Summary: Mrs X complained about the Council’s handling of a safeguarding incident relating to her father. The Council was at fault for long delays in its process and for failing to keep Mrs X updated. It will apologise and make a payment to remedy the upset and uncertainty caused by not finding out what had happened, and for her time and trouble repeatedly chasing the Council for information.

The complaint

1. Mrs X complained the Council failed to investigate a safeguarding referral relating to her father, and failed to keep her updated and informed.
2. She says she was put to the time and trouble of chasing the Council repeatedly and is upset that she still does not know what happened during the incident.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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)

Back to top

How I considered this complaint

5. I considered:
• the information provided by Mrs X and the Council; and
• our guidance on remedies
6. Mrs X and the Council had an opportunity to comment on my draft decision and I considered their comments before making a final decision.

Back to top

What I found

Background

7. 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)
8. This Council’s policy on protecting vulnerable adults says it will take concerns seriously, make enquiries about them, and work with a range of organisations to safeguard adults from abuse and neglect.

Care Quality Commission (CQC)

9. CQC is the independent regulator of health and adult social care in England. It carries out inspections of care homes to ensure they provide people with safe, effective, compassionate, and high quality care. It issues inspection reports and supports care homes to make improvements where appropriate.

What happened

10. Mrs X’s father, Mr F, was discharged from hospital to a care home in April 2018. Mrs X visited him there a few days later. She was unhappy with the level of care he was receiving, the dirty room and said the staff were rude to her. She contacted the Council to report her concerns and the Council recorded this as a safeguarding alert.
11. The following day Mr F was found on the floor in his room by care home staff. The accident record stated he had lost his balance when walking to the toilet and fallen. It noted a skin tear to the left side of his forehead and a cut on his left arm. Staff called an ambulance but before it could arrive a district nurse attended and applied a dressing.
12. The next day Mr F had another unobserved fall in his room. The accident record says he told staff he had slipped off his bed whilst trying to put his sock on. The record stated he had a small skin tear on his left hand. It stated staff called the G.P for advice as there were concerns Mr F may have a urinary tract infection (UTI). The advice they were given was not recorded on the accident record.
13. Two days later Mr F moved to a new care home. Mrs X visited him in the new care home, took photos of his injuries and reported her concerns to the Council. The Council recorded this as a second safeguarding alert.
14. The next day a social worker met Mr F in the new care home. Mr F said care home staff at the previous care home had shouted at him. He said said they were “bullies” and “abusive”. He said his room was not kept clean. He said he had fallen on the stairs, which was not correct. The hospital social worker noted he seemed more confused than when he was in hospital. A second safeguarding alert was recorded about care in the first care home in light of the significant bruising noted on Mr F’s face and hands as a result of the fall.
15. The Council visited the first care home. It interviewed relevant staff. It looked at the records for Mr F. It noted there was no care plan and no risk assessments had been carried out. The Council also contacted Mrs X to discuss the safeguarding concerns she had raised and confirm it was investigating.
16. Mrs X did not hear anything further from the Council and reported her concerns to the Care Quality Commission (CQC). A CQC officer informed her the Council was investigating and CQC would liaise with it with a view to deciding what action should be taken.
17. The Council held a strategy meeting on 30 May 2018. Mrs X was informed of the meeting but was not able to attend. Mrs X says it took seven months and several telephone calls before the Council sent her the minutes for that meeting.
18. In June 2018 Mr F died.
19. In December 2018 the Council contacted Mrs X about arranging a case conference. At this point, Mrs X had not received the minutes from the strategy meeting and asked for all relevant information to be provided to her before the case conference went ahead. Although there were several further contacts with the Council and CQC, the Council did not arrange a case conference.
20. Mrs X complained in mid September 2019 and the Council responded in early October 2019. It said:
• it accepted the length of time the process had taken was unacceptable;
• there were a number of factors involved that were outside its control, although that did not excuse its poor communication with Mrs X;
• it would arrange for a case conference to be held as soon as possible.
21. In December 2018 the Council suggested a meeting in advance of the case conference to go through some reports that it planned to send out after Christmas. Mrs X was unhappy about the need for an extra meeting. The reports were sent in January 2019. Mrs X says they were inaccurate. By this point, several of the care home staff had left and Mrs X felt the Council was brushing her concerns under the carpet.
22. In response to our enquiries, the Council said:
• it accepted the time taken to complete the investigation was not acceptable;
• it had worked with the first care home and CQC to ensure that improvements were made, and this had taken priority over dealing with the safeguarding referral because Mr F had moved to a new care home and was no longer at risk;
• it should have closed the safeguarding referral as part of the collective process with the care home and CQC;
• it had reviewed the case and made changes to its processes to reflect the lessons learned;
• it would apologise to Mrs X for the delay, and the distress this caused the family, and offered to pay her £250 to reflect the time and trouble she was put to.
23. The Council also provided copies of relevant records to show the action it had taken with the first care home and CQC to respond to the concerns Mrs X had raised. This included an action plan identifying the areas that required improvement, officer support for the care home to implement the changes, and regular meetings and visits to monitor progress. In addition, CQC did an unannounced inspection in December 2018, during which it noted improvements that had been made but concluded the care home still required improvement in some areas.

My findings

24. The Council responded to the safeguarding referral by talking to Mr F and Mrs X, and visiting the care home to check its records and interview staff. It held a strategy meeting on 30 May 2018, at which it agreed further enquiries were needed and a case conference would be arranged. These actions were appropriate, and the Council was not at fault.
25. It then failed to send Mrs X the minutes of the strategy meeting and failed to keep her informed of action it was taking. Although it did work with the care home and CQC to ensure that the care home made appropriate improvements, it overlooked completing the safeguarding process for Mr F and arranging the case conference. The Council accepts it delayed and failed to keep Mrs X informed. This was fault.
26. This fault meant Mrs X did not know what had happened when Mr F had falls at the care home and was unaware of improvements the care home made as a result of her safeguarding referral. It also meant she had to repeatedly chase the Council for information.
27. Although the Council did not arrange a case conference, I am not recommending that it does so now because more than two years have elapsed since the incidents complained about and it is unlikely that anything further could be achieved after this length of time. The Council has made changes to its process after reviewing the case but it is not clear whether these include improving its communication so I have made a specific recommendation about that.

Agreed action

28. The Council will, within one month of the date of the final decision, apologise to Mrs X for its delay in concluding the safeguarding investigation and failure to keep her updated. It should pay her £250 for the uncertainty and time and trouble caused. This is in line with our guidance on remedies.
29. The Council will, within three months of the date of the final decision, review its processes to ensure that it finalises its safeguarding enquiries within a reasonable time period and keeps families updated, particularly in those cases where it is taking action with other agencies to achieve wider improvements in care homes under its collective care process. It should report to the Ombudsman on the outcome of its review and the changes it has made as a result.

Back to top

Final decision

30. I have completed my investigation. I have found fault leading to personal injustice. I have recommended action to remedy that injustice and prevent recurrence of the fault.

Back to top

Investigator's decision on behalf of the Ombudsman