Summary: Mrs X complained on behalf of her father, Mr Y, about the Council’s safeguarding enquiry into the care Mr Y received at Cromwell House Nursing Home. The Ombudsman found no fault in the outcome of the enquiry.

The complaint

1. Mrs X complained on behalf of her father, Mr Y, about the Council’s safeguarding enquiry into the care Mr Y received at Cromwell House Nursing Home, leading up to his hospitalisation. She said information was withheld and facts were not established. Specifically, Mrs X complained about:
• The length of time the nursing home took to contact Mr Y’s doctor.
• A lack of recording and detail in Mr Y’s care notes.
• Being excluded from the Council’s safeguarding enquiry.
2. Mrs X wanted an explanation of what caused Mr Y’s injuries and for the nursing home to be up front and provide answers. The family have suffered frustration, distress and uncertainty.

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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. 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)
5. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
6. Under our information sharing agreement, we will share this decision with the CQC.

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How I considered this complaint

7. As part of the investigation I have considered the following:
• The complaint and the documents provided by the complainant.
• Documents provided by the Council, including its safeguarding enquiry records.
• The Care Act 2014.
• The Care and Support Statutory Guidance.
• The Council’s safeguarding procedure.
8. Mrs 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

Legislation and guidance

9. 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 (section 42 Care Act 2014).
10. The aims of a safeguarding enquiry are to establish facts, 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 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 (the guidance) sets out what a safeguarding enquiry should look like. This could range from a conversation with the adult or their representative, through to a 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 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.
17. Care providers must securely keep accurate, complete and detailed records for each resident. This includes a record of care and treatment provided. The care provider must always keep records for three years from the last entry and ensure they are available for inspection.

What happened

18. I have summarised below some of the key events leading to Mrs X’s complaint. This is not intended to be a detailed account of what happened.
19. Mr Y went into the nursing home in July 2018 after fracturing right his hip. He could still carry out most activities but needed help with personal care. He also suffered from dementia.
20. On the morning of Sunday 25 November 2018, Mr Y told staff at the nursing home that he had pain to the left hip or groin area.
21. Over the course of the next couple of days, staff offered Mr Y pain killers and visually inspected his left hip area. Staff continued to help Mr Y to mobilise out of bed and into his chair or to the toilet, and to provide personal care.
22. A member of staff contacted Mr Y’s doctor’s surgery (the surgery) on the morning of 27 November 2018. The surgery added Mr Y to their visit list at about 9.30am on 27 November 2018 after receiving a fax from the nursing home.
23. Mr Y was seen by a nurse practitioner (the nurse) from the surgery that morning. He was examined by the nurse, who recorded he had been in pain since the weekend.
24. At about 12.30pm the nurse discussed Mr Y’s symptoms with a doctor from the surgery and they made the decision to send him to hospital due to a possible strangulated hernia. An ambulance was called, with a two-hour response time. A summary was sent to the nursing home.
25. At about 4.20pm Mrs X called the surgery because the ambulance had not arrived. The surgery called the ambulance service and found there was a three-hour delay on top of the two-hour response time.
26. At about 5pm the ambulance service upgraded the response to a priority call at the request of Mr Y’s doctor’s surgery.
27. Just before 7pm the ambulance service spoke to a nurse at the nursing home. They said Mr Y was in quite a lot of pain and the pain was worse.
28. An ambulance attended the nursing home at 7:13pm. Paramedics assessed Mr Y for a potential stroke. They noted a right sided facial droop and slurred speech. On assessment, paramedics found Mr Y pale and hot to the touch. He was leaning on his right-hand side. His abdomen was soft, tender, and swollen. Mr Y complained of left hip pain and his mobility that day was reduced.
29. Mr Y was taken to Addenbrookes hospital by ambulance 8:26pm, arriving at 9:06pm. The hospital found Mr Y had a fractured hip and splintered pelvis, delirium, and faecal impaction.
30. Mrs X complained to the Council about the nursing home on 28 November 2018. She said the nursing home suspected a strangulated hernia, but ambulance paramedics thought Mr Y had a fractured hip from a fall. This was confirmed in hospital. She said the nursing home failed to diagnose the fracture and Mr Y had a skin injury to his left arm which the nursing home was unaware of. She said Mr Y told paramedics he had fallen and a member of staff at the nursing home hurt him.

The nursing home’s investigation

31. The nursing home started an investigation into Mr Y’s injuries on 28 November 2018. It told the CQC and the Council’s safeguarding team about the incident. It collected statements from all members of staff and reviewed Mr Y’s handover notes.
32. The investigation found Mr Y complained of pain to his left leg since 25 November, but it could not establish how his fracture happened. No fall was seen, and Mr Y is reported to have told staff he did not fall. Body checks were completed by staff. There was no evidence of a skin tear. Mr Y was able to rotate his legs and mobilise. No shortening of limbs was observed. The unit manager believed Mr Y’s existing hernia could be the cause of his pain.
33. Following the report, the nursing home recommended staff should have supervision to discuss hip fractures and signs of hidden symptoms. The nursing home accepted Mr Y would have benefitted from an earlier x-ray. A phone call should have been made to Mrs X when Mr Y’s symptoms first appeared, so the family could be part of decision making.

The safeguarding enquiry

34. The social worker (Officer A) leading the Council’s safeguarding enquiry spoke to the manager of the nursing home on 28 November 2018. The manager of the nursing home said Mr Y needs minimal care and mobilises at his own pace. He may have fallen and picked himself up.
35. Officer A also spoke to an adult safeguarding nurse at the hospital. The nurse confirmed the extent of Mr Y’s fracture. It was considered he had bones which were prone to fracture, but it was not possible to say the cause of the injury. The adult safeguarding nurse did not think Mr Y could have got up on his own after such an injury. They considered it may be an impact injury, such as by banging into something.
36. Officer A spoke with the doctor who cared for Mr Y while he was in hospital. The doctor said it was possible the fracture occurred a few days prior to admission and weight bearing, repositioning, and personal care led to shattering. They said, in general, if someone is mobilised after a fracture it will make it worse, but it was difficult to say for certain what happened due to limited available information.
37. On 10 December 2018, Officer A spoke to the nursing home manager. They discussed concerns about the timeline of events and actions taken by the nursing home. Officer A arranged to visit the nursing home to conduct a full enquiry.
38. Officer A then spoke with Mrs X to discuss the concerns she raised about the nursing home.
39. Officer A visited the nursing home on 14 December 2018 to review all the information and records relating to Mr Y. The nursing home provided information from its own investigation.
40. On 19 December 2018, Officer A spoke with Mrs X. Mr Y was due to be discharged from hospital into a different nursing home. Officer A arranged to visit Mr Y.
41. Officer A met Mr Y on 3 January 2019. Mr Y could not remember the incident. He said the nursing home was good and he liked the staff. When Officer A asked Mr Y about a possible fall, Mr Y spoke about a fall he had at home before he went into the nursing home. Mr Y could not say where he was or why he was in a nursing home.
42. Officer A spoke to Mrs X on 4 January to discuss the visit with Mr Y. Officer A said Mr Y could not remember what happened. Mrs X felt Mr Y could remember but did not want to talk about it. Officer A arranged to visit Mr Y again with Mrs X.
43. On 15 January 2019, Officer A met with Mrs X and Mr Y. Mr Y said the care at the nursing home was good and he got on well with staff. He could not remember having a fall. He again spoke about a fall he had before he went into the nursing home.
44. Officer A told Mrs X it was unlikely they could establish what happened to Mr Y, or whether he had a fall. They asked what outcome Mrs X wanted. Mrs X wanted to complain about the nursing home and the doctor’s surgery, and she wanted a meeting with both.
45. On 22 January 2019, Officer A met with the multi-agency safeguarding hub (MASH) manager. They discussed the case and the emotional impact on Mrs X of meeting with care home and doctor’s surgery managers. They did not consider this would bring any new information or answers for Mrs X.
46. Officer A spoke to Mrs X on 23 January 2019. Mrs X repeated her concerns about what happened to Mr Y. Officer A explained the Council were unable to establish how the injuries occurred. They again asked Mrs X what outcome she hoped for. Mrs X wanted to meet the managers of the nursing home and doctor’s surgery to discuss what happened. She wanted them to say sorry and acknowledge things went wrong.
47. Also on 23 January, the Council received a timeline of events from the doctor’s surgery. On 24 January, the Council received a timeline and despatch report from the ambulance service.
48. Officer A called Mrs X on 4 February 2019 to provide an update on their findings. They explained, other than evidence of delays, there was no evidence of how the injuries happened. Mrs X was unhappy and felt people were covering things up.
49. The Council’s enquiry found no evidence of a fall in Mr Y’s care plan, daily logs, statements from nursing home staff, or the nursing home’s own investigation. This was supported by the hospital finding no bruising. Mr Y was asked if he fell, but he said not.
50. There was no evidence a member of staff at the nursing home harmed Mr Y. There was also no evidence of a bleed to Mr Y’s arm. It was not on any body maps or in any reports.
51. Mr Y’s records indicated he was prone to constipation and faecal impaction. He declined fluid on several occasions between 25 and 27 November. The Council said this could have contributed to Mr Y’s faecal impaction and partially upheld this element of Mrs X’s complaint.
52. Mr Y had a hernia which sometimes caused pain. The practice nurse visited Mr Y two weeks before this incident due to hernia related pain. This was followed up by a doctor on 20 November.
53. The Council found no concerns about the doctor’s surgery or practice nurse. They used their professional knowledge and experience to decide there was a possible strangulated hernia. Hospital notes confirm the reason for the fracture as unknown. There was no mention of a possible fall. The doctor responsible for Mr Y could not say for certain how it happened.
54. The Council agreed with the nursing home’s finding that senior staff should have sought medical attention sooner. If Mr Y was taken to hospital sooner, it could have reduced the risk of delirium and splintering to his pelvis. It upheld this element of Mrs X’s complaint.
55. The Council confirmed it was supporting the nursing home to improve its practice. Staff wrote statements to support their development and management will ensure staff are up to date with training. The nursing home manager will address the actions of senior staff involved via their internal processes.

Complaint to the Council

56. Mrs X complained to the Council about its safeguarding enquiry on 29 January 2019. I have summarised her complaints as being:
• The nursing home took too long to contact the doctor.
• There was a lack of recording in the nursing home’s care notes and lack of detail about what happened.
• She was excluded from the safeguarding enquiry and not included in meetings.
• She wanted a full explanation of what happened to Mr Y and a meeting with relevant managers from the Council and nursing home to discuss what happened.
57. The Council wrote to Mrs X on 12 February 2019 providing a summary of its safeguarding enquiry and findings. Officers then met with Mrs X on 19 February to explain how the enquiry was conducted.
58. The Council responded to Mrs X’s complaint on 12 March 2019. It said:
• Its safeguarding enquiry found there was a delay by the nursing home seeking medical help. The Council told the home it must seek medical advice as soon as possible if a resident has unexplained pain.
• It could not say if the lack of a recorded fall in the nursing home’s care notes is because a fall did not happen or because of a failure to record.
• It should have explained to Mrs X how and what it would investigate as part of its safeguarding enquiry. It should also have agreed when and how it would feed back to her on its findings. It apologised for this.
• It met Mrs X to discuss the findings of its enquiry, but unfortunately it could not determine the cause of Mr Y’s injuries.
• It encourages open discussion with care providers, but it cannot enforce meetings.
59. Mrs X wrote to the Council on 21 June 2019 to express her dissatisfaction with its findings. She said the Council and the nursing home failed in their duty of care to Mr Y and did not have suitably qualified staff. She said the Council allowed neglect to happen.
60. On 8 October 2019, the Council sent its review of Mrs X’s complaint, carried out by a senior manager. It said nursing home staff have the required training and this is documented. The Council carries out monitoring to check records are up to date. This includes safeguarding and medical emergencies. Record keeping at the nursing home has improved. The Council has no concerns about nursing home staff qualifications. This is checked by the Council and the Care Quality Commission. The Council offered a meeting with Mrs X to discuss the outcome in more detail.
61. Mrs X wrote back to the Council on 31 October 2019. She declined a meeting with the Council, as she wanted to know facts, not hearsay. She raised a grievance against the senior manager who conducted the review. She said there was no mention of the missing documents from 4 to 27 November 2018.
62. The Council sent its final response on 11 November 2019. It confirmed Mrs X made a subject access request to see documents, which is being handled. It apologised for the delay sending the senior manager review, which was unsigned, but the Council’s complaints process was concluded. It signposted Mrs X to the Ombudsman.
63. Mrs X brought her complaint to the Ombudsman on 19 November 2019. She told me she is unhappy with the Council’s investigation because it makes no fact findings. She felt the nursing home tried to put her off complaining and would not meet to discuss what happened. She also felt the nursing home’s records are fraudulent.
64. She accused the nursing home of abuse. They rotated Mr Y’s hip when it was not right to do so. In her view this caused his injuries. There was no swelling or redness, so it could not be a hernia as they had said. If the nursing home suspected a strangulated hernia it should not have been a low priority hospital admission but an emergency.
65. She said it would have been different if the home did things the right way and met her to discuss things. But she was told they don’t do meetings. She feels they did not want to apologise for fear of financial consequences.

Response to my enquiries

66. The Council told me Mr Y’s placement at the nursing home was funded by the NHS through continuing health care. Its involvement was limited to the safeguarding enquiry.
67. The outcome of the investigation was inconclusive because the Council could not say whether the lack of recording by the nursing home was due to an omission or because no event or fall happened.
68. The nursing home told the Council its staff did not rotate Mr Y’s hip, this was done by the practice nurse from the doctor’s surgery when she assessed Mr Y.
69. The social worker who conducted the enquiry spoke to Mr Y. He could not remember the incident and said the care at the home was good and he liked the staff.
70. The Council acknowledged it could have consulted with Mrs X more during its investigation. It said she did agree to the scope of the investigation. The Council was sorry it could not resolve Mrs X’s concerns.

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Analysis

71. Mrs X’s complaint to us was about a failure to safeguard Mr Y. She is understandably upset and angry it took the nursing home two or three days to seek medical help for her father. She thinks the home failed in its duty of care towards her father.
72. The nursing home conducted its own investigation into what happened. The Council verified its findings by visiting the home, checking Mr Y’s care plans and records, and by taking copies of records and statements from staff members.
73. As part of the Council’s own enquiry, it collected evidence from Mr Y’s doctor’s surgery, hospital doctor, the ambulance service, and the nursing home. No evidence could be found for what caused Mr Y’s injuries. Mrs X thinks this suggests the nursing home is covering up what happened. She thinks something did take place, either a fall or rough treatment from a member of staff, and this has not been recorded. The Council did not find any evidence about these suspicions. It therefore concluded the cause of the injury was unknown. It cannot speculate or blame the nursing home, or its staff, for what happened without evidence.
74. The Council received a timeline of events from Mr Y’s doctor’s surgery and the ambulance service. This helped to establish what happened when but did not go into detail about how Mr Y was examined and what the views of the practice nurse or the doctor were about his symptoms. Given Mrs X’s complaints about Mr Y’s hip being rotated, and about incomplete records, it would have been useful if the Council had obtained Mr Y’s medical records from the surgery. However, I do not consider it was at fault not to do so and it did not affect the outcome.
75. I can understand why Mrs X thinks the nursing home’s delay seeking medical advice is a failure in its duty of care. The nursing home accepts it should have acted sooner. However, there is no evidence to say the delay definitely made Mr Y’s injuries worse, or that the splintering to his pelvis was caused by staff continuing to move him, or by the nurse practitioner rotating his pelvis. Mr Y’s hospital doctor confirmed this was possible, but there was not enough information to say for certain. The Council cannot make positive findings or hold individuals to account based on suspicion and speculation.
76. I consider the Council discussed its enquiry with Mrs X enough to understand her concerns and what outcomes she wanted. Officer A met with Mrs X and Mr Y, as well as speaking to Mrs X about the findings of the enquiry before the Council completed its report. The Council accepts it could have kept Mrs X more informed during the enquiry. It apologised for the distress caused.
77. The Council met Mrs X to discuss its enquiry findings when she complained. It is unfortunate the manager of the nursing home would not meet Mrs X. I appreciate the Council cannot force the nursing home manager to attend a meeting, and it is not obliged to do so as part of its safeguarding enquiry. The Council did consider Mrs X’s request to meet the nursing home manager. I can understand its concerns about the emotional impact on Mrs X, and the likelihood it would not add to the investigation. However, the Council could have communicated this to Mrs X better, as it knew this was an outcome she wanted. But it was not fault on the Council’s part.
78. Ultimately, I consider the Council was entitled to reach the conclusions it made. I appreciate this was upsetting for Mrs X and her family. They wanted answers about how Mr Y suffered such serious injuries. But when the Council makes findings about the cause of injuries, or the impact of possible neglect or ill treatment, it must rely on medical opinion and the available evidence.
79. It is clear the nursing home should have sought medical advice for Mr Y sooner. The home recognised this in its own investigation and planned to arrange relevant training for staff. The nursing home also accepted it should have told Mrs X about Mr Y’s symptoms sooner. Staff were reminded to keep relatives informed. The Council was satisfied with the action taken and is entitled to reach that view. The Council should ask the care home for feedback once the training takes place.
80. I have not found evidence of fault with the Council’s enquiry or the outcome reached. Broadly speaking, it contacted the relevant parties and agencies involved and collected the evidence we would expect. It has identified areas where the nursing home got things wrong and it was satisfied with the actions put in place to prevent similar issues happening again. This included suitable training for staff.
81. After the Council’s enquiry concluded, I found the nursing home lost some of Mr Y’s records. I appreciate this will add to Mrs X’s feeling that the nursing home’s records are unreliable. However, this did not impact the Council’s safeguarding enquiry, as the Council carried out an inspection of the records before they were lost and took copies of the relevant documents. These records were made available to me by the Council. The only records I have not seen are Mr Y’s care plans, but the Council did see them. I have seen the care logs for the relevant days around Mr Y’s hospitalisation and had enough information to complete my investigation.
82. If Mrs X wishes to complain about the missing records, she can take her complaint to the Information Commissioner’s Office. They have the power to take action against the nursing home for data protection breaches. The Council told me it will also be addressing the issue with the nursing home.

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Final decision

83. I have completed my investigation. I found no fault in the outcome of the Council’s safeguarding enquiry.

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Investigator's decision on behalf of the Ombudsman