Summary: There was no fault in how the Council investigated Ms X’s safeguarding concerns related to her mother’s care in a nursing home. The Council’s delayed complaint response was fault. The Council will apologise and make a symbolic payment to Ms X to recognise the avoidable frustration she was caused.

The complaint

1. Ms X complained on behalf of her mother Mrs Y. Ms X complained about the Council’s safeguarding investigation of her concerns related to Mrs Y’s care in a nursing home. She complained the Council’s investigation was flawed and biased and that it took too long to respond to her complaint.
2. Ms X also complained about the quality-of-care Mrs Y received in the nursing home and that the care home ended Mrs Y’s contract without notice.
3. Ms X said as a result they were caused worry, frustration and distress.

Back to top

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 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)
5. 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)
6. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
7. 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(1), as amended)

Back to top

What I have and have not investigated

8. I have investigated Ms X’s complaint about the Council’s safeguarding investigation. I have not investigated Ms X’s complaint at 1 b) above about the quality-of-care Mrs Y received in the care home and the subsequent termination of her contract because her care was arranged and funded by another council.

Back to top

How I considered this complaint

9. I spoke to Ms X and considered evidence provided by her and the Council as well as relevant law, policy and guidance.
10. Ms X and the Council had an opportunity to comment on the draft decision. I considered any comments before making a final decision.

Back to top

What I found

Relevant law and guidance

11. A council must make whatever enquiries it thinks necessary if it suspects a person may be at risk of abuse or neglect and has care and support needs which means the person cannot protect themselves.
12. 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 any action should be taken to protect the person from abuse and if so, what and by whom. (section 42 of the Care Act 2014)

The Council’s complaints policy

13. The Council operates a two stage complaints process:

• Stage one: The Council will acknowledge the complaint within five working days and issue a response within 10 working days of complaint acknowledgement. The policy states that if the Council needs more time to investigate complex issues, it will explain why to the complainant and any extension will be no more than 10 working days without good reason.
• Stage two: The Council will acknowledge the complaint escalation request within five working days and issue a response within 20 working days of acknowledgement.

What happened

14. This section sets out the key events in this case and is not intended to be a detailed chronology.
15. Ms X’s mother Mrs Y has dementia and other health conditions. Mrs Y was discharged from hospital into a care home in late September 2024.
16. In mid-October 2024 Ms X raised safeguarding concerns related to Mrs Y’s care in the care home.
17. Ms X raised concerns the care home neglected Mrs Y’s care and support needs including her personal care and hygiene, continence, food and hydration needs. She also said it did not provide Mrs Y one-to-one, personalised care which she needed for her medical conditions. Further, the crash mat needed to alert the staff of any falls was left unplugged on some occasions. Ms X also said the care home did not speak to previously involved health care professionals to understand Mrs Y’s needs, was reluctant to seek medical support for her when Ms X noticed Mrs Y had very swollen legs and it refused to monitor her blood pressure three times a day.
18. The Council case notes showed that its safeguarding officer called Ms X to discuss the information on the safeguarding referral. The officer also arranged a visit to Mrs Y’s care home. Records of the visit showed the officer discussed and sought clarification on the concerns raised by Ms X with the care home staff. Ms X was unhappy the officer had not met with Mrs Y who was out on a trip during their visit.
19. The officer contacted Ms X to share feedback from their visit to the nursing home and it was noted that the officer told Ms X they would liaise with Mrs Y’s independent advocate and other professionals including her allocated social worker.
20. Records of the officer’s conversation with Mrs Y’s social worker noted that they said Mrs Y “appeared happy and settled and it was felt the home was meeting her needs” and that Mrs Y did not require constant one-to-one support. The social worker said that Mrs Y looked happy, clean and was dressed in clean clothes. They recommended that a key worker was allocated to build a relationship with Mrs Y as a familiar face would encourage her to accept personal care and that an additional sensor mat was placed next to Mrs Y’s bed.
21. Records of the officer’s conversation with the nurse assessing Mrs Y stated that she did not require one-to-one supervision.
22. Records of the officer’s conversation with Mrs Y’s advocate showed that Mrs Y raised no concerns with them during their visits with her. The advocate stated that Mrs Y’s care was “well managed but unpredictable” and agreed that constant one-to-one supervision was not needed but they were “worried that due to the long corridors (of the nursing home) there was not the level of oversight required.” The notes stated that Ms X was looking for alternative placements where the layout of the home was more appropriate to aid supervision. It also stated that the advocate said they got a “feeling that staff do not always know where Mrs Y is, the recording is poor but there are no significant concerns regarding abuse or neglect.” The advocate advised that it would be beneficial for the officer to revisit the home and meet Mrs Y and the officer agreed.
23. Records of the officer’s conversation with Mrs Y’s GP surgery showed that there were no concerns noted by anyone who visited Mrs Y from the surgery. They said that Mrs Y’s blood pressure was normal when last checked in her annual review and that no specific clinical advice about how often it should be checked was given by the GP. It said the nursing home team matron assessed and prescribed compression hosiery and asked to elevate Mrs Y’s legs to reduce the swelling and no concerns were noted.
24. Records of the officer’s conversation with the community matron previously involved in Mrs Y’s care showed that they stated Mrs Y needed “help to meet her hygiene needs, blood pressure done daily and not one-to-one but more stringent checks”. The matron added that the hospital where Mrs Y was previously admitted should have contacted her and if not them, the care home should have to understand how to support Mrs Y.
25. In late October 2024 Mrs Y was admitted to hospital. The Council noted that the care records stated “whilst attending to Mrs Y to instil eye drops, her eyes rolled and she became unconscious.” Mrs X went to an alternative placement on her discharge in November 2024.
26. In December 2024 the Council concluded its investigation and closed the safeguarding process.
27. The Council’s records of its investigation outlined its rationale. The Council stated that:

• Mrs Y did not have a care plan as her placement in the care home was for a period of assessment to compile a long-term care plan.
• the care home confirmed Mrs Y had oedemas to her legs. The care home matron offered advice to relieve this which worked to reduce the swelling. It said while Ms X wanted a GP to assess Mrs Y, the matron had no concerns. The Council was satisfied the care home had managed this appropriately. It decided this concern was not substantiated.
• all professionals including the GP, Mrs Y’s social worker and other professionals agreed that Mrs Y did not need one-to-one observation at all times for her medical condition. The Council said there were “evidential flaws” in the care home’s records which meant there was no clarity on the level of oversight the care home provided to Mrs Y. The Council concluded that the care home did not neglect to provide one-to-one care as this was neither recommended nor commissioned. It decided this concern was not substantiated.
• the care home’s notes recorded some evidence of Mrs Y’s personal care being taken care of and that she also refused this when offered, and Mrs Y’s social worker said that Mrs Y appeared clean and was in clean clothes when they visited her. The Council said that the care home’s records were not “thorough enough” to show the intervention the care home provided when Mrs Y refused personal care. It found this concern ‘inconclusive’.
• the care home was not required to speak to professionals previously involved in Mrs Y’s care in the community but noted that doing so would have provided the care home with a better insight into Mrs Y’s history and level of care. The Council said the lack of this contact did not result in harm to Mrs Y. It decided this concern was not substantiated.
• the care home staff ensured they were close by when Mrs Y used the toilet. They did not have “eyes on her” to maintain her dignity. Further it had not received clinical advice that this was needed at the handover from the hospital. The Council said as the care home did not receive any directions regarding Mrs Y’s toileting needs, they had not neglected or omitted to this care. The Council added that the care records did not provide a clear picture of the level of oversight Mrs Y received regarding her toileting needs and that implementing the views of previously involved professionals would have highlighted a need for more oversight. It found this concern ‘inconclusive’.
• there was no GP advice to take blood pressure recordings three times a day although the previously involved professional said Mrs Y’s blood pressure should be checked daily. The Council said as the care home had not received any clinical direction to carry out frequent checks, it had not neglected or omitted to this care however implementing the views of previously involved professionals would have clarified appropriate care. It decided this concern was not substantiated.
• the care home was aware Mrs Y threw away fluids. It only recorded fluids it had seen Mrs Y consume and there was no evidence to suggest its recording was inaccurate. The Council said there were no dehydration concerns noted.
• there was no evidence of the crash mat being left unplugged and no harm came to Mrs Y from this. It decided this concern was not substantiated.
• Mrs Y was out on a trip when the officer visited and before it could arrange a further visit to speak to Mrs Y, she was admitted to hospital and did not return to the care home again.

28. The overall outcome of the Council’s investigation, on the balance of probabilities, was inconclusive as there was not enough evidence to conclude all the concerns were not substantiated.
29. The Council’s recommendations to the care home included:

• For the care home to consider a key worker system,
• Further staff training to ensure accurate and appropriate documentation of intervention and care,
• For the care home to seek additional information regarding new residents from previous care provider and other relevant professionals,
• For the care home to review staff recording regarding interventions.

30. The Council said it discussed the outcomes and recommendations with the care home and other professionals.
31. In early January 2025 Ms X complained to the Council. She also complained to us that the Council’s safeguarding investigation was flawed and biased. She said the investigating officer did not meet with Mrs Y or her in person as part of the investigation.
32. In mid March 2025 the Council told Ms X that it needed further time to investigate her complaint and that it would contact her again in four weeks.
33. In mid April 2025 the Council wrote to Ms X to say that it needed more time (20 working days) to respond to her complaint as the service was making some additional enquiries. It apologised for the delay.
34. In mid May 2025 the Council issued its complaint response. In it the Council:

• Explained that it required a high level of evidence to substantiate concerns.
• Explained that it visited the care home, who the concerns were about, to make enquiries and it was not always appropriate or necessary for it to speak to families/alerters face to face. It said it had spoken to Ms X to understand her concerns which were considered within its enquiry.
• It would have been beneficial for its officer to check Mrs Y’s room for cleanliness but cleanliness concerns alone would not have met the criteria for safeguarding enquiries.
• Following its decision letter, it had explained its outcome to Ms X on a call and shared the justification for its decision when this was requested.

Findings

Safeguarding investigation

35. It is not our role to decide the outcome of a safeguarding investigation; that is the Council’s role. Our role is to look at the process by which the Council made its decision. If there was no evidence of fault in the Council’s decision-making process then we cannot question the decision itself.
36. The law says it is up to the Council to decide what enquiries are needed, and how these are made, when it has reason to believe a person is at risk of harm.
37. The Council properly investigated Ms X’s concerns – it spoke to various professionals involved in Mrs Y’s care and support to gather their views. It identified areas of improvement and learning for the care home and made recommendations to that effect.
38. The Council also noted that it was unable to make conclusive findings on some concerns due to the care home’s lack of detailed records and poor records in itself was not an indication that Mrs Y’s care was neglected. It explained its decision to Ms X. Records also showed that the Council spoke to Ms X about her concerns during the safeguarding investigation – there was no legal requirement for it to meet with Ms X in person. While the Council was unable to speak to Mrs Y when it visited the care home, it noted that Mrs Y had not reported any concerns to her advocate. It said it would have arranged a further visit to speak to Mrs Y but she was admitted to hospital before it could do so. The Council completed its safeguarding investigation of Ms X’s concerns without fault.

Complaint handling

39. The Council responded to Ms X’s complaint of January 2025 in May 2025 which was not in line with the timescales set out in its complaints policy and was fault. While the Council explained the reasons for its delayed complaint response, its delay in responding was still fault that caused Ms X avoidable frustration.

Back to top

Action

40. Within one month of this decision the Council will apologise and pay Ms X £150 for the avoidable frustration she was caused by its delayed complaint response. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council will consider this guidance in making the apology.
41. The Council will provide us with evidence it has complied with the above action.

Back to top

Decision

42. I found fault causing an injustice and the Council agreed actions to remedy that injustice.

Back to top

Investigator's decision on behalf of the Ombudsman