Summary: Mrs B says the care home commissioned by the Council neglected and abused her mother and, in investigating those concerns, the Council failed to properly consider the evidence. The Council failed to consider all parts of the referral but there is no fault affecting its decision that there was insufficient evidence of neglect in this case. A reminder to officers is satisfactory remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs B, complained:
• the care home commissioned by the Council neglected and abused her mother with the result that she returned home following respite with several injuries; and
• in investigating those concerns, the Council failed to properly consider the evidence.
2. Mrs B says her mother suffered injuries as a result of neglect and she has been caused distress.

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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. 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 an injustice, we may suggest a remedy. The Ombudsman cannot question whether a Council’s decision is right or wrong simply because the complainant disagrees with it. He must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, sections 26(1) and 26A(1), as amended and 34(3))
4. If we are satisfied with a council’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. As part of the investigation, I have:
• considered the complaint and Mrs B's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
6. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What should have happened

7. Section 42 of the Care Act 2014 applies where a local authority has reasonable cause to suspect that an adult in its area:
• (a)has needs for care and support (whether or not the authority is meeting any of those needs),
• (b)is experiencing, or is at risk of, abuse or neglect, and
• (c)as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it.
8. The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult’s case and, if so, what and by whom.

What happened

9. Mrs B’s elderly mother had dementia and had been in hospital until September 2020. Mrs B’s mother normally resided with Mrs B but went into Tunbridge Wells Care Centre (the care home) from hospital for a period of respite. Mrs B’s mother was discharged from the care home in December 2020. Following her discharge Mrs B took her mother to hospital as she was concerned about various injuries including a pressure sore, red marks and bruising.
10. The police began an investigation. The Council began a safeguarding investigation in December 2020 following a referral from the police. That concluded in March 2021 when the Council decided the case should be closed as there was insufficient evidence to conclude the care home had neglected Mrs B’s mother. Some issues were identified and accepted by the care home around recording of body maps and reporting falls to family members and the care home has taken action to address those failures.
11. In May 2021 Mrs B’s mother sadly died.

Analysis

12. Mrs B says a care home commissioned by the Council to provide respite care to her mother neglected and abused her with the result that she left the care home with multiple injuries. Mrs B says the Council, in investigating those concerns, failed to consider the evidence she provided.
13. I have considered the documentation completed by the care home as well as the Council’s safeguarding investigation documentation. The evidence I have seen satisfies me the Council decided there was insufficient evidence to conclude the care home had neglected Mrs B’s mother. I am satisfied in reaching that view the Council obtained the documentary records from the care home, spoke to Mrs B and considered the evidence Mrs B provided, discussed the case with the Council’s commissioning department which is responsible for identifying suitable care placements, discussed the case with the police and discussed the case with CQC. It is clear the Council’s view was influenced by the fact the care home had not completed a body map when Mrs B’s mother entered the home, which meant it could not establish how Mrs B’s mother had sustained the injuries reported as well as the fact that neither commissioning nor CQC had concerns about the care home. The Council also took into account the evidence provided by the GP for the care home who suggested some of the injuries could have occurred as a result of scratching and movement. As I have found no evidence of fault in how the Council reached its decision in relation to the injuries Mrs B’s mother sustained there are no grounds on which I could criticise it.
14. I recognise Mrs B remains unhappy with the Council’s conclusions. However, as I said in paragraph 3, it is not the Ombudsman’s role to comment on the merits of a decision reached without fault. In this case I am satisfied the Council took into account all the relevant evidence when considering the evidence of injuries Mrs B’s mother had sustained, including the photographs provided by Mrs B. The issue is not whether Mrs B’s mother sustained injuries. That is clear from the photographs provided by Mrs B and that evidence is not disputed by the Council or care home. The issue is how those injuries were sustained and whether there is sufficient evidence to show the injuries were as a result of neglect by the care home. The Council has decided there is insufficient evidence and that is not a decision the Ombudsman could criticise given there is no evidence of fault in how that decision was reached.
15. In reaching that view I am aware Mrs B refers to hospital discharge papers which she says refer to neglect by the care home. I have not seen a copy of any hospital discharge papers referring to neglect. In any event, it is the Council’s role when carrying out a safeguarding investigation to establish whether there is evidence of neglect. In this case the Council has determined there is insufficient evidence of neglect.
16. I also recognise though the police referral raised additional concerns about Mrs B’s mother’s health declining. Mrs B had referred to her mother being able to walk when she entered the care home but being bedbound by the time she left. The police referral also mentioned Mrs B’s mother returning home in clothes that did not belong to her. Mrs B suggests those matters also indicate neglect. As those were matters referred to in the police referral I would have expected the Council to refer to its view on those matters when concluding the safeguarding investigation. Instead, the Council concentrated solely on the issue of the injuries sustained and whether there was evidence of neglect which caused those injuries. I recognise the injuries were the most significant factor for the Council. Nevertheless, it should have also referred to the other matters raised and recorded its view as to whether those matters indicated neglect. Failure to do that is fault.
17. Having considered the documentary records submitted by the care home though I note they show detailed daily records of the support and care provided to Mrs B’s mother. There is also evidence of Mrs B’s mother being seen by the doctor and nurse, with no concerns raised, other than in relation to skin integrity where a plan was put into place. There are also documentary records referring to Mrs B’s mother’s decline in mobility. I do not consider it likely given those records and Mrs B’s mother’s age that, on the balance of probability, the Council would have reached a different conclusion on neglect had it covered those two additional issues in its safeguarding conclusions. In those circumstances I make no recommendation for a personal remedy for Mrs B. I recommended though the Council ensure its safeguarding officers are aware of the need to consider all aspects of a referral when reaching a conclusion on a safeguarding investigation. The Council has agreed to my recommendation.
18. I appreciate Mrs B continues to believe the care home neglected her mother. That is not something I can comment on as it is not the Ombudsman’s role to determine how Mrs B’s mother sustained the injuries she had when she left the care home or whether she was neglected. Instead, the Ombudsman’s role is to consider the administrative process followed. I have considered the documentary records kept by the care home which confirms the evidence the Council took into account. In those circumstances I have no grounds to criticise the Council. The Council has, however, identified issues with the way the care home kept its documentary records. The care home has accepted it failed to complete body mapping appropriately and has committed to ensuring all residents have a body map completed at the beginning and end of their stay. I appreciate that is likely to offer little comfort to Mrs B. However, it should ensure in future that when injuries are sustained and an allegation of neglect is made the Council will have more information to enable it to reach a firm conclusion.

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Agreed action

19. Within one month of my decision the Council should send a reminder to officers dealing with safeguarding investigations to ensure that when reaching a conclusion on a referral the decision covers all aspects of the original referral.

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Final decision

20. I have completed my investigation and found fault by the Council in part of the complaint which did not affect its decision-making.

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Investigator's decision on behalf of the Ombudsman