Summary: the complainant, Mrs X, complained the Council failed to properly conduct a safeguarding enquiry into concerns raised about her mother’s care in a care home. The Council says it followed protocol and considered all information shared. We found the Council at fault for delays causing avoidable distress and inconvenience. The Council has agreed to our remedy.

The complaint

1. The complainant whom I shall refer to as Mrs X complained the Council failed to properly investigate safeguarding concerns, she raised about the care home in which she had placed her mother, Mrs Y.
2. Mrs X says the Council’s decision that her allegations were unsubstantiated reflects the failures in the investigation. Mrs X says the investigation took too long, did not include advance notice of the issues so she could not prepare for the safeguarding strategy meetings and did not gather all necessary information.
3. Mrs X wants the Council to apologise, review how it conducts safeguarding investigations and offer training to the chair of the Enquiry and review the decision.

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The Ombudsman’s role and powers

4. 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)
5. If 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

6. In considering this complaint I have:
• Contacted Mrs X and read the information provided with her complaint;
• Put enquiries to the Council and reviewed its response;
• Researched all relevant law, guidance, and policy.
7. I shared my draft decision with Mrs X and the Council and have reflected some of their comments in this my final decision.

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What I found

The Law and guidance

8. Section 42 of the Care Act 2014 says 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.
9. In May 2011 the Government issued its ‘Statement of Government Policy on Adult Safeguarding’ setting out the principles by which to judge adult safeguarding arrangements. The principles include support and representation for those in greatest need and; proportionality through using the least intrusive response appropriate to the risk presented.
10. Under the Council’s Safeguarding Adults Protocol, the Council will assess a person’s capacity and risk and review protection. Where an allegation meets the enquiry threshold it will begin a Section 42 Care Act enquiry and arrange a safeguarding adults’ case conference. The conference on hearing from those concerned will draw up and carry out a safeguarding plan where necessary, review progress and agree when to close the case.

What happened

11. Mrs Y moved into a Care Home in July 2017. During her stay which lasted until September 2019 Mrs X raised several complaints about Mrs Y’s care at the Care Home which have been the subject of a separate investigation.
12. In September 2019 the Council received a safeguarding alert about Mrs Y. Mrs X told the Council about the significant bruising to Mrs Y’s right thigh and lower leg causing her severe pain. The start of this bruising is recorded in photographs but due to Mrs Y’s declining health further photographs could not be taken as the bruising progressed. Mrs X also raised concerns the batteries from the call button in Mrs Y’s room had been removed, preventing her from calling for help.
13. Mrs Y first complained of pain on 18 September 2019. Records show a doctor already present in the care home that day assessed Mrs Y. He recommended observations and pain killers. With Mrs Y continuing to complain of pain, she was admitted to hospital. The hospital found Mrs Y had not broken her leg but could not walk on it. Mrs Y returned to the Care Provider’s Care Home the following day. Mrs Y continued to complain of pain in her leg. Mrs Y’s GP examined her again on 24 September 2019 following which Mrs Y was admitted to hospital for a further time. Mrs Y’s GP wrote to the hospital saying he had concerns about the “significant unexplained bruising on her…leg.” Following this event, the Council received a safeguarding alert.
14. The Council’s safeguarding adults team assessed the complaint as meeting the threshold for a Section 42 enquiry. A Council officer visited Mrs X at home on 4 October 2019 to discuss her concerns. The Council called a safeguarding strategy meeting and an officer visited Mrs Y in hospital. On 24 October 2019 the Council wrote to Mrs X confirming it had begun a safeguarding enquiry. A strategy meeting met on 30 October 2019 attended by Mrs X. The Chair told those present the purpose of the meeting was to discuss Mrs Y’s bruising and the call button’s missing batteries.
15. In the strategy meeting the Care Provider’s representative accepted staff had not followed proper procedure by reporting the injury to Mrs X rather than also to the Care Home management. The strategy meeting considered how long the bruising had been evident and what action the Care Provider took. The Care Provider said it had reported the incident to the Council, CQC, the Police and Mrs Y’s GP. The Care Provider also said Mrs X had only recently told staff of Mrs Y’s diagnosis with dementia. Mrs X says she had no previous notice of this allegation. Therefore, Mrs X says she did not have time to prepare an answer for the strategy meeting and felt the Care Provider had tried to unfairly blame her for what happened to Mrs Y. Mrs X says the Chair should have prevented this or challenged the Care Provider on the relevance that information had to these incidents.
16. The strategy meeting discussed the information gathered from the GPs, and concerns Mrs X raised about staff training. Action points set by the strategy meeting included Mrs X getting a written record of a conversation with the GP, and the Care Provider reviewing staff training in handling and lifting elderly people. The Meeting decided this first allegation was Inconclusive.
17. The strategy meeting then discussed the second allegation that someone had removed the call button batteries preventing Mrs Y calling for help. The Care Provider’s staff said they routinely checked call buttons at 10.00pm every day. The Chair pointed out the call button batteries had either fallen out or someone removed them. In her view the care workers or housekeeping team should have reported the incident and had not. The strategy meeting found this allegation substantiated. It decided the Care Provider needed to learn lessons from the complaint for the benefit of all residents at the home.
18. Following the strategy meeting the Council shared the Section 42 Enquiry report with Mrs X in November 2019. The Council confirmed it had closed the enquiry because Mrs Y had recently moved to live with Mrs X and therefore not at risk.
19. In December 2019 Mrs X wrote to the Council challenging the Section 42 Enquiry decision. Mrs X asked the Council re-open the Section 42 Enquiry so she could present further information. On receiving the further information, the Council called a further strategy meeting which met in February 2020. The meeting noted it had only the draft minutes from October 2019’s meeting, they had not yet been finalised. The action points included Mrs X raising a new safeguarding referral which she did the day after the meeting. The February strategy meeting said the Council would arrange another meeting to discuss the issues with the Care Provider to prevent similar issues affecting other residents.
20. Following the Council’s Enquiry Officer’s departure from the Council in March 2020 the Council took no further action. In September 2020 Mrs X contacted the Council because she had not received any further contact. In response the Council contacted the GP and hospital which treated Mrs Y for information. The Council received that information by the end of September 2020. In November 2020 the Council issued its review of the original Enquiry decision. It confirmed it had changed the decision on bruising from ‘Inconclusive’ to ‘Not Substantiated’ and added an addendum to its original report. The Council explained the further information from the GP and hospital suggested the bruising most likely resulted from a fall Mrs Y experienced during the week before 24 September 2019, possibly the event on or around 18 September 2019. Therefore, it decided, not from abuse or a safeguarding risk.
21. Mrs X says the Council’s safeguarding enquiry took too long and failed to robustly challenge the evidence provided. Mrs X believes the evidence provided does not explain how Mrs Y received the bruising to her leg that caused her so much pain. In her view the Council should have found the bruising allegation as substantiated.

Analysis- was there fault leading to an injustice?

22. My role is to consider if the Council properly investigated the safeguarding referrals it received by following the correct procedures and considering all the information presented. If it has not, then I must consider if that led it to a different decision from that which it would otherwise have reached. If so, I must also consider what impact that has had and what it should do to put it right.
23. No one disputes that Mrs Y experienced painful bruising while in the care of the Care Provider. On receiving the safeguarding referral, the Council followed the local protocol by contacting the parties involved and calling a strategy meeting. The local and London Area protocols do not call for councils to share agendas and information ahead of the strategy meeting. Where someone may be at risk sharing that information ahead of time may not be in the best interest of the person at risk. Therefore, I find the Council acted without fault in following the protocols.
24. At the strategy meeting the parties share information. The minutes note the Care Provider commented on the time it had taken for Mrs X to tell the Care Provider of Mrs Y’s dementia. The strategy meeting’s purpose is to decide if someone is at risk or has suffered abuse or harm and to impose measures to lessen or remove that risk. I understand Mrs X found the allegation she failed to pass on important information upsetting. However, I have seen no evidence it affected or influenced the final decision. I understand Mrs X thought the Chair should have addressed the comment, asking her if she needed a break to consider it, or ask the Care Provider to explain the relevance of the allegation to the events under consideration. The minutes do not record the strategy meeting finding this put Mrs Y at risk of harm and so it in effect exonerated Mrs X. In the Council’s view now Mrs Y had moved to live with Mrs X she was no longer at risk which indicates the comments made by the Care Provider did not influence the decision. The Chair could not prevent a party introducing information that party felt may be relevant to the discussion. Mrs X believes the Chair managed the strategy meeting poorly, but the evidence does not suggest this put Mrs X at any disadvantage in sharing her view. Calling the second strategy meeting and further gathering of evidence shows the Council’s willingness to review the decision taken at the first strategy meeting. Therefore, I have seen no evidence the Council prevented Mrs X sharing information or the Care Provider’s comments influenced its decision.
25. Mrs X challenged the Council’s finding that the ‘bruising’ referral was Inconclusive. Following the strategy meeting in February 2020 and later information gathering the Council changed this to ‘Unsubstantiated’. It decided the bruising most likely resulted from a fall Mrs Y experienced during the week before 24 September 2019. Therefore, not due to any abuse or safeguarding risk. In deciding its view, the safeguarding enquiry had to consider the evidence on the balance of probabilities, i.e., what in its view most likely caused the injury on the information before it. When taking this view the Council’s safeguarding team had before it all relevant information including information from the hospital and GP, as well as Mrs X’s information. Therefore, I cannot challenge the merits of that decision.
26. The view taken by the safeguarding team is that this is a likely explanation for the bruising and pain experienced by Mrs Y. I cannot say what caused Mrs Y’s bruising. However, I am concerned at the conduct of the Section 42 Enquiry. The Council only gathered information from the hospital and GP in September 2020 following contact from Mrs X. I have not seen evidence of it gathering this information for the February 2020 meeting. The minutes of the October 2019 meeting had not been finalised by the February 2020 meeting. That is too long. There is also no evidence of the Council continuing work on the Section 42 Enquiry between March and September 2020. Gathering information in September 2020 is long after the event and over six months after the second strategy meeting. I recognise the Covid -19 pandemic affected the Council’s ability to call meetings in person, but this took too long. The Council should have sought this information much earlier in the investigation. While records remained available recollections of those involved may have dimmed. This led Mrs X to doubt the probity and robustness of the Section 42 Enquiry and its final decision. I find the Council at fault in failing to gather the information earlier in the Section 42 Enquiry, finalise the minutes of the meeting and to follow up the investigation between March and September 2020. This caused Mrs X avoidable distress and inconvenience when she was already grieving for the loss of her mother who sadly passed away in December 2019.
27. In our ‘Guidance on Remedies’ we explain we try to place people in the position they would have been but for the fault identified. Where, as here, that is not possible we recommend a payment on a scale between £100 and £300 as a symbolic recognition of the distress and inconvenience caused.

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Agreed action

28. To address the avoidable distress and inconvenience caused to Mrs X I recommended, and the Council agrees to within four weeks of my final decision:
• Apologise to Mrs X for the faults identified;
• Pay Mrs X £200 in recognition of the avoidable distress and inconvenience caused to her at a time of grief;
• Share the final decision with the Adult Safeguarding Team so it may learn lessons from Mrs X’s experience.

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Final decision

29. In completing my investigation, I find the Council at fault in its handling of the Section 42 enquiry.

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Investigator's decision on behalf of the Ombudsman