Summary: Mrs X complained about the standard of care her mother (Mrs Y) received in a council commissioned residential care home. She also complained the Council delayed completing the subsequent safeguarding investigation. The Council was at fault as it took 6 months to complete the safeguarding investigation and found the Care Home failed carry out some of Mrs Y’s care in line with her care plan. The Care Home also delayed making referrals on Mrs Y’s behalf for her health. This has caused distress, frustration and uncertainty about the care Mrs Y was receiving. The Council has agreed to apologise and make a symbolic payment to acknowledge the injustice caused.

The complaint

1. Mrs X complained about the standard of care her mother (Mrs Y) received in a residential care home between October 2023 and May 2024. She also complained the Council delayed completing the subsequent safeguarding investigation. This has caused them distress, frustration and uncertainty about the care her mother was receiving.

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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(i), as amended)
5. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

6. I have spoken to Mrs X and considered information she has provided.
7. I considered information from the Council.
8. I considered the relevant law and guidance.
9. Mrs X and the Council had an opportunity to comment on this draft decision. I considered comments before making a final decision.

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What I found

10. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
11. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help and protect the adult.
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.
13. The Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively. 
14. The Care and Support Statutory Guidance says it is of critical importance that allegations are handled sensitively and in a timely way both to stop any abuse and neglect but also to ensure a fair and transparent process.
15. 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. The standards include:
• Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment (regulation 9)
• Providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times (regulation 10).
• Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe (regulation 12).

What happened

16. The information below is not a comprehensive overview of everything that happened. It is a summary of key information.
17. Mrs X’s mother Mrs Y has a neurological disorder and lacks capacity to make decisions about her own care and treatment. Mrs Y lived full time in a Council commissioned residential care home between October 2023 and May 2024.
18. During this period, Mrs X complained about the following aspects of Mrs Y’s care:
• Failure to provide Mrs Y with the care she required with personal hygiene
• Bedding not changed appropriately when wet
• Delays in making referrals in respect of Mrs Y’s health
• Lack of supervision resulting in Mrs Y ingesting another residents medication on two occasions
• Lack of supervision resulting in Mrs Y accidentally locking herself in her room
• Failure to administer Mrs Y’s medication at the correct times
• Losing Mrs Y’s clothing items when doing her laundry
• Poor communication from staff
• Staff leaving toiletries accessible to Mrs Y despite there being a risk she would ingest these
• On one occasion, a carer grabbed Mrs Y’s arm and forcibly manoeuvred her to the bathroom to change her incontinence pad
19. In March 2024, the Care Provider provided a complaint response upholding the following:
• Staff have not always followed care plans to ensure Mrs Y has received the correct support including personal hygiene and oral care
• There were delays in making the appropriate referrals for Mrs Y due to poor communication from the home
• Poor communication in respect of care delivery and updates regarding Mrs Y
• Poor laundry service including loss of clothing items
20. The Council carried out a safeguarding enquiry into the concern around Mrs Y ingesting another residents medication. Mrs X raised this in March 2024 and the Council substantiated the incident on a balance of probabilities in September 2024.
21. In May 2024, the Council carried out a separate safeguarding enquiry in relation to:
• Delays in making referrals in respect of Mrs Y’s health
• Mrs Y not receiving the care she required with personal hygiene
• The Care Provider not changing Mrs Y’s bedding when wet
• The Care Provider not administering Mrs Y’s medication at the right times.
• A member of staff forcibly manoeuvring Mrs Y.
22. In July 2024, the Council substantiated the allegations of neglect. The safeguarding investigations recommended the Care Provider take the following actions:
• Dementia training for staff
• Ensure there is a comprehensive induction for both new starters and agency staff
• Ensure staff are following care plans for all residents
• Ensure it escalates appropriate reviews for any residents it supports where there is noted difficulties with meeting their needs
• Further medication admin training for all staff who administer medication
• Ensure staff are supervising service users taking their medication
• Ensure staff seek medical attention as a priority when such incidents occur
• Inform next of kin when such incidents occur
• Encourage and support staff with whistle blowing to avoid delays in the Council and Care Provider addressing issues.
23. Mrs Y moved to another care home in May 2024. However, Mrs X remained dissatisfied with the Council’s handling of the matter and complained to us.

Council’s response to our enquiries

24. The Council has confirmed there was an incident where Mrs Y was locked in her bedroom for a short time which the Care Provider quickly rectified. It says this was an isolated incident where no harm occurred and plans are in place to reduce the risk of this happening again.
25. The Council has confirmed Mrs X left a memo in Mrs Y’s bedroom instructing staff to place toiletries back in her wardrobe after use. However, the Council says staff did not always follow this placing Mrs Y at risk of ingesting the toiletries.
26. The Council says the concerns raised have been upheld by the Care Provider and it is working with the Provider in relation to this. It says it shared the recommendations from the safeguarding enquiries with the Council's Health and Residential Settings team which works with care providers to improve quality and performance. The Care Home is subject to on-going monitoring under the Council's Quality, Performance, and Improvement Planning process (QPIP).
27. The Council has provided evidence of how it has overseen and ensured the Care Provider carried out recommended actions from the safeguarding enquiries. However, it says the Care Home is still working towards improvements.

My findings

Standard of care

28. The Council and Care Provider have accepted all the concerns raised in paragraph 18. We are satisfied with how the safeguarding investigation was carried out and as the concerns have been upheld, we are relying on the findings which was substantiated allegations of neglect. The care given to Mrs Y between October 2023-May 2024 was not in line with CQC fundamental standards and was fault. This caused distress, frustration and uncertainty about the care Mrs Y was receiving.

Delays in completing the initial safeguarding investigation

29. The Council received a safeguarding notification in March 2024 about Mrs Y ingesting another residents medication. The Council did not conclude the safeguarding investigation until September 2024 and took a total of six months to complete. The Care and Support Statutory Guidance says it is of critical importance that allegations are handled sensitively and in a timely way both to stop any abuse and neglect but also to ensure a fair and transparent process. Whilst the new safeguarding concerns raised in May 2024 may have delayed the investigation, it should not have taken 6 months for the Council to conclude the original concern. This was fault which has caused the matter to drift without meaningful progression. This caused distress, frustration and uncertainty about the care Mrs Y was receiving.

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Agreed action

30. Within one month of the final decision the Council has agreed to take the following action:
1. Apologise to Mrs X to recognise the distress, frustration and uncertainty caused to them about the standard of care Mrs Y received and the delays with the safeguarding investigation. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology I have recommended.
2. Pay Mrs Y £300 to acknowledge the distress, frustration and uncertainty caused by the standard of care she received and the delays with the safeguarding investigation.
31. Within three months of the final decision the Council should take the following action:
1. Create an action plan targeting the areas the Care Home still needs to improve in and provide evidence all actions have been carried out.
32. The Council should provide us with evidence it has complied with the above actions.

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Final decision

33. I have completed this investigation. I found fault and the Council has agreed to my recommendations to remedy the injustice caused by the fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman