Summary: There was fault in the way the Council carried out a safeguarding enquiry into concerns about a care home. This meant there is uncertainty of what would have happened if the enquiry had been carried out differently. The Council has agreed to apologise, pay a symbolic financial remedy and review its practice.

The complaint

1. Mrs B complains on behalf of her mother, Ms C, who has died. Mrs B complained about the Council’s delays and failures in its safeguarding enquiry into concerns she raised about a care home.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

4. 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

5. I have discussed the complaint with Mrs B and I have considered the information that she sent.
6. The care package was funded by Trafford Council under a deferred payment agreement. As the Home was located in Cheshire East, the safeguarding enquiry was carried out Cheshire East Council. I have considered the information sent by both councils and the relevant law, guidance and policies.
7. I have considered all sides’ comments on the draft decision.

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What I found

Law, guidance and policies

Safeguarding duty

8. Section 42 of the Care Act 2014 says the local authority should start a safeguarding enquiry if an adult in its area:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

What happened

Chronology

9. This is a chronology of Mrs B’s complaints and the investigations that have taken place into the complaints.
• 12 January 2022: Ms C moved into the Home.
• 20 January 2022: Mrs B complained to Trafford Council about the Home and Ms C’s GP. She had made complaints and safeguarding referrals about the two previous care homes where Ms C had resided.
• 30 March 2022: Mrs B made a safeguarding referral regarding the Home to Trafford Council. Trafford Council emailed the referral to Cheshire East Council as the Home was located there.
• 27 May 2022: Mrs B made a safeguarding referral to Trafford Council and Trafford Council sent it to Cheshire East Council. Cheshire East Council decided that the referral did not meet the threshold for a safeguarding enquiry and closed the matter. The Council decided that the issues related to quality issues and shared them with the Home’s manager.
• 15 June 2022: Ms C was diagnosed with a terminal illness.
• 17 June 2022: Mrs B made a safeguarding referral to Cheshire East Council.
• 22 June 2022: Mrs B complained to the Home.
• 6 July 2022. Ms C was taken to hospital but returned later that day. The hospital made a safeguarding referral based on Mrs B’s referral.
• 6 July 2022: The Home responded to Mrs B’s complaint.
• 10 July 2022: Ms C died.
• 11 July 2022: The Home responded to Mrs B’s complaint.
• 13 July 2022: Ms C called the police about the Home’s alleged failures. The police took no further action and closed the matter.
• 3 August 2022. Cheshire East Council started a safeguarding enquiry.
• 13 December 2022: Cheshire East Council completed the safeguarding enquiry and emailed the outcome to Mrs B. The allegations were partially substantiated.
• 20 January 2023: Cheshire East Council made a referral to the Safeguarding Adult Board (SAB) to consider whether a Safeguarding Adult Review (SAR) should be held.
• 26 January 2023: Following an SAR panel, the SAB decided that the threshold for an SAR was not met.
• 9 March 2023: Mrs B contacted her MP to complain about the Home.
• 13 March 2023: Cheshire East Council responded to the MP’s referral by organising a meeting between Mrs B, the Chair of the SAB and the Council’s Chair of Safeguarding to go through the decision of the SAB.
• 20 March 2023: The Chair of the SAB wrote to Mrs B with a list of actions agreed at the meeting.
• 26 March 2023: Mrs B complained to Cheshire East Council about the safeguarding enquiry and made a complaint to the CCQ about the Home.
• 3 April 2023: The CQC carried out an inspection of the Home as a result of Mrs B’s complaint.
• 18 April 2023: Cheshire East Council provided a stage 1 response to Mrs B’s complaint about the safeguarding enquiry.
• 24 April 2023: Mrs B escalated her complaint about the safeguarding enquiry to stage 2.
• 9 May 2023: Cheshire East Council provided its stage 2 response to the complaint.
• 18 June 2023: The Chair of the SAB wrote a 7-page letter to Mrs B reviewing the actions that had been taken following the meeting on 13 March.
• 23 July 2023: The CQC published its report on the Home and downgraded the Home’s rating to ‘requires improvement.’
• 20 October 2023: The Home completed its 45-page investigation report into Mrs B’s complaints and upheld most of the complaints.
• 21 February 2024: Both councils sent a final joint response to Mrs B’s complaints as she had continued to make complaints.

Safeguarding referral – 15 March 2022

10. Mrs B made a safeguarding referral to Trafford Council on 15 March 2022. Mrs B said:
• The Home was not providing Ms C with a bath or shower and was not applying the cream that the GP had prescribed for haemorrhoids.
• One of the residents went into Ms C’s room at night and attacked Ms C. There was not enough monitoring in the Home.
• Ms C’s bedding had not been changed for 3 weeks and the bins containing the continence products were not emptied.
• Ms C B had been prescribed medication 1, but this had been changed to PRN only and that was not sufficient to manage her pain.
11. (Note: PRN medication means medication to be used ‘as and when required’.)
12. Trafford Council explained to Mrs B that, as the Home was in Cheshire East, any safeguarding duties lay with Cheshire East Council so it would forward her referral to Cheshire East. Trafford Council sent the referral to Cheshire East’s safeguarding team on 29 March 2022. The referral was sent by email and not through Cheshire East Council’s safeguarding portal. Cheshire East Council has said there was no evidence of a portal referral.

Safeguarding referral – 27 May 2022

13. Mrs B contacted Trafford Council again on 27 May 2022 and raised further safeguarding concerns.
14. These related to:
• The Home’s management of Ms C’s nutrition as Ms C continued to lose weight.
• The problems with Ms C not having a bath continued.
• The Home’s management of Ms C’s pain and administration of medication was still poor.
15. Trafford’s social worker rang Cheshire East as she noted she had previously contacted them and had not heard back. The note of the conversation said: ‘No referral has been received for [Ms C].’ Trafford’s social worker forwarded the email she had previously sent on 29 March and was advised to upload it to the safeguarding referral hub.
16. Cheshire East Council registered a safeguarding referral on 27 May 2022, but this related to the email that was sent on 29 March.
17. Cheshire East’s manager spoke to Mrs B to discuss her concerns. The note of the conversation said:
• Mrs B agreed that Ms C often refused a bath or shower so the lack of bath/shower was not entirely the Home’s fault. The Home provided a standup wash as an alternative. Ms C had had broken skin but this had now been resolved and she had no sores.
• The Home denied that Ms C had been attacked by another resident and a gate was put on Ms C’s door to stop people wandering in so any risk had been addressed.
• The Home’s manager had said they were addressing the problems with the bedding and bin emptying, but Mrs B said the bedding was still not being changed.
• Mrs B had challenged the Home about administering medication 1 on a PRN basis, but the Home said that this was what the prescription said. This was then raised with the GP and they prescribed a regular dose of medication 1.
18. Mrs B also raised additional concerns about nutrition. She said the Home was not providing Ms C with prompting and encouragement when eating. Ms C needed a lot of support with nutrition but was not receiving this and was losing weight.
19. The manager decided that the referral did not meet the threshold for a safeguarding enquiry and recorded the outcome as follows:
• ‘Discussed that much of the concerns raised are historical and have been resolved through discussion with the Home and GP – bathing, cleaning, risk from other residents and pain management. [Mrs B] said things are generally improving but she remains concerned about staff attitude and the food issue… Advised that there is no indication of abuse or neglect at this time but agreed to share [Mrs B’s] concerns with the Home manager for her awareness and so she can monitor and take any further action as appropriate.’

Safeguarding referral – 17 June 2022

20. Mrs B sent a text to Cheshire East Council on 17 June 2022 and said:
• Ms C had been diagnosed with a terminal illness following the scan. The ambulance crew had told her that Ms C had not received pain medication 1 since 7 June. Ms C would have suffered ‘horrific pain’ as she had a serious mouth infection at the time.

Further safeguarding concerns – 20 June 2022

21. Mrs B rang Cheshire East Council on 20 June 2022 and said:
• Ms C had been suffering with mouth sores but the Home had not given her pain relief since 7 May.
• Ms C should have been given a soft diet, but the Home were giving her inappropriate food.
• Ms C was prescribed a cream for haemorrhoids but the Home never asked for a review and continued to put her on the cream.
22. Mrs B was advised to put these concerns in an email to the Council. The Council decided to add these concerns to the existing safeguarding referral.

Safeguarding referral – 6 July 2022

23. Ms C went to hospital on 6 July 2022 and the hospital made a safeguarding referral to the Council which said:
• ‘’her daughter expressed safeguarding concerns about the Home due to these reasons; 4/52 ago patient had episodes of sore mouth, lost ability to swallow and take tablets… [Ms C] received inadequate analgesia, no blue book and no DNAR…’

Further communications

24. Cheshire East’s case notes show that Trafford Council contacted Cheshire East on 27 June 2022 and discussed the concerns about Ms C’s weight loss and Ms C being given inappropriate food despite being unable to swallow.
25. Cheshire East’s manager said the plan was to review the care records to corroborate or not the Home’s response and to make further enquiries with health services.
26. The manager spoke to Mrs B on 6 July 2022 to discuss the safeguarding referral. The manager noted that Mrs B’s concerns had continued from the referral she made earlier in the year which had been addressed by the Home. The note of the conversation said: ‘Through discussion I was able to focus [Mrs B’s] concerns to 3 specific areas’. These were pain management, dietary needs and health care. He said Mrs B raised concerns covering 18 months which included the previous care homes and hospitals and he explained to her that this would be outside of the remit of the safeguarding enquiry.
27. A social worker was appointed to carry out the enquiry and she spoke to Mrs B on 5 August 2022 with the aim of clarifying the safeguarding concerns. The social worker said that it was a difficult conversation as Mrs B blamed the Council for not starting a safeguarding enquiry earlier and also raised a lot of historical concerns about the previous care homes Ms C had lived in and concerns about the GP. The social worker said Mrs B ended the conversation as she said the social worker was ‘grilling’ her. Mrs B said she did not want the social worker to contact her again.

Safeguarding enquiry report – December 2022

28. The social worker investigated the following concerns:

Pain management / medication

• The Home did not give Ms C medication 1 four times a day, even though that was the prescription.
• Two pain patches were found on her body when she was taken to hospital on 5 July 2022.

Dietary needs

• The SALT assessment was done remotely, but should have been done in person.
• The Home did not meet Ms C’s nutritional needs, the food quality was poor and the Home delayed accessing SALT advice. The Home gave Mrs B food she was unable to swallow.

Health care

• Ms C had a mouth infection and the Home failed to address this early enough.
• The GP prescribed a cream for Ms C’s haemorrhoids and staff continued to apply this for 12 weeks without asking for a review by the GP.
5. The Council made the following findings in the safeguarding enquiry:

Pain management / medication

• The Council reviewed the MAR charts from 1 May to 15 June 2022. Medication 1 was prescribed on a PRN basis until 16 June when it was changed to four times a day. The medication was administered as prescribed after 16 June.
• The Council upheld the complaint that two pain patches were applied at the same time and this should not have happened.

Dietary needs

• The Home had no control over the SALT’s visits and whether the assessment would take place in person or remotely.
• Ms C experienced a loss of appetite and weight loss and chose to eat very little. This was in line with her diagnosis of a terminal illness. Mrs B had mental capacity to make decisions about her health and care needs so the Home had to offer her some choice in what she ate.

Health care

• The Home applied the same cream for 12 weeks for the haemorrhoids without checking with the GP and this resulted in a sore on the area. The Home confirmed that this should not have happened.

Home’s investigation – October 2023

30. In October 2023 the Home carried out its own investigation into Mrs B’s complaints and upheld most of her complaints in the areas of nutrition, medication, falls prevention, failure to seek medical advice, poor hygiene and other areas.
31. In terms of nutrition, the Home’s investigation found that the Home did not keep adequate records, did not evidence that it followed the SALT’s advice and failed to properly administer prescribed nutritional supplements.
32. In terms of medication, the Home’s investigation found that the GP prescribed medication 1 to be administered four times a day on 17 March 2022 but the staff continued to administer medication 1 on a PRN basis until Mrs B raised this and the GP wrote another prescription on 15 June 2022 for medication 1 to be administered four times a day.

Analysis

33. It is not the Ombudsman’s role to carry out a safeguarding enquiry so I have considered whether there was any fault in the way the Council carried out the enquiry.
34. I appreciate that I am looking at the complaint with the benefit of hindsight. There was a further investigation by the Home into Mrs B’s complaint which upheld most of her complaints. The CQC then downgraded the Home’s rating following its inspection of the Home as a result of Mrs B’s complaint.
35. I can only consider whether there was fault in the way the Council made its decision based on the information it had at the time.
36. The Council had a duty to consider whether the referral met the section 42 threshold for a safeguarding enquiry. If the Council decided the referral did not meet the threshold, it should set out reasons in writing. If the referral met the threshold, it should start an enquiry.
37. Trafford Council has provided evidence that it emailed a safeguarding referral to Cheshire East Council in March 2022. Unfortunately the referral was not sent via the Cheshire East’s safeguarding portal but was sent by email. I agree that it would have been better if the referral had been sent via the portal. Nevertheless, I would still have expected the Council to consider the referral even if it was not sent via the portal. There is no evidence to show how the Council considered this referral/email so there is some fault in that respect.
38. The Council considered the referral that was sent in May 2022 (via the portal). The Council decided that this referral did not meet the threshold for an enquiry as most of the concerns were historic and had been addressed. Of course, one of the problems may have been that the Council was considering the referral which had been sent in March 2022. That may have contributed to the decision that the concerns were historic.
39. However, overall the Council has explained how it reached the decision that the matter did not meet a safeguarding referral. The Ombudsman cannot question a decision if there is no fault in the way the decision was made. In any event, the Council then decided to carry out an enquiry a few weeks later after it received further referrals in June and July 2022 so the delay was short-lived.
40. Mrs B said the Council’s enquiry did not address all her complaints and was not thorough enough in its investigation so I have focussed on those aspects.
41. I note that the enquiry only investigated a small number of concerns compared to the much broader and in-depth investigation the Home carried out which found significant failings.
42. However, that in itself would not be an indication of fault. The Council’s duty was not to investigate all complaints but only to investigate those concerns which met the threshold of a section 42 safeguarding enquiry which is set higher.
43. Also, I do not think the Council had been made aware of all the complaints Mrs B made and so it would only have a duty to investigate those concerns it had been made aware of and which had met the threshold.
44. I note that the manager spoke to Mrs B on 6 July 2022 to discuss her concerns and explained that the Council would focus on three areas.
45. I think there was some fault in the Council’s investigation into the areas it had agreed to look at. The Council relied too much on the Home’s response to the complaint (which, at that time still denied any fault) and did not always carry out its own investigation.
46. For example, I would have expected the Council to fully investigate the complaint about nutrition. I would have expected the Council to check what the Home’s care plan for Ms C said about her nutrition and then read the Home’s records to check that the Home was providing nutrition as set out in the care plan.
47. There was no evidence that this complaint was properly investigated as the Council said Ms C was bound to lose weight because of her terminal illness. That may have been true but did not mean that the Council did not have a duty to properly investigate the administration of nutrition.
48. Similarly, the Council accepted the Home’s statement that medication 1 was prescribed as PRN so there was no fault in the administration of medication 1, but the Council did not check whether this was actually correct. So overall there was some fault in the way the Council carried out the enquiry.
49. I have also considered the injustice that resulted from the fault. It is impossible to say what the outcome would have been if the Council had fully considered the safeguarding referral in March 2022 or had carried out a more thorough enquiry in December 2022. Therefore, the injustice is distress caused by the uncertainty that things may have been different if the fault had not happened.
50. Sadly, as Ms C has died, the Ombudsman cannot remedy her distress. But I do not underestimate the distress Mrs B suffered. In cases such as this one, where the injustice is distress the Ombudsman can recommend a small symbolic sum and I recommend the Council pays £300 to Mrs B.
51. The Council should also review how it responds to safeguarding referrals to ensure that referrals are not missed.

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Agreed action

52. The Council has agreed to take the following actions within one month of the final decision. The Council will:
• Apologise in writing to Mrs B for the fault.
• Pay Mrs B £300.
• Review how it responds to safeguarding referrals to ensure that referrals are not missed.

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Final decision

53. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman