Summary: Ms C complains about the process through which the Council carried out a safeguarding investigation into the concerns she had raised about her grandmother’s care. She did not complain about the outcome. The Ombudsman found fault with the way in which the Council carried out the investigation, which resulted in some delays and in distress to Ms C. The Council has already apologised for this and has agreed to share the lessons learned with relevant staff.

The complaint

1. The complainant, whom I shall call Ms C, complained to us about the way through which the Council carried out a safeguarding investigation into the concerns she had raised about her grandmother’s care. Ms C complained the safeguarding investigation took longer to complete than the four weeks she was told it should take; it took 16 weeks. Ms C said:
• Three different social workers in total were responsible for investigating the concerns. The Council passed the investigation to another social worker on two occasions. This resulted in delays.
• The Council postponed the safeguarding conference numerous times. She believes the meeting would not have been held at all (in the end) if she had not chased the Council so much.
2. Ms C also complained:
• The Council, initially, denied the family’s request to have an advocate present to support them at the safeguarding conference.
• The first version of the safeguarding report she received had many mistakes, which she had to point out to the Council to correct.
• It took an unreasonable amount of time before she received a copy of the minutes of the safeguarding meeting. She received them on 19 March 2018, which was three weeks after the meeting. She had to chase the Council for this several times and believes she would not have received them if she had not chased the Council so much.

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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 cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), 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 considered the information I received from Ms C and the Council. I also interviewed the Council’s Safeguarding Lead. I shared a copy of my draft decision statement with Ms C and the Council and considered any comments I received, before I made my final decision.

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What I found

What should have happened?

7. The Council’s Adult Safeguarding Practice Guidance says that:
• A Safeguarding Adults Manager (SAM) will oversee the investigation by the Investigating Officer, who will be responsible for ensuring the investigation is carried out effectively.
• The safeguarding enquiry needs to be concluded within four weeks, unless it is a criminal enquiry. Once the enquiry is finished, the Council needs to hold a safeguarding conference within four weeks. The purpose of this meeting is to determine if the adult suffered abuse or neglect and what support is needed to prevent the likelihood of the adult suffering further abuse.
• The victim of the alleged abuse, their family/friends or their advocate can be invited to this meeting, where appropriate.

What happened?

8. Ms C says her grandmother had several falls within a short time, at the extra care sheltered housing complex she lived. She went into hospital following the sixth fall in November 2017 and died shortly after. However, Ms C told me her complaint to the Ombudsman was not about the care her grandmother received, as they were pursuing that separately. Ms C complained about the way through which the Council had carried out its safeguarding investigation into the above concern. While she was satisfied with the outcome of the investigation, she was not happy with the process it went through.
9. Ms C made a safeguarding alert to the Council on 14 November 2017. She says the Council first promised her it would organise a safeguarding meeting in December 2017. However, it cancelled this meeting at the last minute, after which it postponed the meeting to January 2018. The meeting took eventually place on 26 February 2018.
10. The safeguarding investigation was carried out by a locum (temporary) social worker. She held a strategy meeting on 16 November 2017 with the SAM to agree a plan for the investigation. The officer:
• Could initially not visit Ms C’s grandmother, because there was an outbreak of Norovirus at the hospital she stayed, which resulted in restrictions on visits. As such, the Council was initially unable to carry out a Mental Capacity Assessment (MCA) of her to determine if she had capacity to agree with the investigation and participate in it.
• Visited the care home on 16 November and inspected/collected records.
• Told the care provider to carry out an investigation into what happened and report back to her. She also made a request for written statements from staff members who had been on duty on the night of the fall.
• Contacted the police on 24 November, to ask if they felt there may be a criminal element of neglect. The police confirmed three days later that they would not get involved.
11. The officer chased the care provider on 27 November 2017, who then provided a report from its contractor about bed sensors (to prevent falls) and statements from its staff. The care provider promised to send a list of staff members who were on duty at the time of the previous falls. The officer carried out further enquiries directly with the contractor.
12. On 29 November 2017, the officer attended a meeting between the care home, Ms C and her family, at which the care home apologised.
13. The officer told Ms C in December 2017 that she would organise a safeguarding Planning & Review meeting on 28 December 2017. As the officer has since left, I am unable to clarify why she made this promise at a time when she had not yet completed her enquiry.
14. While the officer promptly progressed her investigation during the first two weeks, the records showed there was a lack of activity and progress between 1 December 2017 and 8 January 2018. The meeting planned for 28 December was rescheduled to 19 January 2018. Again, the officer set this date before she received all the information she needed and completed her enquiry. Ms C’s grandmother moved from the hospital into a nursing home at the end of December 2017.
15. On 8 January 2018, the officer asked the care provider to return the completed Provider Led Enquiry report. The Council explained to me that, when it asks a care provider to investigate a safeguarding alert, it sends them a template that includes an extensive list of questions. The care provider has to complete and return this report. The provider does not need to produce a separate investigation report. However, on this occasion, the officer had also asked the provider to produce its own investigation report. Furthermore, the officer had only sent a copy of the report template to the care provider on 13 December 2017 (four weeks after the investigation started). This contributed to the delays.
16. The Council received the “Provider Led Report” on 11 January 2018. The officer told Ms C the same day that she would have to postpone the meeting again, because the Council would need time to consider the case.
17. On 12 January, Ms C asked the officer for a copy of the provider’s report, which had been promised to her.
18. The officer told Ms C on 15 January 2018, that she would leave the Council on 26 January 2018. She would therefore have to hand over the case to another social worker. Furthermore, the meeting proposed for 26 January would have to be proposed and the SAM would be in contact about this. Ms C reported the officer had been extremely helpful and supportive to her family.
19. There were various emails between Ms C and the SAM during 15 and 16 January 2017:
• The SAM said the officer should not have set a date for the meeting, because this should only take place once the investigation is completed. She would hand over the case to a new officer by the end of the week, who would look at all the information the Council had received, conclude the investigation and then set a date for the conference.
• Ms C would receive any information about her grandmother’s safeguarding case before the meeting.
20. Ms C was frustrated that, despite her requests, she had not yet received a copy of the care provider’s report, as had been promised to her. In addition, the meeting had to be postponed again without a new date being known yet.
21. The new officer allocate was unable to immediately take on Ms C’s case. As such, the Council transferred the case to another officer on 17 January. The SAM was replaced by the Council’s Safeguarding Lead. The new officer called Ms C and arranged a meeting with her for 23 January 2018. The officer said she would bring the report to the meeting but could also send it to Ms C in the post beforehand.
22. The officer visited Ms C in the nursing home on 23 January 2018 to review her care plans and the placement. She also carried out a mental capacity assessment and handed over a copy of the provider report to Ms C. The officer explained she had to gather further evidence, after which she would complete a report and set a date for the safeguarding meeting. The Council has apologised to Ms C for the delays. The officer completed the investigation on 8 February 2018 and send a copy of her report to Ms C for comments.
23. Ms C provided her comments on the draft report to the Council. The Council told me that most errors in the report were not critical in terms of the enquiry’s purpose, with only one exception (the medication was Aspirin not Warfarin). Any point Ms C raised was discussed and clarified at the meeting. The Council included Ms C’s comments on subsequent forms in the file after discussing at the meeting.
24. The Council said it organised the safeguarding conference on the next available date of 26 February 2018, when all attendees were available. This was within four weeks of completing the investigation.
25. Ms C complained the Council initially did not allow her to take an advocate along to the meeting to support her. She told the Council that the family were feeling nervous and the advocate, who was a friend and confidante, would be there to reassure and support them.
26. The Council told me that:
• While the meeting could be stressful, the family already present could have provided each other with support. Ms C’s parents wanted to attend the meeting, both of whom held joined Power of Attorney. In addition, Ms C wanted to attend the meeting, because she had taken on the tole of her grandmother’s advocate with regards to this case.
• The Council explained to Ms C that meetings with a large number of people were usually less effective. The Council would therefore normally ask that no more than two family members attend.
• In the end the Council agreed to an advocate being present. However, it agreed with Ms C that the advocate would not be allowed to speak in the meeting and would only be there to help and support the family. Nevertheless, despite Ms C’s assurance, the advocate talked about general non case specific issues, which was not the purpose of meeting.
27. Ms C says she asked for a copy of the minutes of the meeting on 9 and 12 March 2018. She was given an update on 12 March but chased the Council again on 15 and 16 March. The Council agreed with Ms C on 16 March that it had taken too long to circulate the minutes and would take this up with the line manager of the minute taker. Ms C received the minutes on 19 March 2018.
28. The Council acknowledged that minutes are ideally completed, confirmed as correct and completed by the chair and distributed to all parties within approximately two weeks. In this case it took longer because the draft minutes produced by the minute taker were not clear and accurate enough. As such, a great deal of cross-referencing was needed to get them to a standard that was adequate, not leaving out salient points. The minutes were six working days later than usual. The Council apologised to Ms C for this. The Council has identified it needs more skilled and confident minute takers. It has developed a template that is now used to make note taking easier and improve the rate at which the notes are sent out. The Council now asks chairs to chase the minute taker if they have not received a draft within one week.
29. The Council acknowledged that:
• The first officer and SAM failed to follow the required safeguarding investigation procedure, in terms of:
1. Working within reasonable timescales to complete the safeguarding enquiry.
2. Recording clear reasons for delays in case enquiry
3. Ensuring that all correspondence, meetings and phone communications were logged on the case file as evidenced from the content of other emails on file and missing information
4. The SAM providing sufficient oversight of the case. This contributed in part to the lack of progress in the early part of the enquiry.
• The length of time it took to complete this enquiry was not acceptable. The Council has previously provided a full apology to Ms C for this as well as informal apologies.
• However, once the case was allocated on 17 January 2018 to another officer and SAM, it progressed at a good pace.
• As a result of the delay in this and other safeguarding investigations, the Council has implemented fortnightly meetings between the Safeguarding Adults Manager and the lead practitioner for safeguarding in which the timely completion of enquiries is discussed, and the importance of preventing drift in enquiries is addressed.
30. The Council’s Safeguarding Lead acknowledged that it appeared that the locum officer (social worker) was not sufficiently aware of the way the Council carries out this type of investigation. There has been a high percentage of locums, which the Council has tried to reduce. This case has identified the importance of:
• Close monitoring of new / locum social workers during the first few weeks to ensure any areas of improvement or training are identified and addressed early on.
• Ensuring new / locum social workers have received training on the Council’s safeguarding process, before they carry out their first investigation.

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Assessment

31. After a good start, the Council failed to progress the investigation with sufficient urgency, allowing it to drift. In addition:
• There was a delay in carrying out the mental capacity assessment. The assessment did not take place once the norovirus outbreak had ended, nor when Ms C’s grandmother moved to a nursing home on 21 December 2017.
• The Council should not have promised Ms C that she would organise a safeguarding meeting at a particular date. The Council should have waited with setting a date until it had received all the information and reports it needed and had completed the enquiry.
• The Council was at fault for asking the care provider to produce its own report, in addition to completing the Council’s Provider Led Enquiry.
• There was a four-week delay in sending the Council’s Provider Led Enquiry template.
• There was a delay in forwarding the care provider’s report
32. However, once the case was passed to the third investigator, it was progressed swiftly and in line with the Council’s safeguarding policy and procedure.
33. The Council acknowledged and apologised that the minutes took slightly longer to be circulated. It has identified appropriate steps to try and address this.
34. The Council considered Ms C’s request to have an additional person present at the safeguarding meeting. The Council initially did not allow this and explained to her why it had some reservations and concerns. This was a decision the Council was entitled to make, which I cannot criticise (see paragraph five above). When Ms C explained why it would be important for her and her family, the Council eventually agreed.

Agreed action

35. The Council has already apologised to Ms C for the above. I recommended that, within six weeks of the decision, the Council should:
• Share the lessons learned above with staff involved with carrying out safeguarding investigations
• Remind its staff, who carry out safeguarding investigations, of the importance to clearly set out at the beginning (as much as possible), what the process will be and ensure people are updated when delays occur.
• Identify a suitable plan to address the issues identified in paragraph 30 above.
36. The Council told me it has accepted my recommendations.

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Final decision

37. For reasons explained above, there was fault in the way through which the Council progressed its investigation. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.

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Investigator's decision on behalf of the Ombudsman