Sandwell Metropolitan Borough Council (20 005 623)
The Ombudsman's final decision:
Summary: Ms K complained about the care her mother received at the care home and the Council’s safeguarding enquiry into the concerns she raised. There was fault in the care provided and the Council’s communications and enquiries into the first safeguarding referral. The Council has agreed to apologise and to pay £250.
The complaint
- Ms K complains on behalf of her mother, Mrs L, who lacks the mental capacity to make the complaint. She complains about the care provided at Ash Lodge Nursing Home in Smethwick and the Council’s safeguarding investigation into her concerns relating to the Home.
What I have investigated
- I have investigated Ms K’s complaint into the actions of the Home and the Council’s safeguarding enquiry into the first safeguarding referral. Paragraph 94 explains why I have not investigated the complaint about the Council’s safeguarding enquiry into the later referrals.
The Ombudsman’s role and powers
- 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)
- We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
- 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)
- 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)
How I considered this complaint
- I have discussed the complaint with Ms K. I have considered the evidence provided by her, the Council and the Home, the relevant law, guidance and policies and both sides’ comments on the draft decision.
What I found
Law, guidance and policies
- The Care Act 2014 and the Care and Support Statutory Guidance 2014 (updated 2017) set out the Council’s duties towards adults who require care and support.
Duty to meet eligible needs
- The Council has a duty to assess adults who have a need for care and support. If the needs assessment identifies eligible needs, the Council will provide a support plan which outlines what services are required to meet the needs.
Safeguarding duty
- Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:
- has needs for care and support
- is experiencing, or at risk of, abuse or neglect and
- as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
- If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.
Council’s safeguarding policy
- The Council has its own safeguarding policy which sets out the process:
- Safeguarding concern. The safeguarding referral is made to the Council and the Council decides whether the referral meets the threshold for a section 42 enquiry.
- The enquiry. The Council:
- Gains the views, consent and desired outcome from the adult.
- Assesses any risk to the adult or other vulnerable adults and agrees the interim safeguarding plan.
- Agrees what enquiries are needed and who will carry out the enquiries. The Council can ask another agency to carry out the enquiries.
- Evaluate and protect. Once the enquiries are completed, the Council evaluates the outcome. The Council decides what actions are needed to address the risk of harm. This may include making a safeguarding plan.
- Close the enquiry. The Council is satisfied that the risk has been addressed, closes the enquiry and informs the relevant parties of the outcome.
What happened
- Mrs L moved to the Home in 2017 after several falls. She had been diagnosed with dementia and had some right sided paralysis following a stroke.
- The Home’s care plan for Mrs L said the following in January 2019:
- Mrs L was unable to mobilise independently. She had to be assisted with all personal care and continence needs by two staff using a stand aid.
- Mrs L had the following equipment: profile bed with bed rails, stand aid, wheelchair, padded rail covers, electric mattress, slide sheet and shower chair.
- Mrs L had extra pillows in bed for comfort and support.
- When Mrs L was in bed, her bed rails should be raised to stop her from falling from the bed.
- Mrs L should have a nurse call button/buzzer near her so she could call for help.
- Mrs L did not like the food offered by the Home on certain days. Therefore, the family would bring in alternative meals which reflected Mrs L’s cultural background and these should be used on days when Mrs L did not want to eat the Home’s food. Mrs L’s amended weekly menu could be found in the small kitchen taped on the door.
- Mrs L had a bottle for squash which should be refilled and placed near her.
Referral 1 – April 2019
- Mrs L complained to one of the care workers on 11 April 2019. She said that care worker M had gone into her room and said: ‘I’ve come to change your dirty knickers’.
- Care worker M was on leave until 21 April 2019 and the manager was on leave between 19 and 24 April 2019. The manager agreed to move care worker M to another floor when she returned from leave until she could establish what had happened.
- On 24 April Mrs L’s family informed the Home that Mrs L had also alleged that care worker M had pushed and pulled her. Also, the family provided more information on the other allegation as they said care worker M had mimicked Mrs L’s dialect when she spoke to Mrs L. The family said that care worker M had said ‘dutty’ knickers and that the word ‘dutty’ had an insulting meaning in her dialect.
Home’s interviews – 24 April 2019
- The manager spoke to Mrs L on the same day and asked her whether care worker M had ever pushed, pulled or hurt her. Mrs L said care worker M had not done this and asked the manager who had told her this.
- The manager spoke to care worker M on the same day. Care worker M denied ever speaking to Mrs L as alleged or being disrespectful to her. The manager asked if there had been any other instances where Mrs L was upset while worker M provided care. Worker M said there was one instance where Mrs L asked worker M to switch off the television while providing personal care as she felt that people were watching her. Worker M said people could not see her through the television. Another time Mrs L asked worker M to open the curtains but she wanted the curtains only slightly open.
- The manager made a safeguarding referral to the Council on the following day.
Safeguarding meeting – 2 May 2019
- The Council held a safeguarding meeting with the manager of the Home and another daughter of Mrs L on 2 May 2019.
- The social worker asked why care worker M had not been suspended during the investigation and the manager replied that care worker M was working on another floor and had been told not to attend the floor that Mrs L was on. The manager said care worker M had had formal supervision following the incident and was subject to ‘a disciplinary’ for the above concerns.
- The outcome of this meeting is recorded as follows: ‘[The Home’s manager] to inform me when this will be, and lessons learnt regarding the issue.’
Meeting with Ms K and Mrs L – 8 May 2019
- The social worker held a meeting with Ms K and Mrs L on 8 May 2019 ‘to establish their views and wishes going forward’. The social worker sent an email to the manager following this meeting listing the ‘family’s wishes/outcomes.’
- The email provided more details on the allegation of physical abuse which was: ‘causing trauma to ‘sick’ arm by pulling [Mrs L] across the bed to attend to personal care – should not have been attempted on her own.’
- The allegations of emotional abuse were ‘overfamiliarity’ (stating that she had come to change ‘dutty’ knickers in Mrs L’s accent) and not turning off the tv/fully closing curtains when asked.
- One of the family’s main concerns was that care worker M was not suspended during the investigation and they felt she should not work for the Home anymore. They were concerned about the Home’s delay in making the safeguarding referral. They wanted staff to treat residents with dignity and respect and felt the comments worker M had made were not acceptable. They said care worker M should not have tried to move Mrs L on her own and staff should be reminded of the need to work together.
- A different social worker took over the case on 13 May 2019.
The Home’s response – 16 May 2019
- The Home sent a response to the Council’s email of 8 May 2019. It said it was ‘concerned’ about this email as most of the information had already been provided to the Council in the original referral documents which were considered during the meeting on 2 May 2019.
- The Home said that, at that meeting, the social worker had told everybody that the allegation of physical abuse had not been substantiated. Therefore, the Home did not understand why the Council was now pursuing this. The Home said: ‘There is a clear breakdown of relationships resulting in a risk of breakdown in [Mrs L’s] care.’
- The Council sent an email to Ms K on 17 May 2019 with answers to the questions she had raised. The Council said that, in response to the allegations, the Home had:
- Moved care worker M to another floor.
- Was taking care worker Mr through disciplinary proceedings.
- Had sought direction from employment law.
- Had notified the CQC.
- The Council said it could not become involved in the disciplinary aspect of the case. The Council said: ‘The safeguarding coordinator has investigated the allegations and measures are now in place by Ash Lodge Nursing Home; therefore the safeguarding team is satisfied that actions were taken and implemented’.
- The family replied and said it did not understand why the Council thought the case was closed. They said the allegation of physical abuse had not been investigated. They said they should have been present when Mrs L was interviewed about this allegation so they could have explained some of the wording better to her. Now it was difficult to investigate this with the passage of time.
- The Home amended Mrs L’s care plan on 23 May 2020 to reflect that Mrs L did not want the television on while she received personal care and that she liked the curtains fully closed when she asked a person to close the curtains.
- The social worker spoke to the CQC on 12 June 2019 as the family felt the CQC should investigate the matter. The CQC inspector said Ms K was not happy that the Council had not investigated the physical abuse. The social worker said the allegations were looked into but there was no evidence to corroborate, ‘but I vehemently told family this does not mean [Mrs L] is not telling the truth.’.
Interview of Mrs L – 13 June 2019
- The social worker visited Mrs L on 13 June 2019. The records show this visit was to ‘discuss safeguarding concerns and to update her on the investigation and outcome.’
- The social worker asked Mrs L about the inappropriate comment. She was unable to recall the name of the worker but recalled the incident
- She said care worker M said that she had come to change her dirty knickers. The social worker said Mrs L used the word ‘dutty’ and ‘dirty’ interchangeably. The social worker asked whether care worker M said ‘dutty’ or ‘dirty’, but Mrs L said she could not remember.
- The social worker asked Mrs L about the physical abuse incident. Mrs L said: ‘She would tear me up’. The social worker asked what she meant by this and Mrs L said: ‘She would tell me this and that and tell me off’. She said: ‘I never expect her to tell me those words.’
- Mrs L then explained more about the incident. She said she was lying on the bed when care worker M pulled on her left hand. She recalled saying: ‘Let me go, let me go, let me go’ at the time. She denied having any markings, pain or discomfort after the event. Mrs L then became confused about which hand it was and said she could not remember. She became teary and said she just wanted all of this to be finished with.
- The social worker informed Mrs L that she would be closing the case. The social worker told Mrs L that ‘from the investigation, the penalty that the carer received is just and losing her job would not be appropriate to the incident that occurred.’ Mrs L agreed.
Conclusion of the enquiry – 14 June 2019
- The Council closed the safeguarding enquiry and said that, following an investigation into the allegations of physical and emotional abuse, the case would be closed with an outcome of ‘inconclusive for both alleged incidents.’
- The social worker said: ‘On account of the incidents not being witnessed and no markings and injuries, there was no evidence to substantiate the claims.’ The Council wrote to the Home on 14 June 2019 and said: ‘The investigation yielded no evidence of the alleged incidents and the carer has denied both allegations.’
Referral 2 – 30 March 2020
- The family installed a video camera in Mrs L’s room so that they could monitor what happened. They say the Home encouraged them to do this to address their concerns about the care Mrs L received.
- On 30 March 2020, the Home made a safeguarding referral to the Council which said:
- They had received a video clip from Mrs L showing two care workers assisting Mrs L to her bed. Mrs L was seated on the bed when one of the workers inappropriately removed Mrs L’s arm causing her to fall to the left side.
- Mrs L did not suffer any injuries.
- The staff member had been immediately dismissed.
- The Council decided on 2 April 2020 that the incident met the criteria for a section 42 enquiry. The Council noted the following in its enquiry:
- The staff member was referred to the DBS.
- The Home confirmed that all staff had completed manual handling training before starting duties. This was re-done annually or sooner if concerns arose.
- The Council closed the safeguarding enquiry on 3 April 2020 and noted that the allegation had been substantiated and that appropriate action had been taken to ensure Mrs L’s and other residents’ safety. The Council wrote to Ms K to inform her of the outcome and informed the CQC.
Referral 3 – June 2020
- Ms K sent an email to the Home on 28 June 2020 with video clips showing that Mrs L’s buzzer had been left on the wall, out of reach of Mrs L.
- Ms K sent an email the Council on 1 July 2020 and raised these concerns:
- Mrs L’s buzzer had been left on the wall and this problem had been raised before.
- Drinks were not left close to Mrs L.
- The Home gave notice to Mrs L on 3 July 2020.
- The Council decided to progress the matter as a section 42 enquiry on 3 July 2020.
- Mrs L spoke to the social worker on 6 July 2020 and provided additional concerns:
- The carers did not wash their hands when administering eye drops.
- Mrs L was meant to have specific meals but this plan had not been followed.
- Mrs L should have had a bed assessment but this had not been completed.
- The carers covered the CCTV when providing support.
- The social worker carried out a safeguarding enquiry which included a visit to the Home to view all the records and to speak to Mrs L on 29 July 2020. The social worker said Mrs L was ‘pleasantly confused’ at times during the visit. Mrs L said she liked the Home but said some care workers were not so good. She was unable to give more detail. She raised no concerns but said she was happy for her daughters to support her to make decisions.
- The investigation over the following weeks noted the following.
- The buzzer had been left over the bedside lamp, out of reach of Mrs L. The Home had spoken to staff about this and had now removed the lights to stop it from happening again. This was raised with the Home in November 2019 and more recently.
- Staff had been reminded to leave the buzzer within Mrs L’s reach.
- The family raised a concern that staff did not use gloves to administer eye drops on 15 November 2019. The family said they had asked the week before that staff should always were gloves. The Home explained that staff were expected to wash their hands before administering eye drops, but they would pass on the request from the family that gloves should be worn.
- Mrs L had a personal weekly meal plan. The Home admitted it received a copy of Mrs L’s meal plan but there was a delay in getting this copy to her floor. The Home said that Mrs L had a choice of meals during that time. The problem had been resolved and the meal plan had now been implemented.
- Mrs L’s care plan said staff should fill Mrs L’s bottle with squash several times a day and this bottle should be left within reach of Mrs L when she is in bed. The social worker said she received ‘numerous’ video clips which showed the bottle had been left out of reach. Ms K said that, on one occasion the bottle was left out of reach for four hours. The Home said it would remind staff of the importance of leaving the bottle within Mrs L’s reach.
- There was a problem with Mrs L’s positioning in bed. She was supported to sit up with pillows but sometimes pulled on the bedrails to the left to reposition herself. Ms K sent several videos which showed that Mrs L was slumped in the bed. Sometimes she was unable to change her position and, as there was also sometimes a problem with the buzzer or the drinks being left out of her reach, she could not call for help or drink.
- Ms K said she raised the issue of a bed assessment ‘weeks and weeks ago’. The social worker asked the Home when Mrs L was last assessed by an occupational therapist or a physiotherapist. The Home said she had an assessment on 12 November 2019 relating to her use of the stand aid, not the bed. Mrs L’s mobility care plan was updated on 23 June 2020. The Home said it had made another referral for a fresh assessment on 13 July 2020.
- One of the care workers covered the CCTV on one occasion when a male voice could be heard talking through the CCTV.
- The Council closed the safeguarding enquiry on 7 August 2020 and sent an outcome letter to the family. It informed the CQC and its contracts and monitoring team.
- The Council said the allegation of neglect had been partially substantiated. The Council said the buzzer had been left out of reach and the social worker questioned whether the referral to ICARES (integrated NHS/adult social care service which carries out assessments including rehabilitation, elderly frail and bed management) should have been completed earlier as Mrs L continued to lean to the left.
- The Council concluded the concerns had now been addressed:
- A referral had been made to ICARES for a bed assessment.
- Staff had been reminded to ensure Mrs L’s buzzer and drinks tray were always within her reach.
- The light shade had been removed so this decreased the risk of the buzzer being left on the light.
- The care plan and risk assessment had been updated.
- The family did not want Mrs L to move from the Home and said they would fight the notice of 3 July 2020. The Home said it was within its legal right to give notice and referred to the agreement that had been signed which included the notice periods. The Council said it had no legal powers to force the Home to retract the notice. I understand that the family sought legal advice on the notice.
- Mrs L moved to a different care home on 10 September 2020.
Referrals 4 and 5 – September 2020
- Ms K sent a video clip on 1 September and on 4 September which she said showed the bed assessment had still not been carried out. In the second video Mrs L’s tray had not been moved to the side.
- The Home said that the referral for the bed assessment had been made in July 2020 but ICARES had not been able to visit the Home because of the Covid lockdown restrictions. Mrs L received two hourly pressure relief and hourly visual checks.
- The Council opened and closed safeguarding referrals following the emails. It acknowledged that the outcome was partially substantiated insofar that it agreed that the bed assessment had not been completed yet. The Council advised the Home to update the care plan and risk assessment to avoid Mrs L being trapped by the tray.
The complaint
- Ms K complained to the Council on 12 March 2021 and said:
- Mrs L reported physical and verbal abuse on 11 April 2019 and the Home did not action this until two weeks later.
- The Council closed the safeguarding complaint without full investigation of the physical and verbal abuse. The Council also failed to contact the police.
- The manager initially praised Mrs L for speaking up. Later the Council told them that, as it was Mrs L’s word against care worker M’s, there was nothing they could do. This made them feel like Mrs L had not been believed and the family was not listened to.
- The Home’s communication was poor as they were not notified of the incident straight away.
- The Home allowed care worker M to continue to work in the Home during the investigation and she was not dismissed.
- The Council said:
- The Home was informed of the inappropriate comment on 11 April 2019 and this was progressed as a complaint. The Home was not informed of the alleged physical abuse until 24 April 2019. It then made a safeguarding referral on 25 April 2019.
- The Council held a meeting with the family and Mrs L on 8 May 2019 where it was explained that, due to lack of evidence, there were no grounds to dismiss care worker M. The removal of care worker M from the floor where Mrs L resided was a sufficient response to the safeguarding concerns. The police were contacted on 23 May 2019, but were unable to progress the matter because of a lack of evidence.
- ‘It is often very difficult to find evidence to substantiate the allegation, however, that doesn’t mean someone isn’t believed. Without evidence it is difficult to pursue further.’ ‘In order to substantiate such concerns, there needs to be more evidence than simply the account of one person.’
- The Home followed its disciplinary process against care worker M, but the Home could not tell the family what the outcome was as this would breach data protection rules.
Complaint to the Ombudsman
- Ms K complained to the Ombudsman about the Home and the Council. She said she wanted ‘an independent investigation of all complaints about the Home as we no longer have confidence with Sandwell Adult Social Services… A very lame and shockingly casual approach was taken by Sandwell Social Services upon the safeguarding issues and concerns.’
- I explained to Ms K that the Ombudsman generally only investigates complaints that have gone through the Council’s complaints process.
- The Council treated all the complaints against the Home as safeguarding referrals rather than complaints. I am of the view there has been a sufficient investigation by the Council into the actions of the Home and it would be unnecessary to ask the Council to investigate the matters again as a complaint against the Home. I have therefore treated the safeguarding referrals as complaints against the Home and investigated them.
- Ms K also complained about the Council’s safeguarding investigation into referral 1 and the Council has responded to that complaint. Therefore, I have investigated that complaint.
- If Ms K is dissatisfied with the Council’s safeguarding investigations into referrals 2 to 5, she would need to make a complaint to the Council first before the Ombudsman can investigate that complaint, so I have not investigated that complaint.
Analysis
Referral 1
- I have considered whether there was fault in the Home’s delay in making a safeguarding referral.
- The Agency says it was not informed of the allegation of physical abuse until 24 April 2019. It was informed of the inappropriate comment on 11 April 2019 but treated this as a complaint, not a referral.
- There is guidance to help agencies make the decision whether they should make a safeguarding referral, but any decision is subject to the judgment of the decision maker. I do not find fault with the way the Home made the decision not to make a safeguarding referral on 11 April 2019, on the basis of the information the Home had received at the time.
- Ms K has also complained that the Home should have suspended and dismissed care worker M. I agree the Council cannot become involved in disciplinary matters and neither can the Ombudsman. However, Ms K has also complained about the Council’s safeguarding enquiry and this touches upon the actions taken in relation to care worker M.
- The Council’s safeguarding policy says that, once the Council has received a safeguarding referral and has decided the referral meets the threshold of a section 42 enquiry, it should carry out a risk assessment and should also decide who will carry out the safeguarding enquiry and how it will be carried out.
- The Council held a meeting on 2 May 2019 but it does not say how the Council considered risk, particularly of physical abuse. I presume the Council agreed with the Home that the risk to Mrs L was sufficiently addressed by moving care worker M to another floor. The documents do not say whether the Council or the Home considered if care worker M posed a risk to any other vulnerable people and that was fault.
- At the meeting on 2 May 2019, there was no discussion or decision making on who would carry out the enquiry and what further enquiries were to be carried out. The only action that was agreed at the meeting was that the Home would update the Council about its disciplinary proceedings against care worker M. The social worker also said at this meeting that the allegation of physical abuse was unsubstantiated.
- Therefore, from the documents I have seen, it appears the Council had decided that the enquiries had been completed. Presumably, the Council was of the view that the Home’s manager’s conversations with Mrs L and care worker M on 24 April 2019 were the only enquiries that were needed. If that were the case, the Council should have recorded this and explained this to the family.
- It is also unclear why, if the Home’s conclusion was that the allegations were not upheld at this stage, it was still pursuing disciplinary proceedings against care worker M.
- The Council then held a meeting with the family on 8 May 2019 and agreed to forward the family’s ‘wishes and outcomes’ in an email to the Home. There was still no further planned enquiry. The Council then tried to close the case on 17 May 2019 after answering the family’s ‘wishes and outcomes’, but the family objected as they felt there had not been any really enquiries into the allegations.
- It was not until the social worker’s visit to Mrs L on 13 June 2019 that Mrs L was ever properly interviewed about the allegations. However, at that stage, the Council had already decided what the outcome of the enquiry was so Mrs L’s disclosures made no difference to the outcome of the enquiry.
- Therefore, there was fault in the way the Council conducted the safeguarding enquiry and its communications relating to the enquiry. The Council did not have a clear plan of enquiry at the outset and there was no clear communication. If it was the Council’s case that it was not carrying out further enquiries after 2 May 2019, it should have explained this to the family and the Home, but it failed to do so.
- I am also concerned about the Council’s statement that, as there was no evidence in relation to the allegations, they could not pursue the investigation. The Council seemed to misunderstand what ‘evidence’ meant. In this case, there was no physical evidence but there was verbal evidence from Mrs L and care worker M. The Council could have made a decision on the balance of probabilities who they believed.
- I accept that there may be cases where it is so finely balanced that it is impossible to say who is telling the truth on the basis of the verbal evidence alone. But at least the Council should have explained that it had performed that exercise and explain why it could not come to a conclusion. The Council never did this in Mrs L’s case as it kept saying there was no evidence. I cannot say whether this was poor communication by the Council or whether they genuinely thought they could not make further enquiries if there was no physical evidence. Either way, there was fault and it meant the family was not sure that the Council had properly considered the concerns they had raised.
- In her response to the draft decision Ms K also said the Council never provided conclusions on the issue of the television/curtains which it included as ‘emotional abuse’ earlier. I agree that the Council’s communication on this was not clear. The Council included this as part of the allegation of ‘emotional abuse’ in the meeting with Mrs L on 8 May 2020, but then did not really say what the outcome was. I note that the Home changed the care plan to reflect Mrs L’s preferences in terms of the television/curtains.
Referral 2
- The Council has already upheld the allegation of neglect in relation to referral 2. I agree there was fault in the Home’s actions as the care worker failed to follow the mobility care plan for Mrs L and put her at risk.
- The Home dismissed the care worker and it is my understanding that the family was satisfied with that outcome and the Council’s safeguarding response. I do not think there is anything further the Ombudsman can add.
Referrals 3, 4 and 5
- In terms of referral 3 , 4 and 5, there was fault in the way the Home provided care and support to Mrs L. The faults were:
- There were occasions when the Home did not leave Mrs L’s buzzer or her drink within reach and this was not in line with the care plan.
- There was a delay in implementing the care plan for Mrs L to have the meals provided by her family.
- The Home made a referral for a further bed assessment on 14 July 2020, but the issue about Mrs L’s positioning in her bed had been ongoing for some time and the Home should have made this referral earlier.
- There was a slight delay in the Home implementing the family’s request that care workers should use gloves when administering eye drops.
Injustice
- Mrs L and her family have suffered an injustice as a result of the actions of the Home as there have been times where her care was not provided as it should have been. The errors identified in the Council’s safeguarding enquiry into referral 1 and its communications in relation to this enquiry have also caused an injustice as there will always be an uncertainty about the outcome of the enquiry and whether it could have been different.
- Mrs L has not suffered a quantifiable financial loss as a result of the fault and the Ombudsman does not provide compensation. The Ombudsman can recommend a moderate symbolic sum to acknowledge the distress the complainant has suffered because of the fault. These payments are usually between £100 and £300.
- The Council has agreed to apologise to Ms K and to make a payment of £250. That is an appropriate remedy for the injustice identified.
Recommended/ agreed action
- When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although we found fault with the actions/service of the Home, we have made recommendations to the Council.
- The Council has agreed to take the following actions within one month of the final decision. The Council will:
- Apologise in writing to Ms K.
- Pay Ms K £250 as a symbolic payment for the fault identified.
Final decision
- I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.
Parts of the complaint that I did not investigate
- I have not investigated Ms K’s complaint that there was fault in the Council’s safeguarding enquiries into referrals 2 to 5 as Ms K has not made this complaint to the Council yet.
Investigator's decision on behalf of the Ombudsman