Summary: We upheld Mr X’s complaint about a safeguarding enquiry into his mother Mrs Y’s care. The Council has already apologised for the delay in investigating safeguarding concerns. It will make a symbolic payment to Mr X to reflect his avoidable distress.

The complaint

1. Mr X complained City of Wolverhampton Council (the Council) did not take prompt action in response to concerns he raised to a social worker about his mother’s (Mrs Y’s) carer workers neglecting her in January 2020. He also complained that when action was finally taken, the Council failed to consider relevant evidence demonstrating neglect (recordings and photos). Mr X also complained about a social worker being unprofessional on the phone.
2. Mr X said the Council caused him avoidable distress and placed Mrs Y at continuing risk of neglect.

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The Ombudsman’s role and powers

3. 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)
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)

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How I considered this complaint

5. I considered the complaint to us, the Council’s response to the complaint, some of Mrs Y’s case records and recordings of calls between Mr X and the social worker. I discussed the complaint with Mr X.
6. Mr 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

7. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
8. Care and Support Statutory Guidance, paragraph 14.13 sets out six principles for safeguarding:
• Empowerment: asking the person affected what they want
• Prevention: taking action before harm occurs
• Proportionality: taking the least intrusive response appropriate to risk
• Protection: support and representation for those greatest in need
• Partnership: working together
• Accountability: being open and transparent.

Key facts

9. Mrs Y has dementia and lives in her own home. She has two live-in care workers which the other siblings (not Mr X) arranged and pay for. The Council was not involved in arranging Mrs Y’s care. The siblings, including Mr X, hold joint Lasting Powers of Attorney (LPA’s) for health and welfare. (The LPA allows the siblings to make decisions about Mrs Y’s health and welfare in her best interests.) Unfortunately, the siblings fell out and they do not agree about the care arrangements.
10. The case notes show a social worker visited Mrs Y before the first lock-down and liaised with all the siblings, including Mr X. In January 2020, Mr X told the social worker he had concerns about the care workers including leaving her in the house alone, not taking her out and ignoring her. Mr X also explained about disagreements between him and his siblings over finances.
11. The other siblings told the social worker they were happy to pay for care privately and did not want the Council’s involvement.
12. An occupational therapist also assessed Mrs Y, she walked independently and could get to the toilet and get in and out of bed and chairs herself. The occupational therapist recommended some small pieces of equipment.
13. The Council appointed an advocate, who did not visit Mrs Y until September 2020 because of the lock-down. The advocate noted Mrs Y said she would like to live with Mr X at first, but later said she was happy to live in her own home with the care workers because Mr X went out to work and she was being looked after in her home.
14. There were three safeguarding alert forms for Mrs Y in November 2020, which the social worker and other council staff completed from information Mr X provided. I have summarised the alert forms below:
• Care workers not being trained or vetted by the Disclosure and Barring Service (DBS) and about one care worker leaving Mrs Y was left alone on one occasion.
• Care workers were telling Mrs X the wrong time so they could put her to bed early. He also said a care worker was stealing his mother’s food.
• General dissatisfaction with Mrs Y’s care arrangements and wanted Mrs Y to live with him.
• Medication administration for one dose of an antibiotic in December 2019 and about finding medication in blister packs.
• Mr X said he had reported similar concerns earlier in 2020.
15. The papers also noted there had been a referral for advocacy and Mrs Y’s advocate had spoken to her and said that she did not want to live with Mr X and that she was happy with the care workers.
16. Information on one of the safeguarding referral forms indicated the police looked at evidence Mr X had provided and it suggested care workers were telling Mrs Y it was later than it was to get her to go to bed early.
17. The Council started a safeguarding enquiry. It sought information from all family members, from the Police, GP and the Office of the Public Guardian (this is the body which supervises holders of LPA’s). The Police took no further action as there was no apparent crime. A social worker spoke to Mr X to discuss his concerns in more detail. He said in December 2019, he visited his mother and there was no carer present for two to three hours. He said he wanted different care workers. A social worker also spoke to one of the siblings who said:
• They were happy with the care arrangements
• The care workers spoke the same language as Mrs Y
• The incident when Mrs Y was left alone was a one-off and the worker had been spoken to
• There was a clock on the table so Mrs Y could see the time herself and she liked to go to bed early
• They paid for food for Mrs Y and the care workers from their own money.
18. Mr X provided me with a recording of two phone calls he had with Mrs Y’s social worker in November 2020. The discussion was heated at times, but there was no rudeness by the social worker. Mr X’s view is the social worker was unprofessional.
19. In February 2021, Mr X spoke to Mrs Y’s GP about some concerns. The GP made a safeguarding referral after, which said Mr X had reported Mrs Y’s care workers were not trained and were illegal immigrants and had left her to sit in a chair all day. The GP also said Mrs Y had developed pressure sores which the GP had referred to the district nurses to look at.
20. A different social worker carried on with the safeguarding enquiry. Their report of the enquiry noted:
• Mrs Y’s advocate had met with her and established her wish to stay where she was with her care workers.
• The care worker alleged to be responsible had not been interviewed because they were no longer working for Mrs Y.
• The district nurse reported they had discharged Mrs Y because there were no pressure sores and no concerns about neglect
• Family dynamics were strained
• Another sibling said:
1. care workers were employed through a company. Mrs Y needed prompting and assistance – meal preparation, prompting with medicine and domestic tasks. No particular training was required. They were DBS checked.
2. The incident where Mrs Y was left alone was a one-off due to a misunderstanding about change over times and Mrs Y was safe to be left alone for a short period.
3. The care worker alleged to have given incorrect time and put her to bed early was no longer working. Mrs Y had structured bedtimes.
4. They paid for all the food in the house and care workers were allowed to eat whatever they wanted.
5. Mrs Y was encouraged to wash and change her clothes daily.
6. They could not comment on the medication issues, which were from 2019, but Mrs Y was being supported to take her medicine.
21. In February and March 2021, a social work manager wrote to Mr X to address his complaints saying:
• The social worker contacted each of the parties every time there was a query and would continue to do so
• The care workers’ immigration status was not for the Council to deal with because it had not arranged Mrs Y’s care
• Issues relating to the quality of care had been raised with the siblings. The social worker had also made safeguarding referrals in November 2020
• Mrs Y met with an advocate alone so the Council could seek her views. It was appropriate that her care worker was there because she knew this person well. The advocate could not prevent the sibling from coming in at the end of the meeting as it was Mrs Y’s home. The advocate’s report noted Mrs Y changed her mind several times about where she wanted to live and this was before and after the sibling came.
• The social worker should have made a safeguarding referral in January 2020. Enquiries were underway and he would get feedback on the outcome
• A different social worker had been allocated to Mrs Y’s case.
22. The conclusion to the safeguarding enquiry was there was no evidence to suggest Mrs Y had experienced harm and other professionals consulted had no concerns. The Council closed the safeguarding enquiry in May 2021. The social worker emailed Mr X to give him feedback on the outcome and informed Mr Y that any of the LPA’s could start proceedings in the Court of Protection or they could arrange mediation between themselves if they were unhappy about Mrs Y’s care or living arrangements.
23. The Council told me:
• The social worker should have made a safeguarding referral in January 2020 and there was an unacceptable delay. It had already apologised to Mr X and addressed the matter with the social worker. The Council would be willing to offer Mr X £150 to recognise his avoidable distress for the delay.
• Its legal advice was that covert recordings may be a breach of human rights and so social workers had not listened to them
• It made proportionate enquiries to establish facts from different sources. It kept Mrs Y at the centre of the process.
• Mr X made allegations that the siblings considered to be false.
• Some allegations could not be confirmed on a balance of probability as to whether Mrs Y had suffered abuse or neglect. Explanations by district nurses and the other siblings provided a different view or disproved some of the allegations Mr X made. Managing risk and preventing injury to Mrs Y was the priority
• Mr X provided transcripts which were considered.
• The Council was not the Police and safeguarding enquiries were not criminal investigations. The enquiries made were proportionate to the allegations made.
• The dispute between the siblings who all hold LPA caused difficulty and this caused everyone distress.

Was there fault?

24. There was fault by the Council: it delayed in dealing with the concerns Mr X raised in January 2020. The Council has already recognised this and apologised for the avoidable distress to Mr X in its complaint response.
25. There was no fault in the Council’s safeguarding enquiry otherwise. The Council has discretion about how to conduct safeguarding and although Mr Y does not agree with the outcome, I am satisfied it dealt with the matter fairly and proportionately in line with the principles described in paragraph eight. In particular, the Council appointed an advocate for Mrs Y, gathered information from different sources, including independent sources and gave feedback to Mr X about the outcome.
26. There was no requirement to seek all possible available evidence and the Council has given a satisfactory reason for not using Mr X’s covert evidence: it would have been a disproportionate response to the concerns raised and there were concerns about the privacy of those involved. As I have not found any fault in the safeguarding process (other than the delay already identified), I have no grounds to criticise the outcome.
27. I have listened to the recordings of the calls between Mr X and the social worker. I find there was no fault by the social worker. I do not share Mr X’s view that she was unprofessional.

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Agreed action

28. In response to my enquiries, the Council suggested a payment of £150 to reflect the avoidable distress to Mr X. This is in line with our Guidance on Remedies and the Council has agreed to make this payment within one month of my final decision.

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Final decision

29. I upheld Mr X’s complaint about a safeguarding enquiry into his mother Mrs Y’s care. The Council has already apologised for the delay in investigating safeguarding concerns. It will make a symbolic payment to Mr X to reflect his avoidable distress.
30. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman