Summary: Miss X complained the Council failed to carry out an adequate safeguarding investigation into the neglect she says her father experienced whilst in a care home. She said the Council failed to keep her informed and then delayed responding to her complaint and this caused her significant stress. We find fault by the Council. To address the injustice caused by fault, the Council has agreed to apologise and make a symbolic payment.

The complaint

1. The complainant, Miss X, complains the Council failed to carry out an adequate safeguarding investigation into the neglect she says her father experienced whilst in a care home. She said the Council failed to keep her informed and then delayed responding to her complaint. She said this caused her significant stress.

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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, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), 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. I spoke with Miss X about her complaint. I considered any information provided by her and the Council.
5. Miss X and the Council had an opportunity to comment on my draft decision. I have considered their comments before making my final decision.

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What I found

6. A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. 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)

The Council’s safeguarding procedure

7. When the Council becomes aware of a situation that meets its criteria, it must made or arrange an enquiry under Section 42 of the Care Act 2014. The Council must make (or cause to be made) whatever enquires it thinks necessary to enable it to decide whether any action should be taken in the adults case and, if so, what and by whom.
8. The Council should aim to provide swift and personalised safeguarding responses. The suggested target time for section 42 enquiry actions is within 20 working days.

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What did happen?

9. This section sets out the key events in this case and is not intended to be a detailed chronology.
10. Miss X’s father, Mr Z who has dementia became a self-funding resident at a care home on 10 February 2022.
11. Miss X raised concerns about the care Mr Z received with the care home and with the Care Quality Commission (CQC) in March 2022.
12. Mr Z was admitted to hospital on 18 April 2022. This was due to a decline in both his physical and mental health.
13. A safeguarding concern was raised by the CQC on 21 April 2022 highlighting concerns raised by Miss X on the day Mr Z was admitted to hospital, in relation to the quality of nursing care her father received. A safeguarding concern was also raised by the hospital and ambulance crew.
14. The Council decided that it warranted investigation and proceeded with its enquiries.
15. Miss X asked the Council in May 2022 for updates on the enquires.
16. On 22 July 2022, the safeguarding enquiry found that:

• Based on the care homes care notes, it had found no evidence to suggest that staff neglected Mr Z’s podiatry needs. It said staff followed the care plan in place and liaised with health professionals as/when concerns arose. The concern was unsubstantiated.
• Mr Z was diagnosed with dehydration on admission to hospital. It said the ambulance crew reported there was no information available regarding his food and fluid intake although staff mentioned he had some drinks. It therefore said this concern was substantiated.
• There was a typo error in Mr Z’s care plan which stated he was on 30mg of Mirtazapine rather than 15mg which has since been updated. But it said there was no evidence to show that staff had administered 30mg of Mirtazapine at any time and the outcome was therefore unsubstantiated.
• In regard to Mr Z contracting Covid more than once despite not leaving his room, it found that Mr Z depended on care workers for support and due to the care homes covid policy and the spread of covid, it said it was unlikely that their actions were negligent and therefore the outcome was unsubstantiated.

17. Miss X complained to the Council on 26 July 2022. She said the safeguarding enquiry was factually incorrect and poorly written.
18. Miss X contacted the Council again on 7 September 2022 to complain. She said since complaining about the safeguarding enquiry, she had contacted the Council a further seven times, plus left voicemails and had no response.
19. The Council responded to Miss X on 21 September 2022. It said a council officer who was due to relook at the safeguarding enquiry had left the team. It apologised and said due to this, this request had not been actioned. The Council said it had reallocated this to another officer who would consider the matter after annual leave. It apologised for the further delay but said in taking the decisions it gave consideration to Mr Z now being at a different care home.
20. On 25 November 2022, the Council sent Miss X the further safeguarding enquiry. It concluded that the outcome remained partially substantiated for the same reasons outlined in the first safeguarding enquiry.

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Analysis

21. The Ombudsman is not an appeal body, and it is not our role to decide whether neglect or abuse has taken place; that is the Council’s responsibility. We do not take a second look at a decision to decide if it was wrong. We investigate the processes the council followed in making its safeguarding enquiries, to assess whether it made its decision properly.
22. The Council’s safeguarding procedure states it aims to provide swift safeguarding responses. The Council initially proceeded with its safeguarding enquires in April 2022 and provided Miss X with an outcome of its decision in July 2022. In that time, Miss X reported her concerns for the Council to consider and asked the Council for updates on the enquiry. The Council said in May 2022 it was waiting for responses from the care home. It then said in June 2022 it would soon be concluding the enquiry once it had management approval. The Council’s safeguarding procedure states suggested timescales for completing section 42 enquiry actions is 20 working days. There appears to have been a drift in this case. This is fault.
23. Overall, there is no fault in the quality of the Council’s safeguarding enquiry. It considered all the information, including the care records, care plan, food/fluid charts and records of visits by GPs/other health professionals. The records show no entries on Mr Z’s fluid chart after the 13 April 2022 which the Council have acknowledged. I am satisfied with the Council’s safeguarding enquiry.
24. Miss X told the Council in July 2022 she was not happy with the safeguarding enquiry. She said it was factually incorrect and poorly written. The Council did not reallocate the case to a different officer until September 2022. This is fault. In that time, Miss X complained to the Council and contacted it numerous times. Whilst the second safeguarding enquiry considered the same information and reported the same outcome, the delay in responding to Miss X’s request meant she spent unnecessary time and trouble contacting the Council.

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Agreed action

25. To remedy the injustice caused by fault, within one month of my final decision the Council has agreed to:

• Apologise to Miss X for the delays in dealing with her request.
• Pay Miss X £150 to acknowledge the unnecessary time and trouble she spent contacting the Council.

26. Within two months of my final decision the Council has agreed to:

• Remind staff to keep within the timeframe for completing safeguarding enquires and where this is not possible keep relatives informed.

27. The Council should provide us with evidence it has complied with the above actions.

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Final decision

28. There was fault by the Council. The actions the Council has agreed to take remedy the injustice caused. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman