Summary: Mrs X complained about the care and support that a Council commissioned Residential Home provided to her son, Mr Y. She also complained about the Council’s safeguarding investigation. The Council was at fault as it poorly communicated with Mrs X in relation to her son’s care and support. The Council made recommendations following its safeguarding investigation which were appropriate. It has also agreed to apologise to Mrs X for the uncertainty and frustration the matter caused her.

The complaint

1. Mrs X complained about the care her adult son, Mr Y, received at a Council commissioned Residential Home, Cabot House. She said:
• her son had sustained multiple unexplained injuries during his stay at the Residential Home;
• staff provided poor personal care to her son; and
• her son’s personal belongings went missing.
2. The Council completed a safeguarding investigation into some of Mrs X’s concerns. Mrs X said the Council did not properly investigate her concerns and it poorly communicated with her.
3. Mrs X said it caused her and the family distress and uncertainty. She wants the Council to recognise its errors and provide them with a financial remedy.

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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. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

6. 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I spoke with Mrs X and considered the information she provided.
9. I considered information the Council provided.
10. Mrs X and the Council had the opportunity to comment on the draft version of this decision. I considered their comments before making a final decision.

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What I found

Safeguarding adults

11. 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)

Background

12. Mrs X’s son, Mr Y, has learning disabilities and other mental and physical health problems. Mr Y can display challenging behaviour which includes injuring himself and smearing his own faeces. This behaviour is usually triggered by certain factors such as Mr Y feeling anxious, distressed or overstimulated.
13. Between July 2021 and August 2022, Mr Y lived in the Council commissioned Residential Home where he received specialist care and support. During his stay, Mr Y participated in a variety of activities such as swimming and trampolining. When Mr Y accessed the community, he required support of two care workers and the use of a walking belt for his safety near cars.
14. In addition, Mr Y:
• attended a specialist school five days a week;
• had private care workers who also provided support to him with activities in the community as well as support during family holidays etc; and
• visited his family regularly and took part in activities with them such as horse riding and ice skating.

What happened

15. In November 2021, a meeting took place between Mrs X, the community learning disabilities services, the School, the Council and the Residential Home to discuss concerns Mrs X had with her son’s care and support at the Residential Home. Mrs X said there was unexplained bruising on her son. Mrs X wanted her son to move to another residential home.
16. Following the meeting, the community learning disabilities services raised a safeguarding alert with the Council’s Safeguarding Team so that Mrs X’s concerns could be investigated further. The Council’s Safeguarding Team commenced its investigation in November 2021.
17. Between November 2021 and March 2022, Mrs X and the School raised multiple safeguarding alerts to the Council’s Safeguarding Team about unexplained injuries on Mr Y’s body and Mr Y appearing with faeces smeared on himself. The Council’s Safeguarding Team decided to investigate all safeguarding alerts under its current investigation.
18. As part of its investigation, the Council’s Safeguarding Team spoke with various professionals involved with Mr Y’s health and social care as well as Mr Y’s school, his private care workers, Mrs X and the Residential Home. It also considered Mr Y’s:
• personal behaviour support plan with the School and the Residential Home;
• activities he participated in;
• use of the walking belt; and
• incident forms and body maps completed by staff at the Residential Home.
19. The Council’s Safeguarding Team completed its investigation by April 2022.
20. In relation to the unexplained injuries on Mr Y, the safeguarding investigation found:
• at times, the Residential Home did not inform the School or Mr Y’s family of incidents which had occurred with Mr Y;
• the incident forms and body maps from the Residential Home indicated Mr Y had injured himself. This explained some of the injuries;
• it was not possible to identify where Mr Y had sustained all unexplained injuries. Mr Y participated in various physical activities and some of these activities were outside the Residential Home. It was possible Mr Y had sustained injuries during these activities;
• Mr Y was at risk of bruising from use of the walking belt if it was overused; and
• it was important for all parties (the Residential Home, the School, and the private care workers) to consistently share information with each other as Mr Y participated in various activities in and out of the Residential Home which may have caused injury.
21. In relation to Mr Y’s bowel movements and smearing of faeces, the safeguarding investigation found:
• on one occasion, the Residential Home believed Mr Y did not smear faeces on himself and instead, it was remains of his breakfast earlier that day. However, the Residential Home recognised staff should have cleaned the food off Mr Y. Since then, staff had monitored Mr Y’s personal hygiene; and
• the smearing of faeces was in response to how Mr Y was feeling such as anxious or distressed.
22. The Council’s Safeguarding Team made some recommendations which included:
• the Residential Home to inform Mr Y’s family and the School of any incidents which caused injury to Mr Y;
• all parties to consistently share information on behavioural incidents or physical activities that may or had caused bruising; and
• the Residential Home to carefully monitor Mr Y’s bowel activity and observe for any changes including behaviours.
23. Mr X moved to another residential home in August 2022. However, Mrs X remained unhappy and complained to us. As part of her complaint, Mrs X told us the Council had not sent her the outcome of its safeguarding investigation. She also said Mr Y’s belongings such as his clothes and furniture went missing during his stay at the Residential Home.
24. In response to my enquiries, the Council told me it had sent Mrs X its safeguarding investigation outcome shortly after it concluded its investigation and provided evidence of this. The Council did not provide me with further information on Mrs X’s complaint about her son’s belongings going missing.

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Findings

Unexplained injuries

25. The Council’s safeguarding investigation could not identify how Mr Y had sustained all injuries however, its investigation considered the possibility of how he could have sustained them.
26. However, the safeguarding investigation found there was poor communication between all parties. This was fault. As a result, the Council made recommendations to improve communication. This was appropriate and what we would expect the Council to do. I recognise however, the poor communication caused Mrs X uncertainty and frustration.

Poor personal care

27. The safeguarding investigation found Mr Y’s behaviour was triggered by certain factors. The Council therefore recommended the Residential Home to monitor Mr Y’s bowel activity and observe for any changes including in his behaviour. This was appropriate and what we would expect the Council to do.

Missing personal belongings

28. In her complaint to us, Mrs X told us her son’s items went missing during his stay at the Residential Home. However, I do not have supporting evidence Mr Y’s belongings went missing and so cannot say the Council was at fault.

The Council’s safeguarding investigation

29. In her complaint to us, Mrs X told us the Council had not sent her the outcome of its safeguarding investigation. The Council told us it had done so and provided evidence to support this. The Council was not at fault.

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Agreed action

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. So, although we found some fault with the actions/service of the Care Provider, we have made a recommendation to the Council.
31. Within one month of the final decision, Council will apologise to Mrs X for the uncertainty and frustration caused to her by the poor communication at the Residential Home in relation to Mr Y’s unexplained injuries.
32. The Council will provide us with evidence it has complied with the above actions.

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Final decision

33. I have now completed my investigation. The Council was at fault and has agreed to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman