Summary: There was delay by the Council when carrying out a safeguarding investigation and responding to an official complaint. Mrs B was no longer in the care home complained about, so a £250 payment and an apology remedies her daughters injustice of time and trouble pursing the complaint. There is no evidence of inadequate care by the care home. The Council properly carried out the safeguarding enquiry but there was minor fault, in that it was missing details of whether the care homes medication policy complied with the fundamental standards of care.

The complaint

1. The complainant, who I shall call Ms X, complains for her late mother, Mrs B. Ms X complains the care home did not administer medication to her mother in accordance with the prescription and did not adequately monitor side effects. She complains the care provided in a care home was inadequate and that her mother’s health deteriorated.
2. There was delay in the social workers response to a safeguarding complaint in February 2018 and it was unsatisfactory. Ms X says the delay was frustrating, especially as she was trying to find a suitable care home for her mother who was then in hospital.

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The Ombudsman’s role and powers

3. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
4. 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)
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 read the papers put in by Ms X and discussed the complaint with her.
7. I considered the Council’s comments about the complaint and any supporting documents it provided.
8. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Law and Guidance

9. 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. (section 42, Care Act 2014)
10. The Council’s safeguarding policy and procedure is available online. Section 9.4 says that ‘the aim should be for planning discussion or a multi-agency meeting, to take place within 5 working days of receiving the concern. The scope of the enquiry, who leads it and its nature, and how long it takes, will depend on the particular circumstances (Statutory Guidance, Section 14.93). The aim however should be to complete required actions within eight weeks, or earlier wherever possible’.
11. The policy says that an outcome discussion meeting would be held within eight weeks and an outcome review meeting, ideally, within 3 months.
12. NICE (the national institute for health and care excellence) publishes guidance for managing medicines for adults receiving social care in the community. Section 1.6 says that when social care providers have responsibilities for medicines support they must have robust processes for medicines related safeguarding incidents. Care workers should raise any concerns about possible adverse effects from a person’s medicines to the social care provider. Care workers should advise family members to seek advice from a health professional if they have clinical questions about medicines. The guidance says social care providers should ensure that care workers know how to report adverse effects of medicines.
13. 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 below which care must never fall.
14. Section12(2)(g) refers to the proper and safe management of medicines. It says that staff responsible for the management and administration of medication must be suitably trained and competent and this should be kept under review.
15. Staff must follow policies and procedures about managing medicines, including those related to infection control.

Chronology

16. Mrs B moved to Ferndale care home on 27 February 2018 from another care home who could no longer meet her needs.
17. Mrs B had Dementia and her symptoms became worse at night, when she could become agitated and anxious.
18. Care home staff recorded on 27, 28 February and 1 March that they managed Mrs B feeling unsettled and wandering out of her room into another resident’s room at night by providing reassurance, chatting and encouraging her to return to her own room.
19. The care home manager rang the family on 2 March to tell them they had asked the psychiatrist to review Mrs B. The psychiatrist prescribed Mrs B anti-psychotic medication as a short term measure to help manage her behaviour and the care home notes record the doctor dropped off the prescription on 2 March. Ms X says she reluctantly agreed to the medication when speaking to the psychiatrist on the telephone.
20. The care home gave the first does of the anti-psychotic medication to Mrs B at tea time on 2 March 2019. The care home gave a second dose at 9pm on 3 March.
21. Family visited Mrs B on 28 February, 2 March, 3 March and 4 March 2019. Ms X complains the care home did not inform the family that Mrs B’s presentation changed after she was admitted and that the care home did not tell the GP.
22. The care home records record that Mrs B did not go to bed at all on 3 March and remained in her chair in the lounge, with a blanket.
23. The care home records record that on the morning of 4 March Mrs B’s mobility was very poor and she was very sleepy. Hospital admitted Mrs B on 4 March 2018. Mrs B remained in hospital and did not return to the care home.

Safeguarding complaint and Council’s complaints procedure

24. Ms X raised concerns with the adult safeguarding team on 1 May 2018. She had concerns about the medication prescribed to her mum and the possible side effects it caused.
25. The Council sent the initial safeguarding report to Ms X on 14 June 2018. Ms X replied on 11 July with her concerns and the safeguarding team then decided to further investigate medication management and allegations made against the psychiatrist and the care home. The Council told Ms X this on 25 July. The safeguarding officer made some further enquires but was then on sick leave for 6 weeks till the beginning of September 2018.
26. The Council sent a revised safeguarding report to Ms X on 1 October 2018. The Council made further enquires of Leeds and York Partnership Trust as the safeguarding officer had not had further comments from the psychiatrist. The file shows the safeguarding officer chased the Leeds and York Partnership Trust for a reply until it was received on 25 April 2019.
27. The Council wrote to Ms X on 3 May 2019. The Council apologised for the time the safeguarding enquiry had taken and said there was further delay as they were waiting for the outcome of the formal complaints being investigated by the Contracts and Commissioning team and the NHS.
28. Ms X complains about delay. There has clearly been delay in the safeguarding investigation, which is fault. The Council’s policy says that an outcome discussion meeting should be held within 8 weeks. The Council did comply with this timescale, as the initial draft was sent to Ms X within 8 weeks. There was some delay when the investigator was on sick leave but it was reasonable for the Council to carry out further investigations. The delay waiting for the Leeds and York Partnership Trust’s response was clearly not in the Council’s control, and this accounted for at least 6 months of the year wait to get a final written outcome.
29. The Council accepts there was delay in responding to Ms X’s official complaint. Its target timescale for responding to most complaints is within 4 to 8 calendar weeks. It took us 22 weeks to respond to Ms X’s complaint.
30. The Council said it offers a sincere apology to Ms X and a payment of £250 in recognition the delay, and her time and inconvenience in making her complaint. The Council has said the Complaints Manager and Complaints Co-ordinator will meet to discuss the learning from this case.
31. I appreciate there was delay in the Council’s response to the safeguarding enquiry and official complaint. I understand that this was frustrating to Ms X, however, Mrs B was no longer in the care home when the safeguarding referral happened so the time taken did not affect her. I therefore consider the Council’s apology and payment is a satisfactory to her time, trouble and frustration at the delayed response.
32. Ms X says that she first raised safeguarding concerns in February 2018 to the social worker about her mother’s care in a different care home. She thinks that if this complaint had been responded to properly at the time, then things may have been different. The Council has said it has no record of a safeguarding concern being raised in February 2018. I can see that Ms X contacted the Council in February 2018 and the social worker approved funding a 1 to 1 carer for her mother at night in the care home. Mrs B went into hospital after a fall but no safeguarding concern was raised. At this point, a move to another care home was considered. I can see no evidence that the fall or care in February 2018 was raised as a safeguarding concern. The social workers notes, to me, are a discussion about Mrs B care and the problems that occurred, with the view to finding a suitable future suitable provision.
33. Ms X also complains the safeguarding investigation was inadequate. My role is not to repeat the safeguarding investigation, but to ensure that it was done properly and considered everything.
34. I have looked at the safeguarding investigation report. It details Ms X’s concerns taken over the telephone, the care home’s response, an email from the psychiatrist, a telephone call to the hospital and a visit to the care home. The investigation got copes of documentation and spoke to the hospital consultant.
35. The investigator reviewed the prescription for medication, the medicine administration chart, the daily records, spoke to the pharmacy, got the 999 call record and spoke to hospital and care home staff.
36. The outcome of the investigation was that the care home had followed the medication procedure correctly and the medication was prescribed correctly. The investigation found there was no evidence to confirm the medication led to the physical deterioration of Mrs B’s health. The investigation did identify the care home should ensure that contact with professionals and family was recorded accurately and that care plans should be up-to-date and stored correctly. (Mrs B’s care plan was lost on her transfer to hospital.)
37. The fundamental standards of care or NICE guidelines are not specifically referred to in the safeguarding investigation. It does not specifically mention the requirement to report adverse reactions. There are also no details of the care home’s formal procedure for managing medication in the safeguarding investigation report. Ideally, these would be included.
38. However, the report includes the care home notes, medication charts and gives comprehensive details of Mrs B’s Health at least twice a day.
39. I now have to consider if the outcome of the safeguarding investigation would have been different if the requirement to report adverse reactions had been considered in the safeguarding report. My view is that it would not have altered the outcome. The conclusion in the safeguarding report was that Mrs B deteriorated before taking the medication was reached after taking account all of the available evidence. So, it is clear the investigator considered whether the there had been an adverse reaction to the medication and concluded there was no evidence to support this. If this was the case, then I can see why the investigator did not go on to consider if staff should have reported an adverse reaction when the conclusion was that no adverse reaction occurred.
40. For completeness, I do think the investigation should have included full details of the care home’s medication procedure to check it included reporting adverse reactions and complied with the fundamental standards. My view is this was fault and while it did not affect the outcome of this investigation and so cause any injustice to Mrs B or Ms X, I do recommend the Council ensures medication procedures are included in investigation reports involving medication in future.

Care home complaint

41. Ms X complains the care home did not give medication to her mother in accordance with the prescription and did not adequately monitor side effects.
42. The safeguarding investigation found no evidence the care home did not give the medication properly, after consulting expert pharmacists
43. I have looked at the medicine charts sent by the care home and can see that care workers recorded they gave Mrs B the dose prescribed. So, I can find no evidence of fault with the care home on this point.
44. The care home notes show close monitoring of Mrs B’s health and behaviour. The daily record detailed whether she was confused, when she had bruises, swelling in her feet, when she ate, what personal care she required and when staff called doctors or nurses.
45. Both Council and care home have referred to the care home’s medication procedure, but I have not seen a copy. So, I can find no evidence that the care homes medication procedure/policy specifically refers to monitoring patients for side effects. However, it is clear from the written evidence in the care home notes that care workers monitored Mrs B closely. So, I find no fault on the complaint that the care home did not adequately monitor Mrs B for side effects.

Agreed action

46. That the Council apologises and pays Ms X £250 for her time and trouble and frustration over delay in dealing with her complaints within one month of the date of the decision on this complaint.
47. That the Council ensures that safeguarding investigations involving medication include details of the relevant medication policy or procedure and ensure that it complies with the fundamental standards of care and NICE guidelines within one month of the date of the decision on this complaint. This could be carried out by updating its internal guidelines or emailing the relevant officers to ensure they are aware.

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Final decision

48. I have completed my investigation of this complaint. There was fault by the Council and I consider the remedy above remedies the injustice caused.

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Investigator's decision on behalf of the Ombudsman