Summary: Mr X complained that, after he made allegations that his father’s care was inadequate, the Council did not inform the Care Quality Commission of its safeguarding investigation findings. He also says the findings did not adequately reflect the seriousness of the care provider’s failings. We have found fault in the Council’s delay in informing Mr X of the outcome of the safeguarding investigation. The Council also failed to inform the Care Quality Commission of its findings or to check the Care Provider had done so. However, these matters did not cause Mr X or his father significant injustice. And we have found no fault in the Council’s safeguarding enquiries.

The complaint

1. Mr X complains that the safeguarding investigation into the care provided to his father, Mr Y, was inadequate. He also complains the Care Quality Commission (CQC) were not informed of the findings and wants sanctions placed on the 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 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)
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(1), as amended)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered evidence provided by Mr X and the Council as well as relevant law and guidance.
7. Mr X and the Council now have an opportunity to comment on my draft decision. I will consider any comments before making a final decision.

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What I found

Law and guidance

8. 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)
9. The CQC is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
10. Under Regulation 18(1) and 18(2)(e) of the Care Quality Commission (Registration) Regulations 2009, the registered person must notify the CQC without delay of any abuse or allegation of abuse in relation to a service user.
11. The Care Act 2014 places a duty on local authorities to cooperate with relevant partners in exercising their functions relating to adults with care and support needs (sections 6 and 7).
12. The Care and Support Statutory Guidance emphasises the importance of information-sharing and cooperation between safeguarding partners. It says organisations should share information relevant to safeguarding concerns and that local authorities should work collaboratively with partner agencies to protect adults at risk.
13. The Joint Working Protocol between the CQC and the Association of Directors of Adult Social Services (ADASS) states that CQC and local authorities should involve each other as soon as possible where safeguarding information relating to regulated services comes to light and should share relevant safeguarding information.
14. The Council’s ‘Safeguarding Adults in Halton: Procedures’ say there are a number of key partners and individuals that should always be notified of concerns and involved as appropriate. Where a safeguarding concern relates to a quality and safety issue concerning a service registered under the Health and Social Care Act 2008, the CQC should be informed.

What happened

15. Mr Y was a resident of a care home and in July 2024 became unwell. He was taken to hospital and treated for urosepsis. His son, Mr X, asked the Council for a safeguarding investigation to be carried out as he was told by hospital staff that this was due to poor hygiene.
16. The Council carried out a safeguarding investigation and concluded it at the beginning of August 2024. It substantiated Mr X’s concern about neglect and identified acts of omission relating to the frequency of continence care. Its findings were that daily notes showed gaps in continence care.
17. The Council considered a concern about a delay in medical treatment but did not substantiate it. Records show that care home staff contacted NHS 111 for advice and also discussed Mr Y's condition with the out-of-hours GP, who decided that Mr Y should be reviewed the following day.
18. The care home took action to address the concerns relating to gaps in continence care provision, including reinforcing the importance of accurate record-keeping, carrying out regular checks of documentation, and providing support to staff.
19. In December 2024, the Council’s quality assurance team completed a full quality assessment of the care home. This looked at all aspects of resident care and support at the home and included a review of care plans, risk assessments, record keeping, staff training records as well as consultation with residents and their relatives, which raised no concerns.
20. The Council wrote to Mr X in December 2024 informing him of the outcome of the safeguarding investigation.
21. The Council did not inform the CQC that they had carried out a safeguarding investigation or its findings and were unable to provide a rationale for not considering this.

My findings

22. The Council carried out its safeguarding enquiries in line with section 42 of the Care Act. The Council considered the concerns raised, reviewed the relevant records and reached findings on each allegation. There was no fault in the way the Council conducted its enquiries or reached its conclusions. Therefore, I have no basis to question the outcome.
23. The Council also considered whether wider quality concerns existed at the care home. Its quality assurance arrangements included routine monitoring visits, quality assessments and Keeping in Touch meetings. The Council advised there were no concerns requiring escalation through its risk management processes. Given the findings of the December 2024 quality assessment, there is no evidence the Council failed to take appropriate action in response to the substantiated safeguarding concerns.
24. The Council delayed informing Mr X of the outcome until December 2024, despite concluding its enquiries in August 2024. This was fault. However, the delay did not affect the safeguarding outcome, prevent Mr X from raising concerns, or cause significant personal injustice. Therefore, no remedy is justified.
25. Although responsibility for notifying the CQC rested with the care provider, safeguarding partners are expected to cooperate and share relevant safeguarding information under the Care Act 2014 and associated guidance. In these circumstances, the Council should have satisfied itself that the provider had notified the regulator following the substantiated safeguarding concerns. It did not do so and was unable to explain why this was not considered. This was fault. However, this did not cause Mr X a significant personal injustice and therefore it would not be proportionate to recommend any further action.

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Decision

26. I have found fault in the Council's delay in informing Mr X of the safeguarding outcome. However, this did not cause significant injustice and I have not recommended a remedy. The Council was at also at fault for failing to share the outcome of the safeguarding investigation with the CQC and for not checking the care provider had done so. I find no fault in the Council's safeguarding enquiries.

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Investigator's decision on behalf of the Ombudsman