Summary: Mrs X complained about the actions of the care provider commissioned by the Council to provide residential care for her late mother, Mrs Z. Mrs X complained the care provider failed to properly investigate safeguarding concerns. She also complained about the conduct of the staff members who carried out the investigation. Mrs X said the care provider’s actions contributed to her mother’s death and worsened her own distress at a time of grief. We found fault. The Council has agreed to provide an apology and a financial remedy to Mrs X and review the service improvement plan regarding the care provider.

The complaint

1. Mrs X complained about the actions of the care provider commissioned by the Council to provide residential care for her late mother, Mrs Z. Mrs X complained the care provider failed to properly investigate safeguarding concerns. She also complained about the conduct of the staff members who carried out the investigation. Mrs X said the failures by the care provider contributed to Mrs Z’s death, and that the care provider’s actions worsened her distress at a time of grief. She would like the care provider to formally apologise for its failings, make service improvements and provide a financial remedy to recognise her distress.

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The Ombudsman’s role and powers

2. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
3. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
4. 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 or care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
5. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

6. 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)

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What I have and have not investigated

7. I have exercised discretion in investigating Mrs X’s complaint dating back to December 2022. I have investigated Mrs X’s concerns about the safeguarding investigations but have not re-investigated the events already considered as part of a coroner’s inquest. This is because further investigation of these events will not add to the coroner’s findings or lead to a different outcome.

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How I considered this complaint

8. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
9. Mrs X and the Council had an opportunity to comment on a draft of this decision. I considered any comments before making a final decision.
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Care services regulation and guidance

11. 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.
12. The standards include Regulation 17 which refers to good governance. This says care providers must securely maintain accurate, complete and detailed records in respect of each service user, including a record of the care and treatment provided.
13. The standards also include Regulation 20, the duty of candour. This requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them. The regulation also defines ‘notifiable safety incidents’ and specifies how registered persons must apply the duty of candour if these incidents occur.
14. A notifiable safety incident must meet the following criteria:
1. It must have been unintended or unexpected.
2. It must have occurred during the provision of an activity regulated by the CQC.
3. In the reasonable opinion of a healthcare professional, the incident already has, or might, result in death, or severe or moderate harm to the person receiving care. This element varies slightly depending on the type of provider.
15. If any of these three criteria are not met, it is not a notifiable safety incident. However, the overarching duty of candour, (to be open and transparent), always applies.

Safeguarding

16. 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)

Background

17. Mrs X’s mother, Mrs Z had a diagnosis of dementia. In 2021, Mrs Z moved into Manor Court Care Home (the Care Home), run by Anchor (the Care Provider). Mrs Z’s care at the Care Home was arranged by the Council.

What happened

18. This chronology includes key events in this case and does not cover everything that happened.
19. In early December 2022, Mrs Z became unwell, resulting in her taking bedrest.
20. Four days later, the Care Home notified Mrs X about health concerns regarding Mrs Z. The Care Home also sought medical advice at this time and called for an ambulance. An ambulance crew attended the Care Home and took Mrs Z to hospital.
21. Three days later, Mr X, (Mrs X’s husband), contacted the Council to report safeguarding concerns regarding Mrs Z’s care at the Care Home. Mr X said he considered the Care Home had subjected Mrs Z to wilful neglect. The Council initiated its safeguarding enquiry.
22. Sadly, two days later, Mrs Z passed away in hospital. Mrs X says the cause of death at the time was attributed to acute kidney injury, sepsis and acute dehydration.

Safeguarding enquiries

23. The Council carried out its safeguarding enquiries, which included a visit to the Care Home. It also made a referral to the local police authority’s safeguarding team.
24. The Care Provider also carried out its own safeguarding enquiries, and in late December 2022, produced an investigation report. The report referred to several of Mrs X’s concerns, including a delay in seeking medical assistance for Mrs Z, a lack of food and fluids for a period of four days, no notification to Mrs X about Mrs Z’s health concerns prior to the day of hospitalisation, and the use of an incorrect lifting method to reposition Mrs Z in bed.
25. The Care Provider’s investigation report said poor food and fluid intake was part of Mrs Z’s normal pattern. It also said it contacted Mrs X as soon as it became clear Mrs Z’s health was in decline. With regards to the incorrect lifting method, the Care Provider said the Care Home had employed agency staff at the time. It said it had contacted the agency, who had informed the Care Provider that it was taking action to address this matter.
26. Mrs X responded to the safeguarding report in mid-January 2023. She said she had several concerns about the content and quality of the investigation, as well as ongoing concerns about the care and sequence of events at the Care Home prior to Mrs Z’s death.
27. Mrs X also shared her concerns with the coroner’s office.
28. In February 2023, the local police authority decided there was insufficient evidence to support proceedings against the Care Home regarding Mr X’s allegations of wilful neglect.
29. In late March 2023, Mrs X provided a further response to the Care Provider’s safeguarding report. Mrs X said she had received Mrs Z’s care records and learned that Mrs Z had suffered a fall from her bed on the same day the Care Home called for an ambulance. Mrs X said the Care Home had not provided this information to the medical professionals or to Mrs X.
30. The Care Provider produced a second safeguarding investigation report in June 2023. The report referred to the same concerns as previously considered and acknowledged the concerns raised by Mrs X with the coroner’s office. The report said there was no evidence of injury following the alleged incorrect lifting method; it said retraining had been provided to the agency staff regarding this. The Care Provider said it had reviewed the Care Home’s records and found they were not of a standard required by the Care Provider. The report acknowledged the Care Home did not contact Mrs X until the day of Mrs Z’s admission to hospital and apologised for this.
31. The Council concluded its safeguarding enquiries in mid-June 2023. It said:
• the carers involved had attended additional moving and handling training
• the Care Home did not inform Mrs X when Mrs Z initially became unwell and did not tell her about this until four days later
• the Care Home did not seek medical advice when Mrs Z initially became unwell and did not seek this until four days later
• the Care Home records referred to Mrs Z having a fall in the early hours of the morning of the day she was admitted to hospital, but the Care Home did not share this information with the medical professionals who attended, or Mrs X
• the Care Home’s records contained limited detail about the quantity of food or fluid intake for Mrs Z
• there was no evidence care staff handed over information about Mrs Z being unwell at shift changes
• the Council’s Quality Assurance and Improvement Team (QAIT) had produced a service improvement plan with the Care Home to reduce risks to others and improve future care standards
• the QAIT would closely monitor and review the service improvement plan

Mrs X’s complaint

32. Mrs X complained to the Care Provider in July 2023. Mrs X considered the safeguarding investigation reports were flawed. She also expressed concerns about the management at the Care Home and the events leading up to Mrs Z’s death.
33. The Care Provider replied in early August 2023. It said it had conducted two safeguarding enquiries and was satisfied it had fully considered Mrs X’s concerns. The Care Provider acknowledged Mrs X did not accept the findings of its investigations and said while the coroner’s investigation remained ongoing, it was not appropriate to provide a further response.
34. Mrs X brought her complaint to the Ombudsman in 2023. The Ombudsman decided not to investigate Mrs X’s complaint at that time because of the outstanding coroner’s inquest, but informed Mrs X she could return to us once the inquest was concluded.

The coroner’s findings

35. The coroner’s inquest concluded in early 2025. As part of the inquest, the coroner considered the circumstances of what happened in the Care Home and the investigation processes that followed. The coroner’s findings and conclusions stated the investigations by the Council and the Care Provider were not robust or comprehensive. However, it acknowledged the Care Provider had appointed a new manager and referred to the Care Home being back on track under the new leadership. The coroner recorded several concessions made by the Care Home, including:
• Carers should have noticed a deterioration in Mrs Z’s health, and should have escalated this
• The Care Home should have told Mrs X about Mrs Z’s deterioration and her fall
• The Care Home should have closely recorded Mrs Z’s food and fluid intake
• The Care Home had inaccurate recording of medication
• Carers had insufficient understanding of capacity and when it was necessary to get urgent medical assistance if someone was not eating or drinking
36. The coroner found that no-one noticed Mrs Z’s condition significantly deteriorated during the days after she initially felt unwell, and no-one notified Mrs X of her deterioration. They also found it was unlikely Mrs Z had drunk enough fluids to sustain her during that period.
37. The coroner stated they could not say the above omissions directly caused or contributed to Mrs Z’s death. However, the coroner said the failure to escalate her care was likely to have left Mrs Z in an increasingly weakened state which destroyed any resilience she may have had to fight the infection process, (sepsis, chest infection and acute kidney injury) that ultimately caused her death. The coroner stated a finding of coronial neglect was not appropriate.
38. Following the conclusion of the coroner’s inquest, Mrs X brought her complaint to the Ombudsman.

Analysis – Mrs X’s complaint about the safeguarding investigation

39. The investigation process formed part of the coroner’s inquest. As a result, and as previously stated, I have therefore not re-investigated the events already considered by the coroner.
40. However, I do acknowledge the coroner’s conclusions. This was that the investigations carried out by the Care Provider and the Council were not robust or comprehensive. The lack of a robust and comprehensive investigation regarding the safeguarding concerns is fault.

The Care Home’s record keeping

41. The coroner said the Care Home’s record keeping was not of a good enough standard. The coroner struggled to see a clear chronology of what happened from the records or be satisfied as to what Mrs Z ate or drank during the days after she became unwell.
42. I acknowledge the findings of the coroner. The poor record keeping by the Care Home is fault and falls below the standard we would expect with respect to Regulation 17 (see paragraph 12 above).

Openness and transparency

43. Mrs X complained the Care Home’s response to her concerns lacked openness and transparency. She also complained the Care Home did not inform her, or the medical professionals who attended the Care Home in December 2022, that Mrs Z had suffered a fall in the early hours of that same day.
44. As stated at paragraph 13 above, registered providers and registered managers have a duty to act in an open and transparent way with people receiving care or treatment from them. This duty of candour also applies if a notifiable safety incident occurs. Mrs Z’s fall may be considered to have been a notifiable safety incident; even if the Care Home considered it was not, the CQC guidelines state Care Providers have an overarching duty to be open and transparent.
45. During the coroner’s inquest, the Care Home acknowledged it should have informed Mrs X of Mrs Z’s fall. I agree with the Care Home’s statement regarding this matter. The failure to notify Mrs X of this incident is fault and falls below the standard we would expect with respect to Regulation 20.

The Care Home’s service improvement plan

46. As part of the Council's safeguarding enquiry, it devised a service improvement plan with the Care Home to reduce risks to others and improve future care standards. The Council says it monitored and version-controlled the plan as it made developments and improvements. The Council says a Care Provider’s service improvement plan is the provider’s responsibility to complete and action, with oversight from the Council’s quality assurance team.
47. I acknowledge the Council’s comments. However, as stated in paragraph two above, for Part 3 complaints, we treat the provider’s actions as if they were council actions. As a result, the Council also has a responsibility to ensure the service improvement plan is completed.
48. The evidence provided by the Council indicates it carried out several visits to the Care Home as part of the service improvement plan development. However, the Council and/or the Care Home appears to have last updated the plan in mid-2023. At that time, there were several actions identified as still being progressed, (and therefore not completed). Outstanding actions included the provision of safeguarding training, training regarding mental capacity and consent to care, and physical deterioration and escalation tool training.
49. The Council’s safeguarding investigation stated it would closely monitor and review the service improvement plan. The Council has not demonstrated it maintained oversight of the service improvement plan to its completion. The Council’s failure to do so is fault.
50. Mrs X says she considers the Care Provider’s actions contributed to Mrs Z’s death and worsened her own distress at a time of grief. I acknowledge Mrs X’s comments and consider the fault identified caused her an injustice, namely avoidable distress and upset. Mrs X states this has been prolonged and unresolved.
51. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.

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Action

52. To address the injustice identified, the Council has agreed to take the following action within one month of the final decision:
1. Provide an apology to Mrs X for the fault identified, from the Council and the Care Provider. 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 in my findings, and
2. Make a symbolic payment of £500 to Mrs X in recognition of the distress and upset.
53. The Council has also agreed to take the following additional action within three months of the final decision:
1. Carry out a review of the service improvement plan to determine whether all actions have been completed/satisfied, and to take appropriate steps to ensure any outstanding actions are completed/resolved.
54. The Council should provide us with evidence it has complied with the above actions.

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Decision

55. I have found fault causing injustice. The Council has agreed to carry out the above actions to remedy the injustice identified and I have therefore concluded my investigation.

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Investigator's decision on behalf of the Ombudsman