Summary: Mrs X complained on behalf of her father, Mr Y, about the Council’s safeguarding enquiry into Mr Y’s care at Madeira Lodge Care Home. The Ombudsman found no evidence of fault with the Council’s enquiry, or the outcome reached.

The complaint

1. Mrs X complained on behalf of her father, Mr Y, about the Council’s safeguarding enquiry after she raised concerns about the care Mr Y received at Madeira Lodge Care Home (Madeira Lodge). Mrs X said Madeira Lodge were negligent towards Mr Y and that resulted in him being admitted to hospital.
2. Mrs X feels things were covered up and the Council’s investigation was insufficient. This caused distress.

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The Ombudsman’s role and powers

3. 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.

4. (Local Government Act 1974, section 26A(2), as amended)
5. 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)
6. 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)
7. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)

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How I considered this complaint

8. As part of the investigation, I have considered the following:
• The complaint and the documents provided by the complainant’s representative, as well as the information we discussed in a telephone conversation.
• Documents provided by the Council and its comments in response to my enquiries.
• The Care Act 2014.
• The Care and Support Statutory Guidance (Updated 26 October 2018).
• The Council’s safeguarding procedure.
9. 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

10. 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).
11. 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.
12. 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.
13. 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.
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.

What happened

17. 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.
18. Mrs X told me Mr Y was a fit, healthy man before he moved to Madeira Lodge in February 2019. His former care home could no longer manage his dementia, so he needed to move. Mrs X was devastated when she saw Madeira Lodge for the first time. Residents were in a communal area, looking unresponsive, and were not allowed in their rooms. Mr Y liked music and his own space but was made to stay in the communal area. Madeira Lodge was strict about visiting times and would not let Mrs X visit Mr Y at mealtimes to help him eat.
19. On 17 December 2019, Madeira Lodge told Mr Y’s family he had a bad cold and was taken to hospital. He was transferred from accident and emergency to the acute medical unit at William Harvey hospital where he stayed until 20 December. He then moved to Kent and Canterbury hospital for a further three weeks. Mrs X told me Mr Y was admitted to hospital with faecal impaction, dehydration, and reduced kidney function. He had lost weight and Mrs X was shocked at how Mr Y’s condition had deteriorated at Madeira Lodge.
20. Mr Y was discharged from hospital on 13 January 2020 and was taken to Hawkinge House awaiting assessment of his care needs.
21. Mrs X contacted the Council on 14 January with the following concerns about Madeira Lodge:
• Residents are not allowed in their rooms during the day. They all sit in one small, cramped, communal lounge.
• She has twice seen residents sitting in this room while sick. As a result, all the other residents got sick.
• A resident was sick on themself but not allowed to go back to their room.
• She was not allowed to see Mr Y at this time as staff said it may affect the dignity of other residents in the lounge.
• She saw staff shout at residents and tell Mr Y off for going back to his room during the day.
• There are steep steps from one floor to another, with only a baby gate for security. Mr Y fell down the stairs on one occasion.
• Mr Y had a black eye on one occasion and cuts to his face on another but with no explanation of how he was injured.
• She asked staff not to shave Mr Y every day due to sensitive skin, but staff said this would make the home look bad.
• Mr Y lost about 3kg in weight in July and staff joked that he was often hungry and ate leftovers.
• She wanted to support Mr Y with eating, but the home would not allow it as residents eat in the lounge and this would encroach on other resident’s dignity.
• Mr Y was not eating or drinking regularly, and this led to him going to hospital.
• She raised concerns with care home manager who said, ‘I am in charge of your dad now’.
22. The Council telephoned Mrs X on 15 January to discuss her concerns. It then checked Madeira Lodge’s Care Quality Commission (CQC) rating, which was ‘requires improvement’, but noted the home was not on the sanctions list. The Council sent Mrs X’s concerns to its safeguarding team, where a case officer was allocated to make enquiries on 17 January.
23. The case officer made an unscheduled visit to Madeira Lodge on 22 January. They discussed Mrs X’s concerns with the home’s manager, reviewed Mr Y’s records, and took copies for evidence.
24. The case officer telephoned Mrs X on 23 January but there was no reply. They also contacted Mr Y’s social worker and asked for information from the hospital.
25. The case officer spoke to Mr Y’s social worker on 19 February. Mr Y’s social worker considered there was a history of his family wanting to move Mr X to Hawkinge House because that is where his ex-wife is, and it is more convenient for family. Mr Y’s family were not happy with Madeira Lodge since Mr Y moved there and often told his social worker about this. Mr Y’s social worker believed his family may want to prevent Mr Y returning to Madeira Lodge. Mr Y’s social worker agreed to the Council closing its safeguarding enquiry and had no concerns about Madeira Lodge.
26. The Council’s safeguarding referral unit sent an email from East Kent University Hospital NHS Trust (the hospital) to the case officer. The hospital said it was not involved in Mr Y’s discharge and did not know the circumstances. The case officer sent an email back asking for confirmation of Mr Y’s diagnosis and comments about his condition when entering hospital.
27. The hospital replied on 25 February. It said Mr Y arrived with low urine output and general unwellness, delirium and agitation. He was dehydrated, though it was not clear how badly. There was no mention of constipation.
28. The case officer asked the hospital to double check Mr Y’s records about dehydration and constipation. The hospital replied on 4 March. It said the accident and emergency matron had checked Mr Y’s records. The hospital found no profound dehydration or faecal impaction so there was nothing that would alert the hospital to the care home neglecting to give fluids.
29. The case officer spoke to Mrs X on 11 March and agreed to send her written feedback on the enquiry. The Council’s letter to Mrs X said:
• According to the hospital’s safeguarding team, Mr Y arrived with low urine output, general unwellness, delirium and agitation. The hospital found no profound dehydration or faecal impaction.
• The manager at Madeira Lodge said residents enjoy spending time in the lounge, socialising and can go to their rooms during the day. Council officers saw this during a visit. The manager described Mr Y as sociable and always up and about.
• The manager was unaware of any incidents of bullying or shouting by staff. The Council did not witness this during its visit.
• The manager was also unaware of Mr Y having any falls. Mr Y had a small cut to his head on 30 August 2019 but the cause was unknown. Madeira Lodge installed a baby gate to prevent less mobile residents from falling down stairs.
• Mr Y’s care plan states carers should shave him every other day. Staff saw a shaving rash on 14 October 2019. They applied cream and reduced his shaving routine to every three days.
• Madeira Lodge weighed Mr Y monthly between March and November 2019. He put on 1.1kg between July and August. He then lost 1.5kg between September and October 2019. He was a low risk for malnutrition.
• It recommended Madeira Lodge continue allowing residents to walk freely around the home and not restrict them going into their bedrooms. It also recommended staff regularly review residents mobility and ability to use stairs.
• It could not confirm some aspects of Mrs X’s concerns due to a lack of supporting evidence or independent witnesses.
30. The Council sent details of the enquiry findings to the manager of Madeira Lodge, and its recommendations.
31. Mrs X brought her complaint to the Ombudsman on 16 March 2020. Despite the findings of the Council’s safeguarding enquiry, Mrs X was convinced Madeira Lodge neglected Mr Y. She wanted the Ombudsman to investigate the Council’s safeguarding enquiry. The Ombudsman referred the complaint back to the Council, as it had not yet had an opportunity to respond.
32. The Council sent its complaint response on 7 August 2020. It said:
• Officers visited Madeira Lodge as part of the enquiry, spoke with the manager, and reviewed Mr Y’s records.
• It also liaised with the hospital. Hospital staff reviewed Mr Y’s medical notes and reported no concerns about abuse or neglect by Madeira Lodge. The hospital did not identify severe dehydration of faecal impaction.
• There was evidence of best practice on multi-agency working and it completed an appropriate enquiry. It considered its enquiries were sufficient to respond to Mrs X’s concerns and to inform the conclusion reached.

Response to my enquiries

33. The Council told me Mr Y was previously a resident at a care home in Hythe, where he had lived. He moved to Kent in 2019 with the help of Wirral Borough Council at the request of his daughters when the home could no longer meet his needs. He was transferred to Madeira Lodge care home. Wirral Borough Council remained the funding authority for Mr Y’s care, but asked Kent County Council to carry out annual reviews.
34. The Council was alerted to Mrs X’s concerns about Madeira Lodge on 14 January 2020. It discussed her concerns and raised a safeguarding investigation. An investigator made an unannounced visit to Madeira Lodge to see the care home manager and review Mr Y’s records and care plan. The investigator also contacted Mr Y’s social worker at Wirral Borough Council, and William Harvey hospital for more information. The Council’s investigation found no evidence of abuse.

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Analysis

35. Mrs X’s complaint to us was about a failure by the Council to fully investigate the safeguarding concerns she raised about Madeira Lodge. She is understandably upset at the deterioration she saw in Mr Y’s condition and thinks Madeira Lodge neglected him.
36. The notes of the Council’s enquiry show it spoke to Mrs X, visited Madeira Lodge and spoke to the manager, reviewed Mr Y’s care records, collected evidence from the hospital, and sought opinion from Mr Y’s social worker.
37. The Council first discussed Mr Y’s care with Mrs X and identified what the issues were and what outcome she wanted. Mrs X said she did not want the same thing happening to others. The Council highlighted there were concerns it needed to investigate, and assessed Mr Y could be at significant risk, as could other residents. The Council recognised Mr Y may not be able to contribute to the enquiry.
38. During its visit to Madeira Lodge, and review of Mr Y’s care records, the Council found no evidence of the injuries Mrs X described Mr Y suffered, or of Madeira Lodge forcing residents to stay in the lounge. Mrs X thinks this suggests Madeira Lodge is covering up what happened. The Council cannot speculate or criticise Madeira Lodge for what happened without evidence.
39. I have reviewed Mr Y’s care notes from Madeira Lodge. The records do suggest Mr Y was in the lounge a lot, so I can understand Mrs X’s concerns about this. However, it is unclear whether this was Mr Y’s choice. The records also state Mr Y wandered around the home at times as well.
40. The records show Mr Y generally ate and drank well, except for the days just before he went to hospital because he was feeling unwell. Staff called a doctor when he did not improve, and Mr Y was given antibiotics. When Mr Y was still unwell the next day, staff again rang the doctor who suggested an ambulance was called.
41. Mrs X said the Council only got details about Mr Y’s condition from the hospital ward he stayed on, not from the accident and emergency department. I have seen evidence the hospital checked Mr Y’s accident and emergency records and I consider the information it supplied was suitable for the Council’s enquiry.
42. The hospital records did not suggest Mr Y was severely dehydrated or suffering from faecal impaction on admission, and the hospital did not have concerns about neglect from Madeira Lodge.
43. Based on the information from the hospital, the opinion of Mr Y’s social worker, the case officer’s visit to Madeira Lodge, and Mr Y’s care records, I consider the Council was entitled to reach the conclusion it made. I appreciate this was upsetting for Mrs X and she wanted Madeira Lodge to be held to account. But when the Council makes findings about possible neglect or abuse, it must rely on medical opinion and the available evidence.
44. While I would not criticise the Council in the main for its enquiry, as it contacted those we would expect, it could have involved Mrs X and Mr Y more throughout. However, I consider the Council took enough information from Mrs X during the first telephone call to understand her concerns and what outcomes she wanted. I also note the case officer did try to telephone Mrs X early in the enquiry but got no reply.
45. The Council’s notes state it would look at the possibility of getting Mr Y’s views about the enquiry. While I appreciate there may be problems on Mr Y’s mental capacity, I have not seen evidence this was followed up or considered again.
46. I do not consider these issues, in this case, were significant enough to amount to fault. I have seen evidence the Council considered Mrs X’s views and the outcome she wanted. It also considered the impact on Mr Y and that he was unlikely to contribute to the enquiry.
47. I recognise Mrs X considers information has been covered up, and the Council did not do enough to investigate her concerns. However, the Ombudsman cannot assume the Council’s role or decide what the outcome of the enquiry should be. It is not enough for Mrs X to disagree with the Council, I must find fault in its actions.
48. 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 to help form its decision. It identified areas where Madeira House can maintain best practice and it made recommendations about this.

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Final decision

49. I have completed my investigation. The Ombudsman did not find fault with the Council’s safeguarding enquiry, or the outcome it reached.

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Investigator's decision on behalf of the Ombudsman