Summary: Mrs X complains about the outcome of the Council’s safeguarding investigation into the care provided to her late father. There was no fault in how the Council carried out its safeguarding investigation. Further investigation by us would unlikely lead to a different outcome.

The complaint

1. Mrs X complains about how the Council responded to complaints she raised about the domiciliary care provided to her late father, Mr Y. She says the safeguarding investigation was inadequate.

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The Ombudsman’s role and powers

2. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

1. we could not add to any previous investigation by the organisation, or
2. further investigation would not lead to a different outcome

(Local Government Act 1974, section 24A(6))

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 have:

• considered the complaint and discussed it with Mrs X;
• considered the correspondence between all parties, including the Council, both Care Providers, the Care Quality Commission and the hospice at home team;
• considered all safeguarding documents and records pertaining to Mr Y’s care (requested by our assessment team);
• considered relevant legislation.

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What I found

Relevant legislation

5. Section 42 of the Care Act 2014 requires that each local authority must make enquiries if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any cation needs to be taken to prevent or stop abuse or neglect, and if so, by whom.
6. Councils play the lead role in co-ordinating work to safeguard adults. Anyone who has concerns for the welfare of a vulnerable adult should raise an alert.
7. The purpose of the safeguarding process is to:

3. find out the facts about what happened; and
4. protect the vulnerable adult from the risk of further harm.

8. We will not normally reinvestigate a council’s safeguarding investigation. We can consider whether the council conducted a suitable investigation in line with its safeguarding procedures. If we find fault in how this happened we can look again at the matters covered by the investigation.

What happened

9. At the time of the events Mr Y was in his eighties and lived in sheltered accommodation. He had dementia and was receiving end of life care. He received domiciliary care services from two different Care Providers, alongside care from a hospice at home team.
10. In March 2021 Mrs X complained about the level of service Mr Y was receiving. She reported an incident in which Mr Y had soiled himself and the carer present ignored it and left. She also reported finding Mr Y in soiled nightwear on other occasions.
11. Mrs X reported a carer falsely completed the visit log for Mr Y. She discovered this during a visit to Mr Y. She found the carer had signed in and out before the time had elapsed.
12. On another occasion Mrs X complained Mr Y had been left over 12 hours without care because carers could not gain access to Mr Y’s property.
13. Mrs X also reported carers were on some occasions not wearing full PPE and wearing their own clothes.
14. Mrs X reported her concerns to the Care quality Commission (CQC) and the Council.
15. The Council conducted two separate section 42 safeguarding investigations. I have had sight of all the safeguarding documents, including the communication between the Council, the CQC, the Care Providers, care workers and with Mrs X.
16. The safeguarding investigations substantiated two allegations.
1. a carer signing in and out of a visit before the time had elapsed;
2. two missed care visits because carers could not gain access to Mr Y’s property, resulting in Mr Y being without care for over 12 hours.
17. Appropriate action was taken to address the failings and prevent a recurrence. This included changes to practice, training of staff and formal action against a carer.
18. On the points not substantiated, the records detail how this decision had been reached, and that although not substantiated, lessons had been learnt which had resulted in changes to practice being implemented.
19. Mr Y sadly passed away on 16 April 2021.
20. Following Mr Y’s death, Mrs X received a final invoice from the Council for Mr Y’s contribution towards his care. She contacted the Council as she believed the amount to be incorrect.
21. There was a delay in the Council formally informing Mrs X of the outcome of the safeguarding investigation. It wrote to her in August 2021 explaining the delay and set out the findings of the two separate safeguarding investigations. The author of the letter explained the allegations had involved two Care Providers which had necessitated two safeguarding investigations, and there had been a delay in gathering all the information. The author apologised to Mrs X.
22. The author addressed each of the allegations in turn, how these were investigated, the conclusion and the action taken by the Council and Care Providers to address the identified failings.
23. In respect of the wrongly completed care logs, the carer in question was subject to formal action, and ongoing monitoring. The Care Provider explained it was in the process of implementing an electronic care log system which would prevent any recurrence.
24. In respect of the missed visits, the Care Provider undertook training of carers in reporting all non-access visits to the Council’s emergency duty team
25. The author apologised to Mrs X saying, “This falls below the standards we hold our partner agencies to, and I hope you are satisfied with the actions taken to ensure that these issues do not repeat themselves”.
26. The author explained the basis on which the Council has not substantiated the allegation that a carer had left Mr Y in soiled nightwear, that there was a lack of evidence to come to a conclusion, but lessons had been learnt and new practices implemented.
27. The author also addressed the issue relating to the final invoice for Mr Y’s care, saying, “…your concerns regarding this matter have been upheld. It appears that your father’s case was mistakenly closed when he passed away, therefore no further action was taken on the case and your supporting documents were not taken into account. It is my understanding that PFU has written to you to explain how this occurred, apologise and inform you that there is now no further charge on the account. This error has been addressed with the staff member who closed the case in supervision. It has also been cascaded down to the wider Team to ensure that it does not occur in the future”.
28. Mrs X was dissatisfied with the Council’s response. She believes it to be inadequate. She “…wants assurance that lessons have been learned and services on Wirral will be improved as a result and that this won’t happen to any other family”.
29. Mrs X is also seeking a refund of care fees for the family, as she says the family have paid for care that was not provided.

Analysis

30. 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.
31. From considering the information, I can see how distressing this situation has been for Mrs X. Mr Y was left without the necessary care for over 12 hours at the end of his life. Mrs X anger and distress is understandable.
32. My role here is to consider if the Council’s safeguarding investigation properly investigated the incidents.
33. I have had sight of all the safeguarding documents. Mrs X can be reassured her concerns were taken seriously and investigated properly, and in accordance with the law.
34. The investigation substantiated some allegations, including the allegation that Mr Y had been left for over 12 hours without care. I am satisfied lessons were learnt and appropriate action was taken to address the failings and prevent a recurrence. I cannot see that any further investigation by this office could achieve more.
35. On matters that were not substantiated, the Council provided a detailed explanation for the basis of its decision. I cannot see that further investigation by this office would lead to different outcome.
36. There was some delay in the Council responding to Mrs X’s complaint. This was far from ideal, but I have taken account of the complexity of the investigation, that it involved different agencies, and the impact of the pandemic. The Council offered Mrs X a sincere apology and I consider this to be adequate.
37. In respect of Mrs X’s complaint about incorrect charging for Mr Y’s care, I note this has been resolved. The Council accepted there had been error, explained the action taken and confirmed there were no outstanding charges for Mr Y’s care.
38. Mrs X is seeking a refund of the care fees already paid. The injustice that arises from the shortcomings identified by the safeguarding investigation is to Mr Y. Sadly he has died so we cannot remedy that injustice.
39. In some case, where a person has died we do consider a remedy. This is usually in cases where this a quantifiable loss, for example, where a person has paid care fees that should have been paid by the Council, or where a person should have received housing benefit. Where the injustice is less tangible, for example distress, harm, risk, or another unfair impact of the fault, we will not normally seek a remedy in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment that would enrich a person’s estate.
40. For this reason, I cannot recommend the Council refund care fees Mr Y paid to his estate.

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Final decision

41. There was no fault in how the Council carried out its safeguarding investigation. Further investigation by us would unlikely lead to a different outcome.
42. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman