Date of decision: 18 Feb 2025
Summary
This report concerns the inadequate care provided to a vulnerable adult with severe learning disabilities in a council-commissioned care home, and the Council’s delay in completing a safeguarding investigation. The failures led to distress, frustration, and uncertainty for the family.
What happened
Between August 2023 and May 2024, an adult with severe learning disabilities lived full-time in a council-commissioned care home, receiving 1:1 daytime support. In August 2023, after experiencing a seizure, safeguarding concerns were raised about the care home’s practices, including inappropriate staff comments and lack of incident recording (which the Care Provider self-reported).
The Council began a safeguarding investigation in September 2023. Over the following months, further concerns were reported: unclean facilities, medication issues, poor diet, staff shortages, inadequate health information sharing, poor record keeping, and problems with access to water from a tap in the man’s room, due to an isolator on it the key to which was lost. He had begun to evidence new self-harming behaviours during the run up to the investigation.
The individual’s mother, acting as his personal welfare deputy, actively raised these issues and participated in monthly meetings with the Council and professionals. The safeguarding investigations concluded in May and June 2024, after the individual moved to a new care home.
She complained about the standard of care received, during the investigation because another unwitnessed seizure occurred in November 2023 – and about the safeguarding investigation itself after it had closed – regarding concerns at
- Delays in completing the safeguarding investigation opened in September 2023;
- Failure to involve Ms X in the investigation as Mr Y’s personal welfare deputy;
- Failure to prevent incidents re-occurring.
The Council partially upheld the complaint as it recognised the quality of care provided to her son to safeguard him in his placement remained a concern.
It said that the Care Home had trained the staffing team more, around reporting and recording of any incidents, including medical events and safeguarding concerns. Further announced and unannounced visits over a six-month period had taken place and the latest visit showed a big improvement with recording.
The Council also visited the Home to do periodic checks to see the menu and food records. It said the Care Provider has made improvements in the diet of people living at the Home. It also created an action plan to monitor the concerns raised, but had not reviewed it.
What was found
The Ombudsman found fault with both the care home and the Council. The care home failed to provide a healthy diet, maintain adequate records, and allowed inappropriate staff conduct, all of which breached Care Quality Commission (CQC) 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).
- Providers must meet people’s nutrition or hydration needs wherever an overnight stay is provided as part of the regulated activity or where nutrition or hydration are provided as part of the arrangements made for the person using the service (regulation 14).
- Providers must securely maintain accurate, complete and detailed records in respect of each person using the service (regulation 17).
- Providers must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people’s care and treatment needs (regulation 18)
There were also staff shortages and an incident where the individual could not access drinking water.
The Council’s safeguarding investigation took eight months to complete, significantly longer than statutory guidance requires, causing unnecessary distress and uncertainty. However, the Council did involve the mother throughout the investigation process.
The delay amounted to fault through allowing the matter to drift without meaningful progression.
The Ombudsman recommended the Council apologise and pay £300 to the individual to acknowledge the distress and uncertainty caused, update the action plan for the care home, and conduct further unannounced visits to ensure improvements.
The decision was shared with the CQC for regulatory consideration.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
Under s42 of the Care Act 2014, councils must make safeguarding enquiries if they suspect an adult with care and support needs is at risk of abuse or neglect and cannot protect themselves.
Safeguarding enquiries must be timely, sensitive, and transparent to protect adults and ensure fair processes.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 require care providers to involve representatives in care planning, ensure dignity and respect, maintain safe premises, meet nutrition and hydration needs, keep accurate records, and deploy sufficient qualified staff.
Failure to meet these standards is a breach of statutory duty and is unlawful. Delays in safeguarding investigations undermine public confidence and can expose individuals to ongoing risk. Councils must ensure robust monitoring of commissioned care homes, promptly address safeguarding concerns, and meaningfully involve representatives in investigations. Action plans must be kept up to date and their effectiveness monitored through regular, unannounced visits. Compensation should be provided where distress or uncertainty is caused by service failures.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Kent County Council (24 005 179) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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