Summary: Ms C complained about the Council’s handling of her safeguarding concerns about her parent’s care home, and the support provided by its Adult Social care team. We found no fault in Council’s safeguarding process. The Council accepted it had failed to ensure a social worker was allocated to their cases and appropriate notes were not kept, which caused Ms C distress and uncertainty. We also found a significant delay in its complaint’s response. The Council will apologise and make payment to acknowledge the injustice Ms C experienced.

The complaint

1. The complainant, Ms C, complained about the Council’s handling of her concerns about the care provided to her parents by Ryhope Manor Care home (the care home – operated by Conags Care Ltd). She said the Council failed to:
• arrange a different care home when she asked for it and act on her concerns about the personal care and support her parents were receiving;
• ensure its Adult Social Care team responded to her requests and kept accurate records; and
• properly consider her safeguarding concerns about the care home’s neglect and wrongly found her concerns were not substantiated.
2. Ms C said, as a result, she experienced distress and uncertainty. She also said her parents experienced distress due to the poor standard of care they received, and they died as a result of the neglect which could have been prevented.

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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. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
6. 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

7. As part of my investigation, I have:
• considered Ms C’s complaint and the Council’s response;
• discussed the complaint with Ms C and considered the information she provided;
• considered the information the Council provided in response to our enquiries; and
• had regard to the relevant law and guidance to the complaint.
8. Ms C and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

Fundamental Standards of Care

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below. These includes:
• Regulation 11 which requires the need for a service user’s, and those acting on their behalf’s, consent before care or treatment is provided.
• Regulation 12 which relates to safe care and treatment. It says care providers must assess the risk to the health and safety of a service user of receiving care and treatment and must take measures to mitigate this risk. This regulation also sets out that care providers must ensure any equipment used when supporting a service user is safe and used in a safe way.
• Regulation 13 which requires people who use services to be safeguarded from abuse and improper care and treatment;
• Regulation 14 aims to make sure people using services have adequate nutrition and hydration to sustain life and good health;
• Regulation 17 relates to good governance. This includes the maintenance of accurate, complete, and contemporaneous records for each service user.
11. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

Safeguarding

12. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.

What happened

13. Ms C’s parents, X and Y, moved into Ryhope Care Home (the care home) in 2021. They had care plans setting out the care and support they should receive.
14. Ms C visited her parents in the care home in Autumn 2021. She said their care and support needs were not being met as they were smelly, in pain, and Y had soiled pad and faeces on her. She asked the duty nurse to see their bedroom and the state of their care.
15. Ms C also said she reported her concern to the Council’s safeguarding team and was told it would come back to her, but no one did.
16. In Summer 2022 the Council’s social worker allocated to X and Y’s case went off sick and did not return until November 2022.
17. In Autumn 2022 Ms C had visited her parents again. She remained concerned about the care and support they were receiving and asked the Council to move them to a different care home.
18. She said the Council told her a reassessment was needed as its social worker was absent. No assessment took place.
19. Ms C says she looked for alternative care homes and contacted the Council again. However, the social worker allocated was off sick again and another social worker would be allocated.
20. Over the following months she raised concerns to the Council about the care they received in the care home which she said included:
• poor personal care for X as he was smelly due to lack of showering, clothes was rarely changed, and a lack of grooming which made him look homeless;
• poor personal care and safety concerns for Y which included the removal of a safety mat and she had falls and broke a bone, and untrained care staff changing her stoma bag causing skin issues and infections;
• poor nutrition and withholding of medication for X and Y. She said X was dehydrated and poorly, and they were both in pain and painkillers did not help;
• lack of cleanliness and unhygienic conditions; and
• she was not informed about Y’s falls.
21. The Council’s social worker spoke with Ms C in late 2022 and a meeting took place between the care home, Council and Ms C. She says the social worker told her X and Y would be placed in a different care home.
22. In early 2023 both X and Y were admitted to hospital. Y had become unresponsive, and an ambulance was called. Mr X was admitted with flu.
23. While X and Y were in hospital, a meeting between Ms C, safeguarding, the social worker, care home staff and other professionals took place in the care home. Ms C shared her concerns, and the Council safeguarding said it would investigate her concerns.
24. Ms C also reported her concerns about the care home to the CQC.
25. X was discharged from hospital back to the care home soon after with antibiotics. The home was on lockdown due to flu. A few days later, Ms C informed the Council X had not eaten, had a drink, or taken his medication since his discharge.
26. The Council spoke with the care home, which explained X had eaten and had water, but had refused food that day and refused his medication. It said it would speak with Ms C.
27. An initial safeguarding meeting took place between the Council and Ms C. She reported her concerns which also included the care home manager’s behaviour and a further bruise Y had which she had not been informed about.
28. X became more unwell again and the care home contacted his GP. He was subsequently readmitted to hospital.
29. Y was not discharged back to the care home. This was because of the lockdown in place, Ms C not wanting her to return, and the care home had concerns about the amount of support she needed for her agitation and aggression. She remained in hospital where she died a few weeks later.
30. X also remained in hospital where he died within a few days of Y.
31. The Council’s safeguarding offered condolences to Ms C and explained it had sought information from the care home and other professionals, but its investigation would take some time.
32. A month later the Council’s safeguarding spoke with Ms C again. Ms C said the officer told her it would take some time to consider the case, but the care home would not be closed down until something serious happened.
33. Ms C complained to the Council about how it had handled her safeguarding concerns and its social workers lack of action and responses.
34. The Council said it could not respond to her complaint until its safeguarding investigation had been completed.
35. Both X and Y’s cases were referred to a coroner, who set out their causes of death and found it was not deemed appropriate to open further investigation.
36. Between March and June 2023, the Council’s safeguarding investigation considered the information it obtained from the care home, nurses, the GP, the hospital, and meetings which had taken place. It also considered information from X and Y’s previous care home.
37. In June 2023 the Council shared its safeguarding investigation outcome with Ms C. It provided its findings on each point of her concerns but did not find evidence of neglect or poor care and some concerns were inconclusive. Its explanation included:
• X had refused support including some nutrition, medication, and personal care and could become verbally aggressive when prompted;
• Y had been pulling her stoma bag and continued to scratch her skin around the area which caused the skin problems, infections and pain. However, appropriate support had been provided and sought which was recorded;
• reasons why the falls mat had been removed and the steps that had been taken after her falls, including involving her GP and nurses. It also explained her broken bone was not known until the hospital confirmed the fracture;
• the support had been appropriate in the circumstances with referrals for health support, but it had been challenging to support X and Y, which was also evidenced in their previous care home and during their hospital admissions;
• concerns about lost items, financial abuse, and care home staff behaviour were unsubstantiated due to lack of evidence; and
• the care home’s investigation of Ms C’s complaint had properly considered her concerns and set out steps for improvements and training which was satisfactory.
38. In early 2024, the Council provided its response to Ms C’s complaint and met with her. It did not uphold her concerns regarding its safeguarding investigation and explained the coroner had not found concerns of neglect in their cause of death.
39. The Council accepted it had failed to allocate a social worker when its allocated worker was off sick in a timely manner and keep accurate case notes. It explained that this did not impact the Council’s overall case management and its social worker had confirmed he did not promise to place X and Y in a different care home. However, it agreed this resulted in uncertainty around Ms C’s request for a different placement for her parents. It apologised and offered a payment of £400 for its faults and her time and trouble to bring her concerns to its attention.
40. Ms C asked the Ombudsman to consider her complaint. She is unhappy about the outcome of the Council’s safeguarding investigation regarding the care home.
41. Ms C has also reported her concerns about the care home to the CQC.

Analysis and findings

42. Ms C’s complaint relates to matters which occurred between 2021 until early 2024 when the Council provided the outcome of its safeguarding investigation and its complaint response.
43. I found Ms C’s complaint relating to concerns in 2021 to be late as there is no good reason why she could not have complained to the Council and brought any concerns to our attention sooner. However, I will exercise my discretion to consider matters from Autumn 2022 as she continued to pursue these concerns and she did not receive the safeguarding outcome until Summer 2023 and the Council’s complaint response in early 2024.

The Council’s safeguarding investigation

44. Ms C says the Council’s investigation should be reopened and she is not satisfied with the outcome. She does not believe it properly considered her concerns and other reported safeguarding concerns from other professionals.
45. I have considered how the Council handled the safeguarding investigation and reached its views. The evidence shows the extent of the Council’s investigation.
46. I have not found fault in the process the Council followed to reach its findings in its safeguarding investigation. This is because the evidence shows the Council:
• considered and recorded Ms C’s concerns, spoke and met with her;
• spoke with all relevant professionals to consider her concerns. This included the care home staff, nurses, the GP, hospital staff, her parents previous care home, and the coroner; and
• obtained and considered evidence of the care home and other records regarding the care and support provided to X and Y. This included information about personal care, nutrition, health treatments, and medication.
47. While I acknowledge Ms C remains unhappy with the outcome of the investigation, as I have not found fault in the process the Council followed to reach its views, I cannot criticise the merits of its decision. I was also conscious it is not possible for the Ombudsman to reach the outcome she wants which is confirmation the care home’s actions led to X and Y’s deaths. Such decisions are for the coroner’s office, which did not find the cases were appropriate for further investigation.

Adult social care support and change of care home

48. Ms C says she asked the Council’s allocated social worker to find a new care home for her parents in Autumn 2022. The social worker agreed a new care home had been discussed, but no promises had been made for this to happen.
49. The Council accepted it had failed to ensure a social worker was allocated to X and Y’s cases when its social worker was off sick for a substantial period of time, and inadequate case notes were made on their cases.
50. I cannot therefore say what advice or promises was made in Ms C’s discussion with the Council’s social worker.
51. On balance, I am satisfied Ms C shared her wish for a new care home placement. The Council should have considered this, recorded its decision-making process, and any advice or requirements it shared with Ms C for finding a new placement.
52. However, there is no evidence this happened, and the social worker continued to be absent or non-responsive following his return in late 2022 and in early 2023, this was both to Ms C and the Council’s safeguarding officer.
53. While I cannot say the Council’s fault meant X and Y should have been placed in a different care home, I am satisfied the fault meant Ms C experienced distress due to the uncertainty around what support her parents could or would receive from the Council.
54. I have considered the Council’s proposed remedy to Ms C for the injustice its faults caused her. I acknowledge the concerns, frustrations and loss Ms C experienced during this time. However, I can only consider the impact the fault the Council was responsible for had on her. I am satisfied its apology and a proposed symbolic payment of £400 to acknowledge the distress and uncertainty she experienced was appropriate.
55. I cannot say the Council’s fault caused an injustice to X and Y as they remained mostly in hospital from early 2023. Nor can I remedy any injustice they may have experienced as they had since died.

Council’s complaints handling

56. The Council informed Ms C it had received her complaint, but it could not provide its response until the safeguarding investigation had been completed. I am satisfied this was appropriate in the circumstances.
57. The Council’s safeguarding investigation concluded in Summer 2023, and it shared its outcome with her. However, it was not until February 2024 it provided its complaint response.
58. I understand Ms C was contesting the safeguarding investigation outcome, however, I have seen no good reason why the Council should take nearly seven months to provide its complaint response. This was therefore fault, which caused her some additional unnecessary distress.

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Agreed action

59. To remedy the injustice the Council caused to Ms C, the Council should, within one month of the final decision:
1. apologise in writing to Ms C. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology.
2. pay her £400 to acknowledge the distress and uncertainty she experienced as a result of the Council’s failure to ensure a social worker was allocated and appropriate notes were kept; and
3. pay Ms D £100 to acknowledge the distress its delayed complaints handling caused her.

In total the Council should pay Ms C £500.

60. Within three months of the final decision the Council should also:
1.  
2.  
3.  
4. share with the Ombudsman the step the Council has taken as a result of its safeguarding and complaint investigation to ensure its Adult Social Care team:
1. reallocates social workers to cases in circumstances where a staff member is away or absent;
2. accurately records case notes following calls, meetings or communications with individuals or those acting on their behalf; and
3. an update on its proposed case audits to ensure cases are appropriately allocated, notes are kept, and cases have been progressed.
61. The Council should provide us with evidence it has complied with the above actions.

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Final decision

62. I have completed my investigation with a finding of some fault around case recording, keeping a social worker allocated, and delayed complaints handling which caused Ms C an injustice. There was no fault in the Council’s safeguarding investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman