Summary: Miss X complains about the way the Council handled a report of a safeguarding concern for her grandfather in a care home, and her subsequent complaint. She says it caused unnecessary distress and trauma, and cost her time and trouble. The Ombudsman does not find fault with the Council.

The complaint

1. The complainant, who I refer to here as Miss X, complains on behalf of herself and her grandfather, Mr B. She complains that:
1. the Council’s safeguarding enquiry did not take account of the evidence she provided;
2. the Council did not contact her for three months;
3. the Council failed to address her desired outcomes;
4. the Council has taken no action against the care home to address the abuse allegations; and,
5. the Council’s process for dealing with allegations has changed and now does not involve family members.
2. Miss X says this has caused unnecessary distress and trauma, and cost her time and trouble.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. 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)
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

Back to top

How I considered this complaint

5. Miss X raised the safeguarding concern and represented this complaint to the Council on behalf of her grandfather, Mr B. For this reason, I find that Miss X is a suitable person to represent the complaint on Mr B’s behalf.
6. I considered the information and documents provided by Miss X and the Council. I spoke to Miss X about the complaint. Miss X and the Council had an opportunity to comment on an earlier draft of this statement. I considered all comments before I reached a final decision.
7. I considered the relevant legislation, statutory guidance and policies, set out below. I read the Care Quality Commission’s most recent two reports on the care home, inspected in November 2017 and more recently in September 2019.

Back to top

What I found

What should have happened

8. If a council funds care in a care home, it remains responsible for the care. This was the case for Mr B during his stay at the care home which forms part of this complaint.

Safeguarding enquiries

9. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
10. The aims of a safeguarding enquiry are to establish facts, find out the individual’s views/wishes, assess the adult’s need for protection, support and redress, and to make a decision about what follow-up action should be taken regarding the person or organisation responsible for the abuse. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help and protect the adult.
11. As part of a safeguarding enquiry, councils must gather relevant information from the person who raised the safeguarding alert, the vulnerable person in question (if appropriate), professionals involved in their care, and family members. Councils should share information and liaise with those involved when making decisions and manage any potential risk. Councils must also keep accurate records of safeguarding enquiries and outcomes.
12. The Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. It says an enquiry could range from a conversation with the adult or their representative before initiating a formal enquiry under section 42, through to a much more formal multi-agency plan or course of action. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry.
13. The guidance says action that can be taken as a result of a safeguarding enquiry can include disciplinary action, complaints or criminal investigations, or work by contracts managers and the Care Quality Commission to improve care standards.
14. Councils are responsible for keeping the person who raised the safeguarding alert updated about any investigation and proposed actions. This can be orally or in writing.
15. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively.
16. It is not for the Ombudsman to reinvestigate the safeguarding referral but to consider whether the council conducted a suitable investigation in line with its safeguarding procedures.

The Council’s ‘Managing Allegations’ policy

17. This says that if an allegation requires police involvement, the Council will send information to the police. The Council will undertake an initial consideration of the allegation.
18. The Council will then decide what action to take. If it decides to convene a strategy meeting there should be police involvement, assessment or intervention from the Adult Social Care team, and action by the employer (in this case, the care home).
19. A strategy meeting should take place within five days of receiving a referral. At the end of the meeting, professionals will be asked whether they find the allegation is substantiated, unsubstantiated, unfounded, or malicious/false.
20. In some cases, an outcome is reached at the end of the strategy meeting. In other cases, further investigation will be needed from police, the Adult Social Care team, or the employer to reach an outcome.

What happened

21. Mr B was a resident in a care home. In February 2019, Miss X raised a safeguarding concern with the Council because of a video the family had covertly taken of carers’ treatment of Mr B. Also, Miss X provided a photograph showing a 21cm pressure sore on Mr B’s back.
22. Mr B’s family removed him from the care home that day and took him to hospital.
23. On the day this concern was raised, the Council arranged a strategy meeting for the next day. Miss X, along with police and Council officers, attended the strategy meeting. Ten actions were agreed at this meeting, including getting clarification from hospital staff on the pressure sore, following the Managing Allegations process, and increasing spot visits to the care home.
24. A few days later, the Council asked Miss X for a list of her concerns and what outcomes she wanted (referred to here as ‘desired outcomes’). She sent this to the Council shortly after.
25. In May, Miss X complained to the Council. She said she had not heard about the outcome of the safeguarding enquiry since the safeguarding manager left her post in February/March. Miss X raised concerns about the likelihood of mistreatment/abuse of vulnerable people at the care home, and said the video she provided proves carers acted criminally.
26. Within a week, the Council called Miss X. It apologised for the delay in arranging the outcomes meeting. It said the delay was because of the vacant role. It said the role was now filled, and therefore the Council wanted to arrange the outcomes meeting as soon as possible.
27. The outcomes meeting was held in June. Miss X and some other family members attended. The Council said the Managing Allegations process is separate from the safeguarding enquiry. It said the Managing Allegations process had made advisory comments to the care home.
28. During this meeting, the Council told Miss X the outcome of the safeguarding enquiry which was that the allegation was unsubstantiated. It said the immediate risk to Mr B was resolved because he went to hospital immediately and was discharged to a different care home. The Council said it had looked at Miss X’s concerns about neglect/acts of omission, organisational, physical, verbal, psychological, and emotional abuse.
29. The Council said it found poor practice at the care home regarding pain relief for Mr B. The social worker involved in the safeguarding enquiry said she had not seen the video or the photo of Mr B’s pressure sore.
30. The Council told Miss X that police had completed their investigation and found that the carers’ actions did not meet the threshold for taking further action. Miss X asked about the desired outcomes she had given the Council. Some of these outcomes were then discussed. The meeting agreed 18 further actions as part of an action plan.
31. At the end of June, the Council reviewed the action plan: all actions had been completed.
32. In July, the Council sent Miss X a letter, following up from the meeting. The Council responded to each of the actions Miss X had requested at the meeting. This letter also addressed some of Miss X’s desired outcomes.
33. In this letter, the Council confirmed that it had viewed the video and read the transcript of the video. It said Miss X had asked why family members were not invited to attend Managing Allegations meetings. The Council said the purpose of these meetings is to share information from various agencies, who have undertaken enquiries, in a confidential setting. It said it was not appropriate for family members to attend.
34. The Council attached to this letter an individual response to each of Miss X’s desired outcomes. It gave Miss X a factsheet about safeguarding enquiries.
35. In August, the Council sent Miss X a letter which said the safeguarding enquiry had been completed. It confirmed that the enquiry found areas of poor practice as discussed in the strategy meeting. It said the care home had taken action about specific carers.
36. The Council attached a document which showed the outcomes of all the actions that had been agreed at the strategy meeting. It gave Miss X a leaflet on the Managing Allegations process which said that a finding of ‘unsubstantiated’ means it cannot be proven either way that an allegation did or did not happen.
37. Later in August, the Council sent Miss X its complaint response. It apologised for any distress she and the family felt during the process. It responded to each of the points Miss X had made in response to the Council’s previous responses. It signposted Miss X to the Ombudsman.

Analysis

Evidence considered during the safeguarding enquiry

38. Miss X complains that the Council’s safeguarding enquiry did not take account of the evidence she provided (part a of the complaint). The evidence Miss X provided was the video and the photo.
39. The safeguarding enquiry was prompted by Miss X’s report of safeguarding concerns and the evidence she provided. The Council confirmed in its July letter that it had viewed the video.
40. I have seen evidence to show that the Council considered Miss X’s evidence as part of the safeguarding enquiry. Further to this, the Council followed up on the photo evidence by discussing Mr B’s pressure sore with the hospital team.
41. The police also considered the video evidence. The Council then acted on the outcome and findings of the police investigation.
42. For these reasons, I do not agree with Miss X that the Council’s safeguarding enquiry failed to take account of the evidence she provided. Therefore, I find no fault with the Council.

Failure to contact Miss X

43. Miss X complains that the Council did not contact her for three months (part b of the complaint). She says the Council did not contact her between 19 February and 13 May, and it only contacted her then because she made a complaint the week before.
44. The Council’s records show that it called Miss X on 22 February, 1 March, 4 March, 8 March and 11 March. On some occasions the Council left messages for Miss X, and on others the Council discussed arranging and rearranging meetings with Miss X.
45. The records show that on 13 May the Council called Miss X and apologised for the delay in arranging the outcomes meeting. It said the delay was because of the vacant role which had now been filled, and it wanted to arrange the meeting as soon as possible.
46. For this reason, I cannot agree with Miss X that the Council did not contact her between 19 February and 13 May. For this reason, I do not find the Council at fault.
47. In May, Miss X complained that she not heard about the outcome of the safeguarding enquiry since the safeguarding manager left her post in February/March. It appears that the vacant post the Council referred to may have been the safeguarding manager’s post.
48. It seems likely the Council delayed arranging the outcomes meeting with Miss X to fill this post. I do not find the Council at fault for this because this is a vital role in dealing with allegations such as this.
49. One of the purposes of a safeguarding enquiry is to assess the adult’s need for protection. In this case, the family removed Mr B from the care home on the day they raised concerns with the Council. He was later discharged from hospital to a different care home. For this reason, there was no immediate risk to Mr B. Therefore, I do not find fault for the time taken to arrange the outcomes meeting with Miss X.
50. While it may have been best practice for the Council to have maintained contact with Miss X between March and May, I do not find this is significant enough to constitute fault. I find the Council kept Miss X informed about action and progress about the safeguarding enquiry.

Desired outcomes

51. Miss X complains that the Council failed to address her desired outcomes (part c of the complaint).
52. Miss X listed 25 desired outcomes. Seven of these were discussed in the outcomes meeting in June. Three of these were addressed in the Council’s July letter to Miss X. Attached to this letter was a document which listed all of Miss X’s desired outcomes in the same format she used, and addressed each one individually.
53. Further, the Council’s letter to Miss X in August addressed 22 of her desired outcomes.
54. Therefore, I do not agree that the Council has failed to address Miss X’s desired outcomes. Miss X may disagree with the Council’s response, or the way it has addressed each outcome, but this is not evidence of fault.
55. Therefore, I do not find the Council at fault.

Action against the care home

56. Miss X complains that the Council has taken no action against the care home to address the abuse allegations (part d of the complaint).
57. The Council says that despite finding the allegation unsubstantiated, the following actions were agreed as a result of the concerns Miss X raised:
• the Council asked the care home to conduct an internal disciplinary investigation and decide what actions to take about the carers;
• the Council asked the care home to use the guidance and support on moving and handling, which the Council is now monitoring; and,
• a multi-agency meeting was held with the care home owner to address the concerns, which resulted in an action plan (including training and support), with the Council undertaking regular quality assurance visits.
58. I find that while the allegations were not substantiated, the Council still had concerns about poor practices which the safeguarding enquiry highlighted. The Council has addressed these concerns through the above actions and is monitoring the care home.
59. I therefore do not agree with Miss X that the Council has taken no action against the care home. The action the Council has taken is in line with the guidance (see paragraph 13). For this reason, I do not find the Council at fault.

A change in process

60. Miss X complains that the Council’s process for dealing with allegations has changed and now does not involve family members (part e of the complaint).
61. Miss X says that the Council’s Managing Allegations process used to hold case conferences and invite family members. She says the Council has told her that case conferences are now superseded by the Managing Allegations process, and this does not involve family members.
62. The Council says that case conferences that form part of safeguarding enquiries have been replaced with outcomes meetings. It says the Managing Allegations process is a separate process from safeguarding enquiries. The Managing Allegations process is a framework to address allegations of abuse, and there is no information sharing with families because the process relates to potential disciplinary actions and therefore cannot be disclosed to third parties (families).
63. I find that Miss X is right to say that the Managing Allegations process does not involve families. There are two procedures that, in this case, ran simultaneously: the safeguarding enquiry and the Managing Allegations process. The only change I have found is that case conferences have been replaced by outcomes meetings. This change is not significant, and I find that it still appropriately involves families in line with the law.
64. I do not agree with Miss X that the Council’s Managing Allegations process used to hold case conferences and invite family members. I have seen no evidence that families were ever involved in the Managing Allegations process.
65. The safeguarding enquiry involved Miss X throughout, as it should have. This is in line with the law and statutory guidance. The Managing Allegations process did not involve Miss X, and this was appropriate. I find that the Council acted in line with both procedures and involved Miss X appropriately.
66. It may be that Miss X has confused the two processes which ran simultaneously. In any event, I do not find the Council at fault.

Back to top

Final decision

67. I have completed my investigation. I do not uphold Miss X’s complaint because there is no fault.

Back to top

Investigator's decision on behalf of the Ombudsman