Summary: Ms X complains the Council failed to provide safe and suitable care for her grandfather Mr Y while he was in a care home causing distress. We have found fault by the Council because it failed to provide clarity to its safeguarding enquiry conclusions in Mr Y’s case. We have recommended a suitable remedy for the injustice caused in this case so have completed our investigation.

The complaint

1. Ms X complains the Council failed to provide safe and suitable care for her grandfather Mr Y in October 2023. Ms X says this resulted in Mr Y developing a severe infection and needing to be admitted to hospital.
2. Ms X wants to Council to refund their care costs for the inadequate care Mr Y received at the care home, for the care home to admit it is responsible and apologise.

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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 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

5. I spoke to Ms X and considered the information she provided with her complaint. I considered information from the Council and the supporting documents it provided along with the relevant law and guidance.
6. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
7. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended). I have decided not to name the care home or provider due to the circumstances of the complaint and because Mr Y may be identified if I do so.

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What I found

Relevant law and guidance

Safeguarding

8. 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)

What happened

9. What follows is a brief chronology of key events. It does not contain all the information I reviewed during my investigation.
10. Mr Y was admitted to hospital and moved to the care home in January 2022 due to a decline in his mental and physical health and wellbeing. Mr Y received nursing care while at the care home.
11. The Council funded Mr Y’s placement. Mr Y paid an assessed contribution towards the placement according to the Council’s residential care charging policy and the outcome of a financial assessment. Mr Y’s placement was monitored and reviewed by the East Locality team. The team last reviewed the placement on 7 September 2022 and considered it was meeting Mr Y’s care and support needs. There were no concerns raised by the care home and family. So, approval for the placement continued.
12. Mr Y was admitted to hospital on 25 October 2023 with a severe infection. Ms X complained to the care home it had neglected Mr Y’s care. In summary Ms X considered Mr Y was in good spirits on 24 October 2023. But family visiting Mr Y raised concerns about some medical equipment he used and whether it was working properly. Ms X complained the care home staff should have been aware of Mr Y’s deteriorating condition on 25 October and taken action sooner. The care home acknowledged the complaint and said it would investigate.
13. The Council received a safeguarding concern about the matter, decided it met the criteria for a section 42 enquiry and allocated it to a senior officer to investigate. The officer asked the care home to carry out an internal investigation. The officer spoke to Mr Y’s family who did not want Mr Y to return to the care home once discharged from hospital.
14. The care home manager responded to Ms X’s complaint and explained they had spoken to the three nurses involved in Mr Y’s care on 24 and 25 October 2023. The manager reviewed the care notes and respect form held for Mr Y. The respect form listed Mr Y’s wishes if he was unwell and needed treatment.
15. The nurses confirmed Mr Y was monitored hourly on 24 October 2023 due to the issues with his medical equipment. The nurses decided to remove the equipment and refer Mr Y to the GP during the ward round the next morning. Mr Y was given pain relief. Mr Y’s extensive medical history ongoing for some years was noted. He wanted to avoid hospital admissions and for his comfort to be prioritised according to his respect form.
16. A nurse reviewed Mr Y on 25 October 2023, and he appeared alert. The nurse attempted to reattach the equipment but decided not to for medical reasons and wait for further advice. The nurse continued to check Mr Y, but clinical observations showed some issues. Because of this the nurse called for managerial help which the care home said was the appropriate action to take. Staff then decided to call for an ambulance and Mr Y was taken to hospital.
17. The manager noted on 25 October 2023 Mr Y was recorded as alert, so the care team gained verbal consent to deliver care to him. The documents noted he was content while staff delivered personal care to him. Mr Y declined medication saying he was not in any pain.
18. The investigating officer visited the care home, reviewed care records, training documents and risk assessments. The officer spoke to the care home management about the safeguarding concerns and considered the care home’s internal investigation report.
19. The officer and manager noted Mr Y’s family disagreed with the internal investigation and considered the care home should take responsibility for what happened leading to Mr Y’s infection.

Safeguarding report

20. The officer’s safeguarding report explained the action taken to investigate the concerns raised. The officer and care home manager considered wording used on records tended to be generic and not always specific to the task or time. This lacked detail and could cause confusion. They noted staff took eight hours after the initial issue with the medical equipment and Mr Y’s complaints of discomfort to access managers from outside for support. They noted the delay could have been prevented if staff had the right training and followed guidance on escalating concerns.
21. But the care home manager considered nursing staff did what they should as the risk to Mr Y was low. And staff acted when he identified as unwell. The manager recognised the case recording on daily notes was limited and required improving. The manager said the care provider would send staff to training courses on dealing with a deteriorating person and escalating concerns.
22. The safeguarding report noted the care home considered the nurses did everything they should have to support Mr Y. Although the family disagreed and felt staff should have acted sooner due to the serious infection. The officer considered the evidence provided showed Mr Y could consent to treatment, staff were treating him on 24 and 25 October with checks made every hour and action taken. Staff had regard to Mr Y’s respect form to prioritise comfort rather than hospital admission and maintain his care with the medical equipment. But when it became clear he was unwell and declining they called an ambulance. The officer considered the time frame was extensive with a delay during the night asking for management to attend, contributing to a decline in health. So, training about necessary care was to be requested for all staff to prevent delay.
23. The officer decided the risk assessment for Mr Y was inconclusive and action had been taken. It noted Mr Y was discharged from hospital and to a placement with a different care home. So, the officer concluded there was no risk identified as he was no longer residing at the care home.
24. The Council considered the officer’s safeguarding report. It noted the risks identified due to the concerns raised about medical neglect and the care home had been investigated. The Council considered the safeguarding enquiry to be unsubstantiated, and action taken to identify areas of learning, training and sharing information with partner agencies. Mr Y had not returned to the care home, so it removed the risk for him. The Council closed the safeguarding enquiry and shared the outcome with its contract management team and the CQC due to other people staying in the care home. The Council also shared the outcome of the safeguarding with the NHS.
25. The Council confirms the Intermediate care team continued to provide oversight until Mr Y’s placement at the current care home became permanent. The North Locality team continues to monitor and review his placement.
26. The Council advised it holds an information sharing meeting every week with the NHS, Adult social care, the Quality in Care team (QICT) and CQC every week to discuss all care homes in Walsall. The QICT were working with the care home management, so information from Mr Y’s safeguarding enquiry and the outcome, were shared at this meeting and informed the improvement plan in place at the care home. The QICT were visiting the care home regularly around this time to ensure they were carrying out the improvement plan.

My assessment

27. The documents provided show the safeguarding investigation carried out by the Council was robust as it investigated the incident with Mr Y, reviewed care records and interviewed staff. Because of this I do not intend to reinvestigate what happened as I do not consider I could add to any previous investigation by the Council. It is also not for us to decide if the actions amount to neglect.
28. However, I consider there is lack of clarity in the Council’s conclusions. This is because Ms X and her family allege there was neglect by the care home. The safeguarding report refers to a delay by care home staff in calling for assistance contributing to a decline in Mr Y’s health. But the conclusions failed to explain whether the Council considered the action of the care home amounted to neglect or not. The lack of clarity is fault by the Council. It has determined the outcome as unsubstantiated despite the comments of the investigating officer referring to delay and making recommendations for improvements. So, there is some contradiction between the comments, findings, and conclusions.
29. However, I do not consider the outcome of the safeguarding enquiry would have been any different even if the conclusion had properly explained whether it amounted to neglect or not and concluded the delay was neglect. This is because the Council was likely to have recommended the care home staff receive training which has been implemented already. In addition, the care home was on an improvement plan, so action has been taken to ensure improvements are made.
30. We cannot say on balance of probabilities whether the delay referred to in the safeguarding report led to a deterioration of Mr Y’s condition as that is not our role. Because of this I consider the injustice caused by the lack of clarity in the safeguarding report conclusions is uncertainty for Ms X as to whether there has been any neglect to Mr Y. So, I recommend the Council apologises to Ms X and makes her a payment of £300 in recognition of the uncertainty she has been caused.

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Agreed action

31. Within a month of my final decision the Council will:
• Apologise to Ms X and make her a payment of £300 in recognition of the uncertainty caused by the Council’s failure to provide clarity in its safeguarding enquiry conclusions.
• Review the safeguarding report and where possible will provide professional judgement whether neglect occurred in the care home in Mr Y’s case. Where this is not possible there will be a clear rationale why it is inconclusive as to whether neglect occurred.
• Carry out training or remind officers who conduct safeguarding investigations to ensure reports are definitive and not contradictory.
32. The Council should provide us with evidence it has complied with the above actions.

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Final decision

33. I have completed my investigation. There was fault by the Council as it failed to provide clarity to its safeguarding enquiry conclusions in Mr Y’s case. I have recommended a suitable remedy for the injustice caused in this case.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman