Summary: Ms X complained about the standard of care her son (Mr Y) received between August 2023 and May 2024 in a Care Home which was council commissioned. She also complained the Council delayed completing the subsequent safeguarding investigation and failed to involve her in this process. The Council was at fault as the safeguarding investigation found the Care Home failed to provide Mr Y with a healthy diet and adequately record Mr Y’s care. The investigation also found the Care Home made inappropriate comments after giving Mr Y first aid. The Council delayed completing the safeguarding investigation however it did involve Ms X throughout. The Council has agreed to apologise and make a symbolic payment to acknowledge the injustice caused.

The complaint

1. Ms X complained about the standard of care her son (Mr Y) received between August 2023 and May 2024 in a Care Home which was council commissioned. She also complained the Council delayed completing the subsequent safeguarding investigation and failed to involve her in this process.
2. This caused Ms X distress, frustration and uncertainty about the care Mr Y was receiving.

Back to top

The Ombudsman’s role and powers

3. 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)
4. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. 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).
6. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

Back to top

How I considered this complaint

7. I have spoken to Ms X and considered information she has provided.
8. I considered information from the Council.
9. I considered the relevant law and guidance.
10. Ms X, the Council and the Care Home had an opportunity to comment on a draft decision. I considered comments before making a final decision.

Back to top

What I found

Relevant law and guidance

11. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
12. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help and protect the adult.
13. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement.
14. The Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively. 
15. The Care and Support Statutory Guidance says it is of critical importance that allegations are handled sensitively and in a timely way both to stop any abuse and neglect but also to ensure a fair and transparent process.
16. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. The standards include:
• Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment (regulation 9)
• Providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times (regulation 10).
• Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe (regulation 12).
• Providers must meet people's nutrition or hydration needs wherever an overnight stay is provided as part of the regulated activity or where nutrition or hydration are provided as part of the arrangements made for the person using the service (regulation 14).
• Providers must securely maintain accurate, complete and detailed records in respect of each person using the service (regulation 17).
• Providers must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people's care and treatment needs (regulation 18)

What happened

17. The information below is not a comprehensive overview of everything that happened. It is a summary of key information.
18. Ms X has an adult son Mr Y. Mr Y has severe learning disabilities and lived full time in the Care Home between August 2023 and May 2024. Mr Y received 1:1 support during the day and 14 shared night hours during the week. Ms X is Mr Y’s personal welfare deputy. This means she can make decisions about Mr Y’s medical treatment and his care as Y lacks capacity to do this himself.
19. In August 2023, Mr Y had a seizure in the Care Home. The Care Home and ambulance service both raised safeguarding concerns. They reported that after a carer gave Mr Y medical treatment, the carer made inappropriate comments and failed to record the incident.
20. In September 2023, the Council opened a safeguarding investigation because of the seizure and the concerns raised. The Council called Ms X at the start of the initial investigation to discuss the concerns and a strategy meeting with the relevant professionals took place. Professionals thought Mr Y’s seizures may be linked to a poor diet.
21. Between September 2023 and May 2024, Ms X and professionals involved in Mr Y’s care raised the following safeguarding concerns about the Care Home:
• Unclean facilities;
• Failure to administer Mr Y’s medication;
• Lack of healthy food options;
• Staff shortages resulting in Mr Y having unwitnessed seizures;
• Failing to update Mr Y’s health information and communicate this to staff;
• Poor record keeping in respect of Mr Y’s seizures, medication and diet; and
• Issues with Mr Y accessing water from the tap in his room
22. Mrs X says around the same time as the concerns Mr Y developed new behaviours which included hitting himself. Mrs X feels this occurred as a result of the poor care he was receiving in the Home.
23. The Council decided to take no further action around the concern about failing to administer medication which occurred in December 2023. This is because the Care Home investigated, completed a stock check and found the staff member had correctly administered the medication. It spoke to the staff member who advised they had administered the medication but had forgot to record this on the Medication Administration Record (MAR) chart. The Council added the other concerns to either the open investigation or progressed them to a new safeguarding investigation.
24. When professionals raised safeguarding concerns regarding Mr Y, the Council called Ms X to ascertain her views and establish what happened. The Council also scheduled monthly meetings from January-June 2024 which Ms X and key professionals attended to discuss Mr Y’s care and any safeguarding concerns. The records and minutes show Ms X attended and contributed to these meetings.
25. The Council closed the safeguarding investigations in May and June 2024 as the risk had been reduced or removed.
26. The key points from the safeguarding investigation are as follows:
• The outcome of the investigation was ‘abuse partially confirmed’ as a carer made inappropriate comments following Mr Y’s seizure in August 2023 and failed to report and record the seizure correctly;
• The Council found issues with the Care Home’s record keeping, poor diets of residents, staffing shortages and Mr Y’s access to water;
• In respect of all concerns raised between August 2023-May 2024, the Council adopted a multi-agency approach and it had spent time training staff, completing visits, monitoring recordings and action planning. This was to mitigate the risk of reoccurrence and up-skill care staff specifically in the area of first aid. It accepted the new staffing team has required time to imbed.

Ms X’s complaints to the Council

27. In November 2023 Ms X made a complaint to the Council about the standard of care Mr Y received from the Care Home. The Council responded in January 2024 saying it was supporting the Care team and CQC were fully aware of the concerns. The Council gave an update on the support the Care Home was receiving.
28. In March 2024, Ms X made a further complaint about the safeguarding investigation. She raised the following concerns
• Delays in completing the safeguarding investigation opened in September 2023;
• Failure to involve Ms X in the investigation as Mr Y’s personal welfare deputy;
• Failure to prevent incidents re-occurring.
29. The Council partially upheld the complaint as it recognised the quality of care provided to her son to safeguard him in his placement remained a concern. The Council also accepted there should have been more consultation with Ms X throughout the investigation as Mr Y’s deputy.
30. Mr Y moved care homes in June 2024. However, Ms X remained dissatisfied with the Council’s handling of the matter and complained to us.

Council enquiry response

31. The Council says it involved and updated Ms X throughout the safeguarding investigation which is evidenced in the case notes and the safeguarding minutes.
32. In response to the delays with concluding the safeguarding investigation, the Council says a long investigation into the concerns took place which included on-going meetings, visits and monitoring. This was to minimise the risk of re-occurrence.
33. The Council says the Care Home has spent time training the staffing team around reporting and recording of any incidents, including medical events and safeguarding concerns. Staff have also undertaken further first aid training. It says it completed further announced and unannounced visits over a six-month period and the latest visit showed a big improvement with recording. The Council has also visited the Home to do periodic checks to see the menu and food records. It says the Care Provider has made improvements in the diet of people living at the Home. It also created an action plan to monitor the concerns raised. However, upon reviewing this, the action plan needs to be updated.
34. The Council says going forwards it will continue to carry out unannounced visits as the Care Home looks to improve its care and support. It says the Learning Disability Team, and the Nursing Team from the GP surgery will continue to work with the Home on improvements.

My findings

Standard of care

35. Ms X complained about the standard of care Mr Y received in the Care Home between August 2023-May 2024. During the safeguarding investigation, the Council substantiated that a carer made inappropriate comments following Mr Y’s seizure. It also found poor record keeping in respect of this incident as well as further seizures, medication and diet. Mr Y then had further seizures in November 2023 and March 2024 which were unwitnessed by care staff. The Council found that due to staff shortages there was four staff on shift that day in March rather than five. There was also speculation around whether poor diet was causing the seizures. Whilst it remains unknown what causes the seizures, the Council did find the Care Home did not always give Mr Y a balanced diet and there was a lack of healthy food options available to him. As well as diet, there has also been an incident of Mr Y being unable to access water. The Council found in May 2024, Mr Y was thirsty and unable to access water independently due to an isolator on the sink tap in his bathroom. The Care Home staff could not resolve this as they could not find the key to the isolator box. The care given to Mr Y between August 2023-May 2024 was not in line with CQC fundamental standards and was fault. This caused distress, frustration and uncertainty about the care Mr Y was receiving.

Delays in completing the safeguarding investigation

36. In September 2023, the Council started a safeguarding investigation into the concerns which occurred the previous month. The Council did not conclude the safeguarding investigation until May 2024 and took a total of eight months to complete. The Care and Support Statutory Guidance says it is of critical importance that allegations are handled sensitively and in a timely way both to stop any abuse and neglect but also to ensure a fair and transparent process. The Council accepts it was a long investigation which included on-going meetings, visits and monitoring. The Council says this was to minimise the risk of re-occurrence. However, Ms X and professionals involved in Mr Y’s care raised further safeguarding concerns during this time. Whilst the new safeguarding concerns likely delayed the investigation, it should not have taken eight months for the Council to conclude the original concerns. This was fault which has caused the matter to drift without meaningful progression. This caused distress, frustration and uncertainty about the care Mr Y was receiving.

Ms X’s involvement in the safeguarding investigation

37. Ms X says the Council did not involve her enough as Mr Y’s personal welfare deputy in the safeguarding investigation. Ms X says the Council did not invite her to safeguarding meetings and it closed the investigation without reassurance the Care Home would improve. The Council called Ms X at the start of the safeguarding investigation to ascertain her views and establish what happened. The records also show that as part of investigation, the Council held four meetings between January and April 2024. The investigating officer attended these alongside other professionals where Mr Y’s care and updates on the investigation were discussed. The Council invited Ms X to all of the meetings, and she attended all but one. In June 2024, the Council also invited Ms X to a final safeguarding adults planning meeting. This meeting discussed any on-going concerns as well as improvements with the Home. The meeting also included a list of actions for how Mr Y would be supported until he left the Care Home. This included ensuring an action plan was finalised for the Home, 1:1 support for Mr Y by familiar staff and correct medical attention given and recorded. The evidence shows the Council consistently involved Ms X in the safeguarding investigation and therefore, the Council was not at fault.

Back to top

Agreed action

38. Within one month of the final decision the Council has agreed to take the following action:
1. Apologise to Ms X to recognise the distress, frustration and uncertainty caused to them about the standard of care Mr Y received and the delays with the safeguarding investigation. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended.
2. Pay Mr Y £300 to acknowledge the distress, frustration and uncertainty caused by the standard of care he received and the delays with the safeguarding investigation.
3. Update the action plan and provide evidence of the Care Home’s progress with this
4. Carry out another unannounced visit in the next three months and provide us with its report on this.
39. The Council should provide us with evidence it has complied with the above actions.

Back to top

Final decision

40. I have completed this investigation. I found fault and the Council has agreed to my recommendations to remedy the injustice caused by the fault.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman