Summary: Ms X complains the Council did not properly investigate a safeguarding referral. She also complaints it delayed providing her with a copy of its report and communicated with her poorly. She says this caused her and her family avoidable and unnecessary distress. We find no fault with the Council’s safeguarding investigation. We find fault with the Council’s communication and delay providing Ms X with the report, which caused Ms X injustice. We are satisfied the action taken by the Council has remedied the injustice to Ms X.

The complaint

1. Ms X complains the Council:

1. Did not properly investigate an incident where a care home did not provide her family member proper medical care;
2. Delayed providing her with a copy of its safeguarding investigation; and
3. Communicated with her poorly.

2. Ms X says this caused her and her family avoidable and unnecessary distress.

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. 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)
4. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
5. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)

Back to top

What I have and have not investigated

6. Ms X complained to the Ombudsman in November 2024. She complained about matters which began several years ago. As I have said above, we cannot investigate late complaints unless there is a good reason. In this case, the Council delayed its complaints process for 12 months. For that reason, I consider there is good reason to begin my investigation from November 2022.
7. I have investigated all parts of the complaint from November 2022.

Back to top

How I considered this complaint

8. I considered the information and documents provided by Ms X and the Council. Ms X and the Council had an opportunity to comment on a draft of this decision. I considered all comments received before making this final decision.
9. I also considered the relevant statutory guidance, and Council’s policy, as set out below.

Back to top

What I found

What should have happened

Safeguarding investigation (part a of the complaint)

10. 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)

Safeguarding investigation sharing (part b of the complaint)

11. The Ombudsman’s published guidance ‘Principles of Good Administrative Practice' says that organisations should handle information properly and appropriately.

Communication (part c of the complaint)

12. The Ombudsman’s published guidance ‘Principles of Good Administrative Practice' says that organisations should inform people who use services what they can expect and what the organisation expects of them.

What happened

13. Prior to November 2022, the Council received a safeguarding referral about an incident regarding Mrs Y who lived at a care home.
14. In mid-November, the Council completed initial information gathering. It contacted Ms X, another family member and medical staff involved in Mrs Y’s care for information. It also considered records from the care home. It decided to progress the safeguarding referral and hold a strategy meeting.
15. In late-November, the Council held a safeguarding strategy meeting. The meeting was attended by Ms X, several social workers from the adult safeguarding team, clinical medical staff, the care home manager and the Council’s contracts officer. The attendees discussed the incident and decided to close the safeguarding investigation.
16. In December, the Council’s contracts officer visited the care home to assess the quality of care and processes being followed. The officer reviewed evidence during the visit. They decided the care home was following proper safeguarding, recording and reporting processes.
17. In January 2023, the written minutes of the safeguarding strategy meeting were checked. The minutes noted the attendees had decided a list of actions for the Council’s contracts officer to complete.
18. The Council sent a copy of the minutes to the attendees. It also sent a copy to the CQC. The Council did not send a copy to Ms X
19. The Council discussed Mrs Y’s care provider at its January monthly multiagency meeting. The meeting was attended by the Council’s contracts officer, an inspector from the CQC, the lead nurse for quality and safeguarding in regulated settings, the Council’s Infection Prevention and Control (IPC) practitioner and several social workers. It decided it did not need to discuss the care home at its future monthly meetings.
20. In November, the Council sent a copy of the minutes to Ms X. Ms X contacted the Council with questions about the minutes.
21. In December, the Council responded to Ms X and answered her questions. Ms X made a formal complaint.
22. The Council met with Ms X to discuss her complaint in person.
23. In April 2024, the Council met with Ms X for a second time. The meeting was attended by senior managers in the adult safeguarding team, including the officer who chaired the original strategy meeting. They discussed Ms X’s concerns and followed them up with other agencies concerned.
24. In December 2024, the Council responded to Ms X’s complaint.

Analysis

Safeguarding investigation (part a of the complaint)

25. Following the safeguarding referral, I am satisfied the Council made sufficient enquiries and held a safeguarding strategy meeting in a reasonable timeframe. Ms X tells me she was disappointed care home staff were not present at the safeguarding meeting. I consider the safeguarding meeting attendees were sufficient to address the safeguarding concerns. The Council conducted a site visit to the care home to assess and monitor the concerns raised by Ms X. It also discussed the care home at its monthly multiagency meeting. On balance, I am satisfied the Council treated Ms X’s safeguarding concerns with sufficient seriousness. I find no fault with the Council’s safeguarding investigation.
26. The Council has since taken positive steps to improve its safeguarding measures for residents in care homes. It has introduced a new team specifically to support individuals in long-term residential and nursing placements. It has also introduced a system for officers to record information about individual providers. The purpose is to collate information so the Council can identify themes and issues and take proactive action before more serious concerns develop.

Safeguarding investigation sharing (part b of the complaint)

27. There was an eleven-month delay in the Council sharing the minutes of the safeguarding meeting with Ms X. This delay was fault which caused Ms X avoidable and unnecessary uncertainty. The Council has apologised to Ms X for this delay and the injustice caused to her.

Communication (part c of the complaint)

28. Ms X tells me her experience of the safeguarding strategy meeting was particularly difficult because she did not know what to expect. The Council accepts it should have communicated with Ms X more effectively. To its credit, following Ms X’s complaint, it arranged two face to face meetings with her to discuss her complaint in more detail and provide additional information about the strategy meeting. However, I consider had the Council effectively shared information with Ms X promptly following the strategy meeting she would not have needed to make a complaint to obtain the information.
29. In response to Ms X’s complaint, the Council provided sessions to support operational teams chair safeguarding meetings. The sessions reminded staff of the importance of effective communication with family members who are representing their loved ones during safeguarding enquiries. I am satisfied this action suitably addresses the communication issues experienced by Ms X within the safeguarding strategy meeting.
30. The Council also tells the Ombudsman it now routinely provides a feedback form for individuals and family representatives to complete once it closes a safeguarding enquiry. The purpose of the form is to help ensure communication has been clear and that expectations have been appropriately managed. I am satisfied this action suitably addresses the communication issues experienced by Ms X after the safeguarding strategy meeting.
31. I consider the face-to-face meetings provided to Ms X following the strategy meeting, and the service improvement actions taken in response to her complaint, sufficiently remedy the injustice caused to Ms X.
32. Ms X and the Council agreed to delay the complaints process because of her personal circumstances. The Council accepts it was responsible for an additional five-week delay in its response. I am satisfied the Council’s apology to Ms X in its final complaint response remedies any additional injustice caused by its delay.

Back to top

Decision

33. I find fault causing injustice. The Council’s actions have remedied the injustice to Ms X.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman