Summary: Mr C complained about how the Council dealt with his safeguarding concerns regarding the actions of a care provider’s carer. We found no fault in the safeguarding process the Council followed to reach its view. However, it apologised for not sharing the outcome of its investigation in a timely manner. Its apology was enough to remedy the uncertainty this caused Mr C.

The complaint

1. The complainant, whom I shall refer to as Mr C, complained about the Council’s investigation into a safeguarding concern relating to his carer in a care home. His complaints included the Council:
• did not act impartially, did not listen to his views or consider the evidence he provided, and sought simply to absolve the care provider of any blame;
• did not adequately share information with him, keeping the content of conversations with the care provider secret; and
• gave him no right to respond to the carer’s claims.
2. Mr C also said the care provider had since served him with an eviction notice in retaliation for his allegations.
3. Mr C said, as a result, he experienced distress and financial loss.

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The Ombudsman’s role and powers

4. 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)
5. 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)
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(i), as amended)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. As part of my investigation, I have:
• considered Mr C’s complaint and the Council’s responses;
• discussed the complaint with Mr C and considered the information he provided;
• considered the information the Council provided in response to my enquiries; and
• considered the law and guidance relevant to the complaint.
9. Mr C 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

Safeguarding adults

10. 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)
11. Making safeguarding personal means it should be person-led and outcome-focused. It engages the person in a conversation about how best to respond to their safeguarding situation in a way that enhances involvement, choice and control as well as improving quality of life, wellbeing and safety. (Paragraph 14.15, Care Act 2014 Statutory Guidance)
12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 says:
• service users must be protected from abuse and improper treatment;
• systems and procedures must be established and operated effectively to prevent abuse of service users; and
• systems and processes must be established and operated effectively to investigate, immediately upon becoming aware of, any allegation or evidence of abuse.

What happened

13. Mr C became a resident at a care home in 2021. The placement was commissioned by the NHS for after care under section 117 of the Mental Health Act 1983.
14. Mr C had care and support in the care home, which was provided by carers. He had a carer (Mr X) allocated to him who he was fond of throughout his stay. Mr X would provide support and accompany him on trips and outings.
15. In Summer 2022, Mr X told Mr C he was resigning from his role with the care provider.
16. In July 2022 Mr C went on a trip. He said Mr X joined him when he was not working, and he bought Mr X various things on the trip.
17. Mr C did not see Mr X after this, and Mr X stopped working for the care provider shortly after.
18. In late July 2022, Mr C told the care provider he did not want Mr X to be his carer anymore as he was being manipulative and controlling. He asked to have access to his care records and CCTV footage from the last year. He did not make a complaint but said he would report his concerns to the Care Quality Commission (CQC).
19. Mr C also found an advocate who supported him with the safeguarding process.
20. The care provider told Mr C he could have access to his care records, but not the CCTV footage. This was because he would need to share specific days and times to ensure others privacy rights were not impacted. Mr C refused to provide dates and times as he believed the care provider would delete the footage.
21. Mr C reported a safeguarding concern to the CQC. He said Mr X had:
• sexually groomed him, including some inappropriate touching;
• financially abused him during his stay at the care home. He said he had been manipulated into buying Mr X food, drinks and other items; and
• hacked his laptop.
22. The CQC shared the safeguarding concern with the care provider and the Council. The care provider also shared Mr C’s concerns with the CQC.
23. In August 2022, the Council started a safeguarding enquiry based on Mr C’s concerns. As Mr X was no longer working for the care provider, its enquiry was based on the potential risk to others. It shared its safeguarding leaflet with him which explained the process.
24. The Council subsequently:
• held a meeting with Mr C and his advocate to discuss his safeguarding concerns. Mr C said he felt the care provider did not answer his questions or comment about what had happened with Mr X;
• liaised with the CQC, the care provider, and the Police regarding Mr C’s sexual and financial abuse concerns; and
• considered what support Mr C needed going forward to meet his care and support needs.
25. The Police considered Mr C’s bank statements and information but found there was not enough evidence of financial abuse or hacking of his laptop. It closed the case and informed the Council.
26. The CQC told the Council it had investigated Mr C’s concerns but found the care provider had met the requirements for Mr C’s case. It would therefore not investigate this further. However, it found the care provider needed to improve some processes regarding supporting and recognising potential abuse. It was satisfied with the actions the care provider had taken and closed its case.
27. The Council met with Mr C again in Autumn 2022. He shared concerns about the care provider’s recording of information, activities and not having a care needs assessment for him when he moved into the care home in 2021.
28. The Council completed its safeguarding investigation in November 2022. It found Mr C was able to protect himself and had capacity to manage his finances. While, Mr C had felt Mr X had influenced him to buy food, drinks and items, there had been no clear evidence of abuse as identified by the Police. It also found no evidence of sexual abuse due to the lack of evidence.
29. The Council did not make any recommendations for the care provider as the CQC had already addressed the concerns identified about its recording and lack of assessments. However, it shared the learning with its Quality Monitoring team.
30. Mr C asked the Council for a further meeting, but the Council refused as it had considered and closed his safeguarding concern. It shared its summary of the safeguarding concerns with him explained it case was closed.

Mr C’s complaint

31. Mr C complained to the Council as he believed:
• his safeguarding concerns did meet the criteria for a safeguarding enquiry. He said he was at risk of abuse, but the Council had failed to understand and accept this;
• his personal outcomes had not been taken into account and was biased. He felt the Council was secretive and accepted what the care provider said;
• the Council should have considered his records of messages with Mr X which showed evidence of buying things such as gifts, food and drinks; and
• the Council had said it would co-produce a safety plan for the care provider, but this was never done.
32. In response the Council did not uphold Mr C’s complaint. It explained the safeguarding process was not to determine if abuse had taken place but to ensure Mr C was safe. It said it had considered his safeguarding concern, including how it had worked with the Police, the care provider and the CQC to reach its decision. It also acknowledged Mr C felt excluded, however, this was because it could not disclose some information to him due to the confidentiality of others involved.
33. Mr C and the Council had further correspondence and met in Spring 2023. It acknowledged and apologised for not sharing its completed safeguarding enquiry in a timely manner and copying information into the safeguarding enquiry which caused Mr C some confusion due to the language used.
34. Mr C subsequently told the Council the care provider was evicting him.
35. Mr C was not satisfied with the Council’s handling of his safeguarding concerns and asked the Ombudsman to consider his complaint. He shared evidence of his communication with Mr X during the time he was supporting him.

Analysis and findings

The safeguarding investigation

36. Mr C’s complaint is about the Council’s handling of his safeguarding concerns relating to his carer’s (Mr X) actions from 2021 to July 2022.
37. The Council, as a safeguarding authority, should take steps to prevent abuse or the risk of abuse. However, in Mr C’s case the Council:
• did not commission Mr C’s care provider in 2021, nor did it have any knowledge of the safeguarding concerns until August 2022 when the CQC and the care provider informed it about his concerns. I cannot therefore fault the Council for failing to take any action before August 2022; and
• from August 2022 Mr X no longer worked for the care provider, it was therefore entitled to reach its view there was no existing risk or concerns about abuse for Mr C.
38. The Council decided a safeguarding enquiry should still be completed due to the potential risk to others. This was not regarding Mr X alleged actions, but to identify any around the systems and processes the care provider had in place to keep its service users safe. I have found no fault in the process the Council followed to conclude its enquiry. In reaching my view, I am conscious it:
• considered Mr C’s and his advocate’s views and met with them to establish what had happened;
• considered the information the care provider and Mr X provided;
• liaised with the Police regarding its investigation into the alleged financial abuse and hacking, which found there was insufficient evidence and the case was closed;
• found the was insufficient evidence available to substantiate Mr C’s allegation of sexual abuse. It explained this was because such concerns were challenging to evidence and Mr C had refused to share time and dates of when the allegations took place;
• liaised with the CQC regarding its investigation into the care providers processes and procedures to protect individuals from abuse. This found there was not enough evidence abuse had taken place, but the care provider agreed to the CQC’s recommendations to take steps to improve record keeping and risk management; and
• considered the CQC’s findings, including its view the care provider had sufficiently actioned its concerns.
39. I understand Mr C disagrees with the outcome of the Council’s safeguarding enquiry. However, as I have not found fault in the process it followed, it reached a decision it was entitled to make.
40. Mr C also said he found the Council to be secretive and did not share information around what the care provider and Mr X had said. He felt this meant he did not have the opportunity to counter respond to their statements. This part of Mr C’s complaint relates to the Council’s decision not to share certain information with him due to data protection rights. Normally, a council cannot normally share information about third parties. However, if Mr C believes it should have, he has the right to ask the Information Commissioner (ICO) to consider the matter, which is the body best placed to consider such disputes.

Sharing the outcome

41. The Council accepted it had not shared the outcome of its safeguarding investigation with him in a timely manner, which caused a short delay. It also agreed some language in it safeguarding record had been copied which could cause Mr C some confusion. It apologised and held a meeting to discuss the steps it had taken to address these issues and its learning from his complaint.
42. I am satisfied the Council’s apology, and steps taken as a result of his complaint, was enough to remedy any uncertainty this caused Mr C.

Eviction from the care home

43. Mr C told the Council in Spring 2023 his care provider had served him with an eviction. I understand the Council has since helped him with finding alternative accommodation. This was not part of Mr C’s complaint to the Council; I cannot therefore consider any concerns Mr C has about the care provider or the Council’s subsequent actions.
44. If Mr C believes the care providers eviction was wrong, he can complain to the care provider and then bring his concerns to the Ombudsman’s attention. Similarly, if he has concerns about the Council’s support to find alternative accommodation for him, he should complain to the Council first before we can consider this.

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Final decision

45. I have completed my investigation with a finding of no fault by the Council on the substantive matters complained about.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman