Summary: There was fault in communication by the Council after Mrs X reported safeguarding concerns about her late mother. The Council has already taken appropriate action to remedy the injustice and so we have not made recommendations.

The complaint

1. Mrs X complained Warwickshire County Council (the Council) failed to communicate with her and failed to share a safeguarding report into concerns she raised about her late mother’s care. She said this caused her avoidable distress.

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The Ombudsman’s role and powers

2. 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 which the council has not already remedied, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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

4. I considered Mrs X’s complaint, the Council’s response and safeguarding records. I discussed the complaint with Mrs X.
5. 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

Relevant law and guidance

6. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make (or cause others to make) whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
7. Councils can ask other organisations to make enquiries. (Care and Support Statutory Guidance, paragraph 14.78)
8. Actions a council takes under section 42 of the Care Act 2014 is often called ‘safeguarding’. Statutory Guidance explains safeguarding duties apply to an adult who:
• Needs care and support
• Is experiencing or at risk of abuse or neglect
• As a result of their care needs, cannot protect themselves from the risk or experience of abuse. (Care and Support Statutory Guidance, paragraph 14.2)
9. Abuse includes neglect (failing to provide appropriate care). Poor care can sometimes amount to neglect, but not always. This is dependent on the context. (Care and Support Statutory Guidance, paragraph 14.17)
10. The Council follows West Midlands Adult Safeguarding Policies and Procedures. I have summarised relevant parts below:
1. When receiving a referral, the Council will make checks with the person raising the concern to establish basic facts and see whether further enquiries under section 42 of the Care Act 2014 are necessary.
2. Once all relevant information is available, including the views of the adult, the Council should decide if the criteria for a full section 42 enquiry are met – the adult has care and support needs, they are experiencing or at risk of abuse or neglect and they are unable to protect themselves. If the criteria are not met, the Council considers what other action, or provision of information or advice is needed to respond to the concern.
3. The person raising the concern should be notified of the decision and outcome whenever appropriate and safe to do so.
4. The Council can ask a provider to conduct its own enquiries and report back to it in order to inform the Council’s decision about what action is required.

What happened

Background

11. Mrs Y had been living with Mrs X who was her main carer. In 2020, Mrs Y’s mobility declined. Mrs Y went into hospital and from there into a care home in October. Care was arranged and paid for privately. Mrs Y had scans while in hospital and dementia was suspected. The scans did not conclusively show dementia and Mrs Y was not officially diagnosed with the condition.

Key events

12. Mrs X visited her mother at the start of January 2021, which was in the middle of the national lockdown. The visit took place in a visiting pod. (Pods are typically enclosed rooms with a window so residents can see their visitor. The visitor sits in the pod and speaks to the resident who is the other side of the screen, through an intercom phone.)
13. The day after the visit, Mrs X contacted the Council’s safeguarding team to report concerns about her mother’s condition and the lack of appropriate support during the visit.
14. The Council’s safeguarding decision-making record noted what Mrs X reported:
• The visit was supervised by a receptionist and not a carer. Previous visits were supervised by a carer sitting in the room next to Mrs Y.
• There were other staff around in the visiting area, including the Head of Care who had her back to the visiting area and two other care staff who were taking down a Christmas tree.
• The receptionist did not stay with Mrs Y to support her (the receptionist also had to answer the care home’s phone).
• Mrs Y could not hold the phone. Her mother tried to put the phone in her mouth. Her mother’s fingers and hair were dirty and she also had food in her mouth. She looked like she had lost weight.
• Mrs Y was not strapped into the wheelchair and she was worried Mrs Y would fall on to a tiled floor.
15. The following day, an officer in the safeguarding team spoke to Mrs X to go through her concerns. The officer also spoke to the manager of the care home and asked for an internal investigation into Mrs X’s concerns.
16. Mrs Y died in the middle of January.
17. The manager sent an email to the Council’s safeguarding team at the start of February saying:
• The care home allowed visits during the pandemic, but as the period was so busy, support of all staff within the home was required. The reception team supported visits during the Christmas and New Year period.
• Mrs X said her mother was unkempt and dirty. The care records indicate she’d had a bed bath on the day, but her most recent shower was five days earlier. The dirty nails were not acceptable and this was discussed with staff.
• The phone was on speaker phone, so Mrs Y could hear Mrs X’s voice.
• The receptionist had to deal with phone calls from other relatives during the visit. Mrs Y was still within her eyesight. The receptionist did see Mrs Y put the phone in her mouth and so put the phone in Mrs Y’s lap so she (Mrs Y) could still hear. With hindsight, the receptionist should have sat next to Mrs Y during the visit.
• There was some dispute about how the receptionist offered a drink to Mrs Y. Mrs X said the receptionist poured water into Mrs Y’s mouth. The receptionist said Mrs Y pursed her lips and took none of the fluid.
• The receptionist suggested Mrs Y went back upstairs and then after she had taken her back to the unit, came to sit with Mrs X and speak to her. The receptionist did not mean to upset Mrs X by talking to her about moving Mrs Y closer to home.
• The receptionist was sorry for any distress caused.
• She (the manager) felt Mrs X did not appreciate Mrs Y’s condition was deteriorating.
18. Mrs X contacted the Council in the middle of February to say she hadn’t heard anything. An officer spoke to her and apologised for the lack of contact. The officer read out the care home manager’s report described in the previous paragraph. Mrs X said this was not an accurate version of events. Mrs X said the receptionist threw the phone on her mother’s lap and her mother flinched. She also said the receptionist was (mainly) on the other side of the room.
19. Mrs X also raised more general issues about Mrs Y’s care that were not part of the original safeguarding issues in her original report to the Council. The officer said she would ask the care home to write to Mrs X with the outcome of their internal investigation. The care home wrote a short letter to Mrs Y with little detail other than to say that the Council did not find anything of concern.
20. The outcome was the Council decided not to make further enquiries as there was no risk of abuse or neglect.
21. Mrs X complained to the Council. Its response set out the actions the Council had taken to consider her concerns and suggested she could make a complaint directly to the care home if she was dissatisfied with Mrs Y’s care. The response went on to say:
• Councils have a duty to make enquiries where there is concern of abuse or neglect.
• Safeguarding processes do not apportion blame, they assess risk and decide if action is required to protect the person.
• Mrs Y died shortly after the safeguarding process. The Council still sought a report from the care home although the risk was not ongoing.
• The Council should have been clearer with her about the difference between safeguarding and the complaints process.
• The Council was sorry it decided not to contact her to discuss the response from the care home. This was because her mother had recently died and officers did not want to cause her further distress.

Was there fault?

22. I am satisfied the Council considered Mrs X’s concerns in line with its safeguarding duties under section 42 of the Care Act 2014. Care and Support Statutory Guidance, Paragraph 14.78 allowed the Council to ask the care home to look into the concerns and provide a report for the safeguarding team to consider. There was no fault in the Council asking the care home manager for a report about the incident.
23. The Council should have given Mrs X some written feedback on the outcome of its safeguarding actions and its decision not to proceed with further action once it had received the care home’s report. The failure to do so was not in line with the safeguarding procedures summarised in paragraph 9c and was fault. The Council has already apologised which was an appropriate remedy for the injustice and so there is no need for me to recommend further action.
24. Mrs X was not entitled to see a copy of the report from the care home. However, the Council’s records indicate an officer read out the report on the phone to her and the complaint response explained the outcome of safeguarding. I am satisfied she received appropriate information about the content of the report and she received feedback about the outcome through the Council’s complaint response as described above.
25. I recognise Mrs X disputes the receptionist’s version of events during the visit and that she feels very strongly that her mother was at risk and was suffering neglect based on Mrs Y’s presentation. However, the Council was entitled to conclude there was no actual abuse/neglect or risk of abuse/ neglect based on the accounts of what happened. It was noted and accepted by the care home that the receptionist should have sat with Mrs Y during the visit. As Mrs Y died shortly after, there was no need for the Council to take further action.
26. The Council’s complaint response gave Mrs X feedback on the outcome of the safeguarding actions. This was an appropriate response.

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Final decision

27. There was some fault in communication by the Council after Mrs X reported safeguarding concerns about her late mother. The Council has already taken appropriate action to remedy the injustice.
28. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman