Summary: There is no fault in the way the Council conducted a safeguarding investigation into concerns raised about the safety and wellbeing of Mr Y in a residential care home.

The complaint

1. Ms X complains the Council failed to properly investigate her concerns about her father’s safety and wellbeing in a care home, under its safeguarding processes.

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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 how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
3. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), 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:

• considered the complaint and the correspondence exchanged between Ms X and the Council, including the Council’s response to the complaint;
• considered information the Council provided to this office;
• taken account of relevant information;
• offered Ms X and the Council an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

6. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• 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.

7. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

Background

8. Mr Y is a senior citizen and has a diagnosis of dementia. He previously resided at Coldwells House residential care home. His care was funded privately, also known as a self-funder.
9. In early May 2024, a male resident moved into a bedroom next door to that of Mr Y. Ms X says immediately there were issues with the resident wandering into Mr Y’s bedroom. Ms X says the family repeatedly expressed concerns to the care staff.
10. Ms X reported bruising to Mr Y’s arm, following which care staff informed her about an altercation between Mr Y and the other resident. Ms X believes the incident took place after the resident entered Mr Y’s bedroom. Following this the care home placed sensor tape across Mr Y’s bedroom with the aim of preventing access to the other resident. Ms X says this restricted Mr Y’s movement and was ineffective in preventing access to the other resident.
11. At the end of May 2024, the care home reported Mr Y to be unsettled and requested another family member visit the care home. Ms X says at this point; the family were increasingly concerned about the escalating behaviour of the other resident to Mr Y and other residents. Ms X says care staff told her family the relationship between Mr Y and the other resident was one of two alpha males with a personality clash. Ms X disputes this, saying conflict only occurred when the other resident entered Mr Y’s bedroom.
12. On 1 June 2024, the care home contacted Ms X to say an incident involving Mr Y and the other resident had occurred early that morning and both parties sustained injuries. Mr Y’s injuries were assessed by a district nurse.
13. Ms X’s relative attended the home and was told Mr Y and the resident had been involved in an unwitnessed altercation in the reception area and both were found on the floor. Care staff said the incident was a safeguarding matter and had been reported to the Council’s safeguarding team.
14. Following the incident, sensor mats were place inside of the door of the other resident’s bedroom and outside the door of Mr Y’s bedroom door. On 3 June 2024, care staff relocated the other resident to a bedroom away from Mr Y.
15. The care home made a referral to the Council’s safeguarding team on 3 June 2024 about the other resident, with Mr Y as a third-party.
16. The safeguarding documents show an officer from the safeguarding team contacted the care home the same day the referral was received to discuss the situation. The care home gave a brief overview of the situation, saying the two residents had taken a dislike to each other, that sensor mats had been placed outside each resident’s room; and one resident had moved rooms; that the families had been informed and were happy with the new arrangements. Further enquiries followed and the safeguarding officer obtained more detailed information about the incident. The Council closed the safeguarding investigation as it believed the risk to Mr Y had been removed.
17. Ms X submitted a safeguarding referral directly to the Council on 10 June 2024, following which the investigating officer contacted Ms X’s sister on 14 June 2024 to confirm his role as investigating officer.
18. Ms X also sent an email to the Council on 14 June 2024 setting out her concerns and to say the other resident had entered Mr Y’s room again the previous night when her sister had been present, and said a male carer had supported the other resident to leave. She said her family did not believe Mr Y was safe. She asked for timescales for the safeguarding investigation.
19. Ms X says she discovered the investigation had been closed when she contacted the Council for an update on the investigation. She was unhappy she had not been involved in the safeguarding process and that she had not been informed of the decision to close the investigation. She sent an email to the Council about this, and saying the care home failed to act when concerns were first raised.
20. An officer from the Council’s safeguarding team contacted the care home again on 13 June 2024 to set out Ms X’s complaint, that there had been a reoccurring pattern of behaviour from the other resident which threatened and intimidated Mr Y, which the care home had failed to address until the events of 1 June 2024. Ms X believed managers at the care home ‘downplayed’ the seriousness of the other resident’s behaviour. The officer asked the care home to provide a full written report by 20 June 2024.
21. The Council contacted the care home the following day to appraise it of Ms X’s contact and concerns about Mr Y. A manager at the care home said a full report would be with the Council’s safeguarding team by the end of the day. I have had sight of this report. The care home acknowledged there had been issues of another resident wandering, and this caused difficulties for Mr Y who tended to be protective over his environment. The care home said Mr Y had previously displayed unpredictable and aggressive behaviour himself, hitting out at a female resident; which the family had been concerned about. After input from mental health services Mr Y’s behaviour had settled. The manager said both residents concerned were independently mobile so there was some risk of them encountering each other, and that the care home had put measures in place to mitigate the risk.
22. Ms X contacted the safeguarding officer to suggest Mr Y and the other resident had bedrooms on different floors. The care home confirmed this was a viable option. The officer recorded Ms X appeared more positive after a discussion about this with the care home, but she was taking Mr Y home for the weekend as weekends appeared to be a time when staffing levels appeared lower. Ms X said she and her family were considering if care home was the right placement for Mr Y. The records show the discussion between the officer and Ms X about the options available should she decide to remove Mr Y. The officer also explained the actions he had taken and action to that point, and actions that may flow from the completed investigation. The officer said he would contact the family to update them after he had reviewed all the evidence.
23. The safeguarding officer contacted the care home to confirm the above discussion with Ms X, and to request the staffing rotas for the care home saying Ms X believed there to insufficient staff on some occasions.
24. Mr Y’s family decided to remove him from the care home on 14 June 2024.
25. Following this the Council closed the safeguarding investigation on the basis, the risk had been removed. It informed Ms X in writing on 20 June 2024.
26. Ms X was dissatisfied and submitted a formal complaint to the Council on 3 July 2025, saying she believed the safeguarding investigation to be inadequate, and that she had not been fully appraised of the process, progress and outcome of the investigation.
27. The Council provided Ms X with a detailed complaint response on 3 October 2024. The author of the letter sets out the legal framework for conducting a safeguarding investigation and that this had been adhered to. She (author) said Ms X had been informed of the process and outcomes, which had been discussed with her thoroughly. She said the care home introduced measures to mitigate risk to Mr Y, but risk can never be eliminated, and the care home would have completed its own risk assessment for each resident in the care home. She concluded by saying “…incidences of residents walking into others’ room is not an uncommon occurrence as many of the residents within care homes have illnesses, diseases or brain injuries affecting the mind and brain which can cause confusion or behaviours that challenge”.

Analysis

28. The Council closed the initial safeguarding investigation based on information provided by the care home; that the risks had been mitigated; and that the families of both residents involved were satisfied with the action taken. There was no fault in this decision. Whilst this referral related to the other resident, Mr Y was involved as a third-party. Had the Council communicated its intention to close the investigation then Ms X, would have had the opportunity to challenge the decision, and provide further information. However, I cannot say with certainty what, if any action the Council may have taken had this occurred.
29. I find no fault in the way the Council conducted the subsequent safeguarding investigation. The Council acted in accordance with the law, and as such I cannot criticise the decisions taken. I am satisfied Ms X was adequately informed about the process, progress and outcome of this investigation.

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Final Decision

30. There is no fault in the way the Council conducted a safeguarding investigation into concerns raised. It acted in accordance with the law.
31. It is on this basis; the complaint will be closed.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman