Summary: Mr Y, on behalf of his brother, complained the Council delayed completing two safeguarding investigations. Both investigations took longer than the normal timescales. One took over 15 months to complete and the other was delayed by two months. This is fault and a suitable remedy is agreed.

The complaint

1. Mr Y, on behalf of his brother Mr X, complains the Council delayed completing two safeguarding investigations.
2. Mr Y says this has caused distress to himself and his brother and resulted in poor care for his brother.

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The Ombudsman’s role and powers

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 investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. 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)
5. 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)

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How I considered this complaint

6. As part of the investigation, I have:
• considered the complaint and the documents provided by the complainant’s representative;
• made enquiries of the Council and considered the comments and documents the Council provided;
• discussed the issues with the complainant’s representative;
• sent my draft decision to both the Council and the complainant’s representative and taken account of their comments in reaching my final decision.

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What I found

Safeguarding

7. 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)

Council procedures

8. The Council has a safeguarding adults policy and also operates under the London multi-agency procedures. The policy highlights the principles of ‘making safeguarding personal’ and ensuring actions are both ‘person-centred and outcome focused’.

Mental capacity assessments

9. The Council’s policy says it should assume a person has capacity to make their own decisions before it treats them as being unable to do so. It also says where an adult at risk appears to lack capacity or there is information from others that there is a question about this, then it should complete a mental capacity assessment (MCA). The policy highlights the test of capacity in this case is decision and time specific.

Safeguarding adults- timescale

10. The policy highlights specific response times following receipt of a referral, and these say the Council has:
• 5 working days to hold an enquiry discussion and feed back to the referrer.
• 25 working days to complete enquiry.

Key facts

11. This section sets out the key events in this case and is not intended to be a detailed chronology.
12. Mr X is a care home resident. He has several health conditions including dementia and Parkinson’s. Mr Y, Mr X’s brother, holds the lasting power of attorney for his brother in respect of health and welfare. Mr X is a strong advocate for his brother and has concerns about the standard of care provided to Mr Y.
13. This complaint concerns two safeguarding complaints made to the Council about Mr X’s care. I will deal with each one in turn.

First safeguarding concern

14. In March 2023, Mr Y raised issues with the Council about the care provided to Mr Y. This included showering, changing incontinence pads, getting Mr Y out of bed and lack of care causing pimples on Mr Y’s head.
15. A safeguarding planning meeting was held at the care home on 14 June 2023. Both Mr X and Mr Y attended. Each issue raised by Mr Y was discussed. It was decided the matters should be investigated and an enquiry report produced. It was also confirmed that everyone would then be invited to an Outcomes meeting. The planning meeting also said that clinical advice should be obtained as well as records from the care home.
16. Throughout July and August the Council gathered information to use in the enquiry report. In September a visit was made to Mr Y and a mental capacity assessment (MCA) completed. The Council wanted to ensure Mr X was happy with Mr Y being his advocate. The MCA found Mr X had capacity to choose his own advocate and that he wanted this to be Mr Y.
17. The investigating officer began writing the enquiry report in September 2023 and submitted it at the end of January the day before leaving their position with the council. The Council took the view the enquiry report was not adequate and it therefore could not make a decision on the case. The Council completed a review of Mr X’s package of care in April 2024 and then re-allocated the safeguarding concern to a new investigating officer.
18. In May a discussion took place about the progression of the enquiry report and it was agreed the draft report should be completed by 10 June and the outcomes meeting would be organised for the week beginning 24 June. The safeguarding outcomes meeting actually took place on 4 July 2024. Although not all invitees could attend, the Council decided to go ahead with the meeting and avoid further delay.
19. The minutes of the outcome meeting indicate Mr Y attended and was able to make his views known. Each of the following concerns were discussed:
• Pimples on Mr X’s head were as a result of neglect
• Call bell disconnected or not accessible and also Mr X’s mobile phone
• Mr X not being changed overnight and pads changed without washing Mr X
• Keeping Mr X for over 12 or 18 hours in bed against his wishes and not transferring him regularly
• Not showering Mr X regularly enough and so neglecting his personal care
• Staff refusing to get Mr X out of bed for meals to save time
• Mr X having to ask staff to clean his teeth
• Deterioration of Mr X’s health following his admission
20. The minutes show the Investigating Officer presented her findings under each heading along with the evidence she considered to reach each view. Mr Y was given an opportunity to comment on each point. The minutes show that he disputed the evidence on each point and felt the Council was siding with the care provider.
21. Although all eight issues were unsubstantiated and it was decided more likely than not that neglect did not occur, the outcomes meeting made several recommendations as follows:
• More detailed notes to be kept of specific incontinence care delivered
• Ensuring Mr X is always given a choice about whether to stay in bed or a chair and his wishes clearly recorded
• A call bell with increased sensitivity to pressure to be considered
• The care home to continue to monitor Mr X’s head and ensure it was washed on days when he did not have a shower as well as reconsidering who would cut Mr X’s hair
• Ensure all staff engage in refresher training in moving hand handling transfers
22. It was also noted there had been significant delays in concluding this safeguarding enquiry.

Second safeguarding concern

23. In early January 2024 an anonymous whistleblower contacted the Care Quality Commission raising concerns about the administration of medication at the care home. The safeguarding concern mentioned Mr X by name and said that his medication was not administered at the correct times.
24. An enquiry meeting was held online and neither Mr X nor Mr Y were included. It was decided that two MCA’s should be completed. One to assess whether Mr X had capacity to give consent for the safeguarding enquiry and the other to establish his capacity regarding medication awareness. The Council contacted Mr Y about this matter and Mr Y said that he assumed the care provider was properly administering Mr X’s medication.
25. The Council visited Mr X to complete the MCA’s on 20 February. It found that Mr X lacked capacity to consent to the safeguarding investigation and also lacked capacity regarding his awareness of medication. The Council decided it was in both Mr X’s best interest and in the public interest to proceed with the safeguarding investigation.
26. It was acknowledged at the outset that concluding the safeguarding enquiry report would take longer than usual because of the volume of information to be collated. The Enquiry Officer began the case on 5 March and completed it by 20 May. On 28 May the Council contacted Mr Y to arrange an outcomes meeting. This was held on 10 June at the care home.
27. Mr Y attended the outcomes meeting. The minutes of the meeting show that the whistleblower had reported that staff at the care home would regularly sign for Mr X’s medicines but not administer them. It was also reported that Mr X’s Parkinson’s medications were not given at the correct times. Mr Y told the meeting he was unable to comment on whether there were issues with the medication. He said Mr X had not raised anything with him other than when cream for his head was not applied.
28. The minutes provide details of the what the Enquiry Officer found including incomplete notes; irrelevant information in Mr X’s care plan; lack of information about the importance of administering the Parkinson’s medication at set times; dates medications were not administered and the reasons for this; discrepancies with the administration of the Parkinson’s medication including when given too early or too late.
29. The outcomes meeting discussed the information and the evidence that medication was not being given on time or as prescribed. It discussed the processes now in place to ensure this does not continue. It concluded, on the balance of probability, it was more likely than not that there was neglect and acts of omission in regard to the administration of Mr X’s medication. A protection plan for Mr X and in the public interest was agreed. The meeting also said a safeguarding review should be arranged in two months.
30. The safeguarding review took place on 8 August 2024. The Council says this was a light touch review as agreed at the Outcomes Meeting in June. The purpose of the review was to check if there had been an improvement in the administration of medication to Mr X. It was particularly focused on the time specific medication. At the review the Council’s Safeguarding Adults Manager and the Enquiry Officer considered the medication administration records for June and July 2024.
31. The records showed there had been some improvement but there were still times the medication was administered outside of the recommended times. The officers decided the protection plan was still relevant in order to protect Mr X and other vulnerable residents living in the care home. The protection plan was retained with one addition to alert all health professionals and request they monitor the administration of medication at the care home particularly for residents with time specific medication. It was also requested the care home pharmacist follow up and review all residents with time specific medication. The Council was satisfied the protection plan was robust and so it closed the safeguarding episode.

Analysis

32. There have been two safeguarding investigations in respect of the care provided to Mr X. The information provided shows the correct steps have been followed in each case including a planning meeting, mental capacity assessments, seeking relevant evidence and information, holding an outcomes meeting and producing protection plans. Mr Y, as the advocate for his brother, has been notified of and included in both processes. A clear decision has been reached on each investigation and shared with the relevant bodies and people.
33. Mr Y complained to the Ombudsman because of the delay to complete these investigations. The first investigation began in March 2023 but was not concluded until July 2024, some 15 months later. The second investigation began in February 2024 and concluded in June 2024, taking four months.
34. There are no statutory timescales for completing safeguarding investigations but the London Multi-Agency Adult Safeguarding policy and procedures does include some as described at paragraph 11 above.
35. In respect of the first safeguarding investigation the Council missed these timescales. It did not hold the planning meeting until three months after Mr Y first contacted the Council and it took 11 months to complete the enquiry report. It is noted the first enquiry report was completed after seven months but this was considered to be inadequate and so further work was required.
36. The time taken to conclude this safeguarding investigation was too long. While there was considerable evidence to collate the Council allowed the process to drift and did not ensure a timely outcome. This is fault. Mr Y was concerned about the care provided to his brother and so the failure to complete the investigation in a timely manner caused avoidable distress.
37. The allegations made by Mr Y were not substantiated. I am aware that Mr Y disagrees strongly with the outcomes. However, it is not the Ombudsman’s role to replace decisions properly made with her own. As explained above, I am satisfied proper consideration was given to the issues and that Mr Y was involved in the safeguarding procedure. Mr Y takes a different view to the Council about the standard of care provided to his brother, but a difference of opinion is not evidence of fault. While I have found fault in respect of the time taken, I am unable to comment on the merits of the decisions reached as I consider the same outcome would have been resulted even if there had been no delay in this case.
38. In respect of the second safeguarding investigation, the Council promptly considered it and the planning meeting took place the same day. It was noted at the outset it was unlikely the enquiry report would be completed within normal timescales. In fact it took about two months longer than the published timescales. The planning meeting included actions and a protection plan for Mr X and other residents.
39. There was delay in completing the second safeguarding investigation which is fault. While it was recognised from the outset that the investigation may take longer than normal, the investigation was concerned with the administration of medication and the issues were substantiated. It was found the care home was not administering Mr X’s medication as prescribed and that this could be impacting on his symptoms. I therefore consider this caused a significant injustice to Mr X and caused distress and uncertainty to Mr Y.
40. The Council appropriately carried out a review of the protection plan in August 2024. After considering new information about the administration of medication to Mr X and other care home residents, the Council amended the protection plan and closed the safeguarding episode. Mr Y has queried this action saying the review found that Mr X’s medication was not always been administered within the prescribed timescale. He was unhappy the Council had closed the case.

I find no fault in the decision to close the safeguarding episode. The protection plan remains in place and the Care Quality Commission (CQC) and three separate health colleagues have agreed to monitor the administration of Mr X’s medication and the situation more generally at the care home.

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Agreed action

41. To remedy the injustice caused to Mr X and Mr Y as a result of the fault identified in this case the Council will, within one month of my final decision, take the following action:
• Apologise to Mr X and Mr Y;
• Make a symbolic payment of £200 to Mr X to recognise the distress and uncertainty caused;
• Make a symbolic payment of £200 to Mr Y to recognise his distress and uncertainty and his time and trouble in pursuing this complaint; and
• Share this decision with staff involved in safeguarding investigations to ensure lessons are learnt and similar delays do not occur in the future.
42. The Council should provide us with evidence it has complied with the above actions.

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Final decision

43. I have completed my investigation with a finding of fault for the reasons explained in this statement. The Council has agreed to implement the actions I have recommended. These appropriately remedy any injustice caused by fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman