalate her complaint to us if she remained dissatisfied. Mrs X did not suffer an injustice in this regard as she approached us in any case.
42. The Council has a webpage about how to make a complaint about adult social care matters. However, this refers only to self-funders and people receiving direct payments – it does not include any information about the complaints process for people who are unhappy with Council-funded care. This is fault, and I will make a recommendation to address that.

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Agreed action

43. To remedy the injustice caused by the faults identified, the Council has agreed to complete the following within one month of the final decision:
• apologise in writing to Mrs X to acknowledge the injustice caused to her and Mrs Y by the Council’s failings as identified above. The apology should be in accordance with our guidance, Making an effective apology
• make Mrs X a payment of £400 to acknowledge the injustice caused to her in terms of distress, worry, uncertainty and frustration by the Council’s faults. This is a symbolic amount in line with our Guidance on remedies.
• produce an action plan which sets out the Council’s progress in implementing the outcomes of both safeguarding enquiries, and the anticipated completion dates of the actions.
• improve the information on its website to include information about the complaints process for people who are unhappy with council-funded care. Ensure that the webpage is clear about the fact the statutory adult social care complaints procedure is a single-stage investigation process before escalation to the Ombudsman.
44. The Council should provide us with evidence it has complied with the above actions.

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Final decision

45. I have concluded my investigation with a finding of fault that caused injustice to Mrs X and Mrs Y.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman