Summary: The complaint is about the Council’s safeguarding investigation into incidents in a care home involving the complainant’s father. The Ombudsman’s decision is there was no fault by the Council. It conducted a proportionate investigation in reaching its view the incidents were one-offs. As there was no fault, we cannot question the merits of the Council’s decision.

The complaint

1. The complainant (whom I shall refer to as Mrs U), is complaining on behalf of her father (whom I shall refer to as Mr V). Mrs U complains the Council’s safeguarding team did not take action against Mr V’s unsafe care home placement. The lack of action meant Mr V and other residents remained in danger.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
3. If we are satisfied with an organisation’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. As part of the investigation, I have:
• considered the complaint and the documents provided by Mrs U;
• made enquiries of the Council and considered its response;
• spoken to Mrs U;
• sent my draft decision to Mrs U and the Council and considered the responses I received.

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What I found

Legal and administrative background: safeguarding

5. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

6. Mr V moved to a care home in March 2021. Mrs U is concerned about the care and supervision the care home provided, from soon after Mr V moved.
7. The care home is located within the city boundaries. But Mr V’s care is arranged by the County Council, as that is where he lived before moving. The City Council (which I shall refer to as the Council) is responsible for the safeguarding of residents living within its boundaries, regardless of the funding arrangements for care. Mrs U has made a parallel complaint about the care home and County Council.
8. The Council’s safeguarding team’s first record of contact that mentions Mr V is an August 2021 note about an earlier incident where Mr V tried to harm another resident. This record suggests the County Council was dealing with this issue. (The care home did report the earlier record at the time, but only in relation to the other resident.)
9. In November 2021, in response to a wider enquiry about the care home, the Council spoke to Mr V’s social worker from the County Council. The social worker advised she had no concerns about the care Mr V was receiving. And she thought the care home was the best place for him.
10. The Council’s next record is from February 2022. The care home reported an incident to its safeguarding team. Mr V was found in another resident’s room touching her inappropriately. The other resident’s room sensor alerted staff.
11. The Council’s officer spoke to Mrs U and the care home manager. Mrs U advised of earlier incidents – of particular concern was a fall in March 2021. The Council also noted an earlier incident in February, when Mr V had hit another resident. The social worker decided the Council needed to investigate “…to see what further can be done to reduce the risk of further incidents.”
12. In early April the Council convened a strategy meeting/discussion with the County Council’s social worker and a member of the management team at the care home. The meeting noted:
• the historical incidents, some of which the care home should have raised at the time with the Council’s safeguarding team. But Mr V had fully recovered from these earlier incidents. And the care provider had introduced more frequent checking and was using a room sensor. So, in terms of the Council’s safeguarding role, no further action was needed;
• Mr V’s challenging behaviours had by then been linked with times when he had urinary tract infections (UTI).
13. The Council listed several actions for the care home and the County Council to take:
• to review Mr V’s care needs and liaise with the family;
• to contact the GP for more regular testing, if Mr V’s UTIs became more frequent;
• for more use of room sensors.
14. In May the Council closed its investigation. It noted:
• Mr V had been settled in the care home in the six months preceding the February incidents;
• Mr V had a UTI at the time of the incidents;
• the care home had implemented some changes, and the County Council’s social worker had no concerns about the placement;
• the County Council social worker would contact Mr V’s family to discuss if they wanted to move Mr V; also whether that was in Mr V’s best interests;
• the risk to Mr V was unsubstantiated, as the February 2022 incidents were one-offs which could not have been predicted.

Analysis

15. It is understandable that the Council’s decision caused distress to Mrs U, as she felt the care home was putting Mr V in danger. But the Council investigated and took the view the home had taken appropriate action in response to the incidents it had investigated. The Ombudsman will not interfere in a decision, unless there was fault in the way it was reached. I do not consider that is the case here.

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Investigator's decision on behalf of the Ombudsman