Summary: The Council failed to properly consider whether it should carry out a safeguarding investigation into the actions of an elderly couple’s carers. The Ombudsman recommends that the Council apologises and pays the family £650.

The complaint

1. Mrs D complains on behalf of her elderly uncle Mr C about the way the Council handled safeguarding investigations into the actions of Mr and Mrs C’s carers.

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The Ombudsman’s role and powers

2. 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)
3. 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( ), as amended)

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How I considered this complaint

4. I have discussed the complaint with Mrs D. I have considered the records that she and the Council have sent, the relevant law, guidance and policies and both sides' comments on the draft decision.

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What I found

5. The Care Act 2014 explains the Council’s duties towards adults who require care and support.
6. The council has a duty to safeguard adults. Section 42 of the Care Act 2014 says a council must make necessary enquiries if:
• It has reason to think a person may be at risk of abuse or neglect and
• The person has needs for care and support which mean he or she cannot protect himself or herself.
7. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.
8. The council’s safeguarding duties apply equally to those adults whether the adult lacks mental capacity or not.
9. The Care Act guidance says financial or material abuse includes theft, fraud, internet scamming, coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions and the misuse or misappropriation of property, possessions or benefits.
10. The guidance refers to the indicators of abuse set out in the Help the Aged report which include the victim’s change in living conditions; possessions sold; unexplained withdrawals from a savings account; unexplained disappearance of financial documents; cut off from family/ friends/social network; carer’s enhanced lifestyle; sudden changes in bank account or banking practice; the recent addition of authorised signers on an older person’s signature card; unauthorised withdrawal of funds using the older adult’s ATM card; abrupt changes in a will or other financial documents.

Mental Capacity Act 2005

11. 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 says a person must be presumed to have capacity unless it is established that he does not.
12. The Mental Capacity Act 2005 sets out the principles for working with people who lack capacity to make a particular decision.
13. The five key principles in the Act are:
• Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise.
• A person must be given all practicable help before anyone treats them as not being able to make their own decisions.
• Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision.
• Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests.
• Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms.

Council’s safeguarding policy

14. The Council has its own multi-agency policy on safeguarding. This says:
• The main objective of any safeguarding action is prevention.
• Any person may raise a concern that a person is at risk. The Council will conduct an initial enquiry and, then, if the matter is not resolved, it will either provide a risk management response or carry out a formal enquiry.
• The Council holds a strategy meeting which will plan the formal enquiry, how to manage risk and to formulate the safeguarding plan.
• A formal enquiry will establish the facts and gather evidence to support a safeguarding plan.
• The Council will carry out an initial risk assessments and possibly further risk assessment to minimise any risk to the person. The safeguarding plan records the agreed arrangements to manage the assessed risk.
• The Council appoints a safeguarding coordinator who coordinates the enquiry and a safeguarding enquiry officer who will carry out the enquiries and write the enquiry report. The Council is the lead agency for making enquiries, but it may require others to undertake them.
• The Formal Enquiry Report should provide a summary of enquiry activities and evidence obtained. This should include activities by other organisations such as the police.
• The Council holds a case conference meeting which is a multi-agency meeting. The target timescale is to hold the conference within 8 weeks of the decision to hold a formal enquiry. The conference will consider risk, the safeguarding plan and the enquiry report.
• The case is concluded based on the evidence within the formal enquiry. The burden of proof is the balance of probabilities.
15. There are the possible outcomes:
• Substantiated - fully or partially.
• Inconclusive.
• Not substantiated.
• Investigation ceased at individual’s request.
16. If a person has mental capacity but has substantial difficulty being involved in the process, the Council may consider providing them with an independent advocate if there is no one in the family or friends who can provide this role.
17. If a person lacks mental capacity, it may be necessary to appoint an independent mental capacity advocate (IMCA).

Allegations against people in positions of trust

18. People in positions of trust are people who work, in either a paid or unpaid capacity, with adults with care and support needs. The Care Act says that councils must have separate procedures for cases relating to people in positions of trust.
19. The Council’s policy say allegations against people in positions of trust should be referred to the Designated Adult Safeguarding Manager who will coordinate the investigation.

People involved

• Mr and Mrs C were a frail and elderly couple who needed care and support. Mrs C had a history of mental illness. They lived in a large house and had savings.
• Mrs D is the couple’s niece and their representative in the complaint.
• Mr E is the couple’s nephew and Mrs E is his wife.
• Mrs F was Mr and Mrs C’s cleaner. She and her husband, Mr F, ran a cleaning company, but the couple then moved in with Mr and Mrs C and became their carers.

What happened

20. The Council became involved in August 2017 when Mr C was in hospital. The Council organised a package of care at home by care agency X to facilitate Mr C’s discharge from hospital. Mr and Mrs B self-funded the support as they were over the financial threshold to be eligible for Council funding.

Safeguarding investigation 1

21. Care agency X made a safeguarding referral on 22 November 2017. This related to emotional abuse and aggressive behaviour by Mrs C towards Mr C and financial abuse by the cleaner, Mrs F and by a friend of Mrs C who was a doctor.
22. Mrs E made a similar safeguarding referral to the Council on 24 November 2017 about Mrs C and the doctor. The Council carried out a risk assessment and allocated a safeguarding enquiry officer and safeguarding coordinator.
23. The social worker visited Mr and Mrs C on 1 and 6 December 2017. Care agency X provided support in the morning and evening, but Mrs F had started to provide the support during the day. The social worker noted no concerns.
24. Mrs F raised concerns of financial abuse by the nephew, Mr E.
25. Agency X raised further safeguarding concerns about Mr and Mrs F on 2 January 2018. Agency X manager said:
• She saw Mrs C in pain and Mr C had implored the carer to take Mrs C to hospital. Mr and Mrs F said they would call the GP. Agency X found out from the GP that Mr and Mrs F did not call the GP. Mrs C was then admitted to hospital with pneumonia on the following day.
• On the following day, Mr and Mrs F cancelled the support package by agency X as they did not want the carers ‘bringing in germs’.
• Agency X no longer wanted to provide care for Mr and Mrs C as Mr and Mrs F made the carers ‘feel uncomfortable.’
26. The social worker visited Mr C while Mrs C was in hospital. Mr F said Mrs C was going to apply for power of attorney for Mr C and she was going to leave her entire estate to Mrs F.
27. Mrs C’s solicitor informed the social worker that two solicitors would visit Mrs C on 2 January 2018.

Strategy meeting – 8 January 2018

28. Mr and Mrs D, Mr and Mrs E, care agency X and the police attended the strategy meeting organised by the Council.
29. The social worker had visited Mr and Mrs C and said everything appeared fine. Mr and Mrs F had now moved into the house full time and agency X had been sacked. The social worker contacted the solicitor who said that no power of attorney had been set up and there had been no changes to the will.
30. Agency X raised the following concerns about Mr and Mrs F:
• Mr and Mrs C had bought a car for Mr and Mrs F as Mrs F said they needed a car.
• Mrs F appeared to try to intervene when the carer told Mr C that his nephew loved him.
• Mrs C had been coughing and needed a doctor, but Mr and Mrs F would not let them call a doctor. Later the carers were told they could not come in as they were bringing germs in.
• Care staff had noticed bruising on Mr C which looked like finger marks.
• The care staff felt intimidated by Mr and Mrs F.
• Mr C said he missed his nephew, Mr E but Mrs F told him that Mr E would never come back to the house as he had sold the furniture.
• Mr and Mrs F then stopped all care from the agency and moved into the property.
31. The family raised the following concerns about Mr and Mrs F:
• Mr C had deteriorated over the last month.
• A wallet with a wad of £20 notes had gone missing.
• Mr C’s bank card went missing and when it was cancelled the family noticed it had been used for a direct debit. Mr and Mrs C could not have set up a direct debit so this must have been done by Mr and Mrs F.
• Mr and Mrs F were asking Mr C to sign cheques for large amounts.
• Mr C used to wear an alarm pendant, but this had been stopped. Mr E used to be the first responder for the alarm, but that had been stopped. Mr C did not have access to a phone.
• Mr C’s friend of 15 years had been banned from visiting the house. He used to visit every day and was the second person of Mr C’s list on the alarm.
• Mr and Mrs C were convinced the family would force them to go to a care home, but this was not the case and they suspected Mr and Mrs F were fuelling this fear and isolating the couple.
32. The chair said there was little the Council could do about Mr and Mrs F because Mr and Mrs C had capacity to make decisions about their care and finances.
33. The police said the issue of capacity needed investigating. Secondly, there was a suggestion of isolation by Mr and Mrs F and this was ‘concerning and could be sinister’ and this also needed further investigation. He said there was no role for the police at this stage.
34. The meeting ended with a plan to proceed to further enquiries.

Further events

35. Mrs C left hospital on 10 January 2018. The doctor at the hospital told the social worker that he had assessed Mrs C as having capacity to make decisions about her care and support needs. Mrs C told the doctor she wanted Mrs F to care for her and she would leave all her money to Mrs F in her will.
36. The social worker visited Mr and Mrs C on 12 January 2018 and spoke to them on their own. She noted that the house was clean and warm and said Mr and Mrs C appeared happy and well.
37. The social worker and another officer visited again on 15 January 2018. They spoke to Mr C on his own and he told them he wanted to be at home with Mrs C and wanted Mr and Mrs F to care for him. He did not want to talk about his family and became distressed.
38. The social worker and the other officer then talked at length with Mrs F. Mrs F said she and her husbands had enhanced DBS checks. She said Mrs C wanted to pay them £50,000 a year. The officer explained about a power of attorney and the rights and responsibilities that came with this. Mrs F said she had used £6,000 of her own money to pay for things while Mr and Mrs C were too ill to go to the bank. She said it was Mr and Mrs C’s decision to change the locks and gave examples of why Mr C was not happy with the family’s involvement. Mrs F showed a care plan that her friend, who she said was a nurse, had drawn up for Mr and Mrs C.
39. The social worker said she would request a DBS check for Mr and Mrs F.
40. On 23 January 2018, Mrs F told some members of the family that Mr C was now close to death and was on a Liverpool pathway (palliative care practice to allow terminally ill people to die with dignity).
41. An advanced clinical practitioner visited Mr C regularly. She worked with the GP practice and her role was to visit patients who were unable to visit the GP. The object of the visit was to avoid hospital admission.
42. She spoke to the social worker on 24 January and said that Mr C was fine and not at the end of his life. She had no concerns about the quality of care Mr and Mrs F provided and said: ‘I cannot fault them.’ She sent a letter confirming the conversation on 26 January 2018. She said:
• She had visited Mr and Mrs C on many occasions and they were always comfortable, warm, hydrated and appeared well cared for.
• Neither Mr nor Mrs B had ever expressed distress at the care provided to them.
• She had no reason for concern regarding Mr or Mr C’s wellbeing.
• All instruction and advice she gave in relation to their medical needs had been provided.
43. Mr C and Mrs C’s solicitor spoke to the social worker on 25 January 2018. She said she had visited Mr and Mrs C on the previous day. The solicitor said Mr C lacked capacity to make decisions about his finances but Mrs C had capacity and could make decisions in Mr C’s best interest. The social worker said Mr C was suffering from an infection which may affect his abilities. The solicitor said Mrs C wanted to grant power of attorney to someone who was not Mr and Mrs F.
44. It is my understanding Mrs C changed her will in favour of Mr and Mrs F at some point and gave Mrs F power of attorney although it is not clear from the notes when this happened.

Safeguarding investigation 2

45. The Council received another safeguarding referral on 27 January 2018. This was made by the couple’s community nurse. He said:
• Mr C sustained unstageable pressure ulcers in Mr and Mrs F’s care.
• Mr and Mrs F had not escalated the concerns.
• He was also concerned Mr and Mrs F were not repositioning Mr C as regularly as required.
46. The Council started a safeguarding enquiry but asked the district nurse to carry out the enquiries.
47. The district nurse completed a root cause analysis investigation report dated 1 May 2018. Her findings were, in terms care and service delivery problems, that:
• There was a problem with the mattress which meant the mattress was not inflating properly.
• Mr and Mrs F had not escalated the problem to the Community Care Team.

Enquiry report regarding safeguarding investigation 1

48. The enquiry report dated 29 January 2018 was focussed mostly on the risk posed by Mrs C to Mr C and said there had been verbal abuse.
49. The enquiry officer recommended an independent advocate for Mr C. The report said, in relation to the risk of financial abuse, that Mrs C had been assessed as having capacity to manage her and Mr C’s affairs and a solicitor was involved regarding this. It said payments to Mr and Mrs F had been arranged but were appropriate. It said: ‘Risk removed capacity has been assessed.’

Safeguarding conference – 31 January 2018

50. Mr and Mrs F attended the conference and brought a document each which they said contained the requests made by Mr and Mrs C.
51. Mr C’s document had 11 requests which included:
• Mr and Mrs F to look after him and his wife until his death.
• Please make appointments to see Mr C as he gets tired very quickly.
• Change all locks on doors as family have keys.
• Visitors are not to use the house phone.
• Visitors are not to roam around in Mr C’s house.
• Please don’t ring the gardeners. These are my friends.
• Progress of my wellbeing will be passed to the family via Mr F, Mrs F or the social worker.
• Mr C would like to know where the family have got the phone numbers for the gardeners as these numbers are in my phone book and I have not given them to any of my family.
52. Mr and Mrs D also handed in a document which listed their concerns about Mr and Mrs F. They said Mr and Mrs F were now living in Mr and Mrs C’s home overseeing every aspect of their life, including care and finance. They said they organised an Age UK pendant alarm in 2012 and Mr E used to be called out. Mr E had now been removed from the contact list and Mr C no longer had his pendant alarm and was now totally isolated.
53. Mrs D wanted an investigation into Mr and Mrs F’s background and qualifications and an independent advocate for Mr C.
54. The outcome of the meeting was that safeguarding investigation 1 would be closed, but there would be a review meeting. The social worker would find an advocate for Mr C.

Further developments

55. Mrs F told the social worker on 22 February 2018 that she now had a power of attorney for Mrs C. She said Mr C also wanted them to hold a power of attorney for him.
56. Mr and Mrs B wrote to the Council on 23 February 2018 with further concerns. Mrs B was concerned that Mrs F had gone from being a cleaner to now being a third party on Mr and Mrs C’s bank account and holding a power of attorney for Mrs C. She said Mr C felt that only Mr and Mrs F had isolated Mr and Mrs C from their family and friends and told them that the family would put them in a care home and that only Mr and Mrs F could be trusted. She wanted to know if the Council had checked any of the records for the care delivered or the payments for the care by Mr and Mrs F.
57. A note dated 2 March 2019 shows that the referral to the advocacy service was still to be actioned and the social worker was going to check Mr and Mrs F’s DBS status.
58. Mrs C was admitted to hospital on 18 March 2018 with a urinary tract infection and delirium/hallucinations/paranoid ideation. She was discharged from hospital in April 2018.
59. On 21 March 2018 the social worker said an advocate had been allocated and would be contacting Mr and Mrs C soon. A note dated 27 March 2018 said the DBS checks were still to be actioned.
60. On 27 April 2018 Mrs C was re-admitted to hospital under section 2 of the Mental Health Act as she was suffering from a psychotic illness and could not remain in the community. The assessors said Mrs C’s mental health had deteriorated over the last two months and she was now delusional and acting in an agitated and aggressive manner.

Safeguarding investigation 3

61. The Council received another safeguarding referral on 10 April 2018. Mrs D made the referral which related to concerns of financial abuse by Mr and Mrs F.
62. The Police contacted the Council on 18 April 2018 and said there were ‘grave concerns’ about financial abuse by Mr and Mrs F and said nearly £100,000 had been withdrawn from the account in the last year. The police was starting an immediate investigation and was going to arrest Mr and Mrs F. The bank had frozen the bank account.
63. The Council held a strategy meeting on 23 April 2018. It noted that a similar allegation of financial abuse had been made by Mr and Mrs D in the past but said that at the time Mrs C ‘had capacity and a solicitor had been involved in drawing up the POA… therefore no further action could be taken’.
64. The meeting concluded that the risk may relate to psychological abuse and grooming as well as financial and material abuse.
65. The police visited Mr C at home on 25 April 2018. The police showed Mr C the bank statements and receipts from the house. The police said it became quickly apparent that Mr C had no idea that £5,000 a month was being paid to the carers or all the large amounts of money that had been paid on various things for the house.
66. The police said it was ‘obvious this family was wide open to financial abuse’ and pointed to an unwritten signed cheque in the cheque book which Mrs F said Mrs C had signed that day. The police officer said that, if Mrs C had been in the same mental state all day as she was when the police met her, she would not have had capacity to sign the cheque.
67. The police officer said there was not enough evidence for a police investigation, but he had alerted the Office of the Public Guardian.
68. On 26 April 2018, two social workers visited Mr C and advised him to open a separate bank account to access money for himself and Mr and Mrs F. Mr C was still saying he wanted Mr and Mrs F to continue to support him.
69. The police uncovered further evidence relating to financial abuse in the following days and arrested Mr and Mrs F on 1 May 2018.
70. Sadly, Mrs C passed away on 4 May 2018.
71. The Council emailed Mrs B on 14 June 2018 and said it would close the safeguarding investigation as it felt that the risk to Mr C was being managed, but it would invite the family to a safeguarding conference before doing so.
72. The Council and the police met on 5 July 2018. The police said that financial abuse by Mr and Mrs F was suspected but had not been proven and the police could therefore not take the matter further. The problem was that the main witness, Mrs C had died. The police pointed out that the Council could decide a safeguarding investigation on the balance of probabilities, whereas a criminal prosecution needed to prove the offence had occurred beyond all reasonable doubt.
73. The Council met with Mr and Mrs F on 11 July 2018 to discuss the allegations. Mr and Mrs F denied all the allegations.
74. The Council had a meeting with Mr and Mrs D on 13 August 2018. The officer informed Mr and Mrs D that the safeguarding process had been completed. The officer explained that the Council did not have prosecuting powers and asked what Mrs D hoped to achieve by any further investigation. Mrs D said she hoped to prevent Mr and Mrs F doing the same to other people.
75. Mrs D sent an email to the Council after the meeting with further concerns about the social worker’s handling of the case and information they had uncovered of the alleged abuse by Mr and Mrs F.
76. The bank contacted the Council on 29 August 2018 and said it confirmed ‘account takeover’ and ‘impersonation’ fraud on Mr and Mrs C’s account.
77. The Council organised a safeguarding conference on 9 October 2018.
78. The chair of the conference called Mr and Mrs D on 5 October 2018. She said she had discussed the case with the safeguarding team. She said that:
• Mr and Mrs C were no longer at risk.
• The police was unable to take further action.
• The Council’s investigation was unlikely to come to another conclusion than the police’s.
• Mr and Mrs D had raised a number of concerns and she would respond to these under the complaints process by 28 October 2018.
• She had cancelled the safeguarding conference and recommended to close the safeguarding investigation.
79. The Council’s internal auditors investigated whether the Council’s internal procedures relating to financial abuse had been followed. The report dated11 October 2018 said:
• There was enough information in February 2018 to suggest that Mr and Mrs C might be subject to coercion or undue influence from other parties. The Council should have considered at that stage whether to raise a financial safeguarding alert.
• While a person may have mental capacity to make financial decisions, there was still a responsibility for the Council to ensure that a vulnerable person was not subject to coercion or undue influence.

Complaints

80. The Council did not respond to Mr and Mrs D’s complaint, so they made a formal complaint on 8 November 2018. I have summarised the complaints in so far as they are relevant to the investigation.
81. Mr and Mrs D said the Council failed to properly consider the safeguarding concerns raised by the family, friends and care agency in January 2018 and failed to protect Mr and Mrs F from financial abuse and inadequate care. They said the police said the abuse should have been ‘nipped in the bud’ by social services in January. They also complained about the Council’s failure to respond to their complaint.
82. The Council replied on 9 January 2019 and said:
• The police had concerns at the strategy meeting on 8 January 2018. The police suggested that the Council review and investigate Mr and Mrs C’s capacity to make decisions. Several capacity assessments were undertaken by various professionals in 2017 and 2018 and they all said Mr and Mrs C had capacity to make decisions. The Council concluded: ‘The police therefore decided not to take any further action at that time.’
• They acknowledged that a further safeguarding should have been considered in February 2018 that Mr and Mrs C could be subject to coercion.
• The capacity of Mr and Mrs C to manage their financial affairs was a key factor. Safeguarding procedures were clear about empowerment of the adult at risk. The Council said: ‘If they have the requisite capacity, they have the right to make their own decisions, even if others might regard those decisions as unwise.’
• All professionals who visited Mr and Mrs C were satisfied with the level of care given.
• The pressure sores related to a mattress that was faulty which Mr C reported. The safeguarding alert identified unintentional harm. It said Mr and Mrs F had not been informed of the need to reposition Mr C every two hours at night.
• It acknowledged that Mr and Mrs D felt that their communications with staff were ignored and they apologised for the distress this caused but said that Mr and Mrs C were assessed as having capacity to make decisions and their privacy and confidentiality had to be respected.
• It apologised for the lack of response to the complaint of 8 November 2018.
83. Mr and Mrs D were not satisfied with the Council’s response and the Council held a meeting with them on 7 March 2019 to discuss their concerns and sent an email dated 26 March 2019 with further detail and questions on why they felt the safeguarding investigation was not conducted properly. Mrs D sent a letter responding to the further issues to the Council on 28 March 2019.

Analysis

84. Mr C and Mrs D are understandably angry at what has happened. They have, after Mr and Mrs F were arrested, uncovered a lot of information about the time Mr and Mrs F were living with Mr and Mrs C. They are convinced that Mr and Mrs F groomed Mr and Mrs C, isolated them and financially abused them. They say the care they provided was poor and led to the deterioration of Mr and Mrs C.
85. I have only investigated the actions of the Council. I have not investigated Mr and Mrs F as their actions are outside of the Ombudsman’s jurisdiction. I cannot make any findings on whether there was financial or other abuse by Mr and Mrs F.
86. My investigation is focussed on whether the Council followed the appropriate safeguarding procedures. I can only consider the Council’s actions based on the information that it had available at the time, not the information that transpired after the events.
87. The Council said it did not start a safeguarding investigation about Mr and Mrs F in January 2018 because Mrs C had mental capacity to make decision so there was nothing the Council could do. Its second reason was the police’s decision not to carry out a criminal investigation.
88. I agree the Mental Capacity Act says a person may make unwise decisions and this does not necessarily mean they lack capacity. However, this did not stop the Council’s duty to act if it suspected that a vulnerable person was being exploited and groomed. The Council’s safeguarding duty applies to any person, whether with or without mental capacity. The Council seemed to misunderstand its safeguarding duties when it said that, as Mr and Mrs C had capacity, there was nothing it could do.
89. The police said, at the strategy meeting on 8 January 2018 that it would not start a criminal investigation. But my reading of the minutes was that the police shared the family’s concerns about Mr and Mrs F which it called ‘sinister and concerning’ and it expected the Council to carry out the further investigation.
90. I accept that, in a case of possible financial abuse, such as this one, any investigation would normally be led by the police. However, the Council’s safeguarding role is different from the police’s role. The threshold for a criminal investigation may not have been met, but that did not mean that the Council should not have considered whether its own threshold for a safeguarding investigation was met.
91. The minutes of the two meetings in January 2018 show that concerns about physical, emotional and financial abuse had been raised. Agency X noticed bruising on Mr C. There were concerns about wallets of cash and a bank card missing, there was a gift of a car and the signing of cheques for large amounts. Agency X and the family raised the issue of the isolation of Mr and Mrs C from their family and friends. The Council knew about the plan to change the will and the power of attorney.
92. These were all markers which should have led the Council to consider a section 42 safeguarding investigation in January 2018 and its failure to do so properly was fault.
93. I am also concerned about the Council’s conclusion that the professionals did not have any concerns about the care Mr and Mrs F provided. The Council has based this largely on the letter dated 26 January 2018 from the advanced clinical practitioner. However, care agency X raised concerns about Mr and Mrs F’s practice as did the district nurse who made the second safeguarding referral. And, although the report in the second safeguarding referral said that the faulty mattress was the main cause of the problem, it also said Mr and Mrs F should have escalated the concerns about the pressure sores but had not done so.
94. I am concerned the Council rarely questioned or checked the information that Mr and Mrs F gave. There is no evidence the Council checked the care records or the medication charts against the care plan. The social worker said she would carry out a DBS check following a meeting on 15 January 2018, but a note dated 27 March 2018 stated that this was still one of the actions that had to be done. There is no evidence the Council checked Mr and Mrs F’s qualifications or their contract with Mr and Mrs C or any of the payments that were being made.
95. The Council also failed to progress the appointment of an advocate. This was identified at the initial safeguarding conference in January 2018, but the advocate was not appointed until two months later.
96. There was also fault in the way the Council conducted the third safeguarding enquiry. The Council decided on 23 April 2018 to proceed to a section 42 safeguarding investigation and hold a case conference. The police would lead the investigation.
97. The police informed the Council on 5 July 2018 that, although it suspected financial abuse, it could not prove this beyond reasonable doubt because Mrs C had died. The Council met Mr and Mrs F on 10 July 2018.
98. The Council then decided in October 2018 to cancel the safeguarding conference and to close the investigation. It told Mrs D it would deal with her concerns as a complaint.
99. In my view there was fault in the way this process was handled, particularly as this was a case where the allegations were so serious and related to a ‘person in a position of trust’. The Council did not complete an Enquiry Report, hold a safeguarding conference or carry out any further investigations from July to October.
100. All the procedures say that safeguarding investigations should be completed as quickly as possible. I accept that this was a complex investigation. I also understand that the investigation was led by the police so the Council could not have completed its investigation before the police closed its investigation in July 2018. I also accept any risk to Mr and Mrs C was removed once Mr and Mrs F had moved out. However, there is no explanation why it took from July to October to close the case and what further actions the Council took in that time.
101. Also, Mr C and Mrs D wanted answers to all the questions they had. If the Council had completed the enquiry report and held the conference, it could have addressed some of these questions.
102. There was then further fault as the Council failed to respond to the concerns Mrs D raised first in August and then in October. On 5 October 2018 the Council said it would treat their concerns about the safeguarding investigations as a complaint and it would respond by 28 October 2018 but failed to do so.
103. Mrs D then wrote to the Council in November 2018 with a further complaint which the Council then responded to in January 2019.
104. I have considered the injustice the family has suffered as a result of the fault. The Council’s safeguarding investigating relating to Mr and Mrs F’s actions was inconclusive. Therefore, Mr C and Mrs D are left with the uncertainty of not knowing whether things would have been different if the Council had properly considered a safeguarding enquiry in January 2018 and the distress this has caused. The second injustice is the time and trouble they had to endure to obtain a response to their concerns which then had to be pursued as complaints.

Agreed action

105. The Council has agreed to take the following actions. It will:
• Apologise in writing to Mr C and Mrs D for the faults identified in the decision
• Pay Mr C £500 for the distress caused by the uncertainty.
• Pay Mrs D £150 for the time and trouble in pursuing the complaint.
• Share this decision with relevant staff, ensures that relevant staff are aware of the Council’s safeguarding duties and procedures and provides further training if necessary.

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Final decision

106. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman