Summary: Mrs Y experienced poor care in a care home acting on behalf of the Council. A safeguarding investigation into this was insufficient and failed to acknowledge the impact the poor care had on Mrs Y’s wellbeing.

The complaint

1. Mrs X complains about the care provided to her late mother, Mrs Y by Hesslewood House Residential Care Home, acting on behalf of the Council.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended
3. We investigate complaints about councils and certain other bodies. Where a care provider is providing services on behalf of a council, we can investigate complaints about the actions of the provider. (Local Government Act 1974, section 25(7), as amended)
4. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), 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. I have:

• considered the complaint and supporting information submitted by Mrs X;
• considered the correspondence between Mrs X and the Council, including the Council’s response to the complaint;
• made enquiries of the Council and considered the responses;
• considered relevant legislation;
• offered Mrs X and the Council an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The following standards are relevant to how the care home managed Mrs Y’s care.
8. Regulation 9 Person Centred Care says the Care Provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs. Each person, and/or person lawfully acting on their behalf, must have all the necessary information about their care and treatment.
9. Regulation 12 Safe Care & Treatment says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Care Providers must assess the risks to a person’s health and safety during any care or treatment and make sure care staff have the qualifications, competence, skills and experience to keep people safe.
10. Regulation 18 - providers must tell the CQC of all incidents that affect the health, safety and welfare of people who use services;
11. Regulation 20 - providers must be open and transparent with people using their services and their families and must notify them and apologise if something has gone wrong with the person’s care or treatment. Providers must tell the person or their representative if there has been a ‘notifiable safety incident’.
12. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect; and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

13. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by who.

Background

14. Mrs Y went into Hesslewood House residential care home on 9 June 2023 for a period of rehabilitation following a hospital stay. The care home is owned and operated by Four Seasons Health Care Limited. The placement was commissioned and funded by the Council.
15. Prior to the hospital stay Mrs Y lived in her own home with domiciliary care services commissioned by the Council.
16. The Council re-assessed Mrs Y’s care needs and completed a support plan for her residential stay. The support plan, dated 9 June 2023, is detailed, and sets out specific aims and outcomes to increase Mrs Y’s independence and aid her return home. Mrs Y made clear her wish to return home, but she acknowledged she needed support to improve her mobility and overall independence. Mrs Y was referred to the community physiotherapist, who recommended she be provided with pressure relief every two hours, and that carers encourage her to stand and walk. The physiotherapist requested records of this be kept.
17. On 29 June 2023 a social worker visited Mrs Y to review her care needs. Mrs X was also present at the review. The social worker noted, that on her arrival at the care home mid-morning, Mrs Y had only just been offered support to get out of bed and had not had any breakfast. She (social worker) had to ask care staff for breakfast for Mrs Y. During the review Mrs X expressed concern about some aspects of the care provided to Mrs Y. Mrs X was particularly concerned that Mrs Y appeared to be sitting in a chair all day and was not receiving support to mobilise, as per the physiotherapy instructions. Mrs Y had an unwitnessed fall the day before whilst trying to mobilise unaided. Mrs Y also expressed her dissatisfaction, and her mood was described as low.
18. The social worker noted several of her own concerns about the care provided to Mrs Y, which included a lack of support to mobilise, poor record keeping, and a significant weight loss (5.6kg) since Mrs Y’s admission to the care home. The social worker noted Mrs Y’s mobility had deteriorated during her stay and that she was unable to stand.
19. The records show the social worker addressed her concerns with a senior member of care staff, who responded by saying the concerns would be addressed immediately.
20. Mrs X says despite the social worker’s intervention there was no improvement in the care provided, and that Mrs Y’s mobility and general wellbeing continued to decline.
21. The social worker carried out an unannounced visit to Mrs Y again on 21 July 2023. She noted “…[Mrs Y] was still in bed, and has deteriorated rapidly within 3 weeks since I first saw her”. The social worker recorded her concerns:

• Care staff not encouraging [Mrs Y] to mobilize.
• Leaving in bed until 11.30.
• No encouragement to eat and drink - lost weight.
• Not attending to [Mrs Y] in a timely manner when she requested assistance.

22. The social worker made a safeguarding referral the same day (21 July 2024). The Council says its safeguarding team:

• Triaged the referral information and cross referenced this with the intelligence held about the care homes performance at that time.
• From the information held an assessment was made regarding the risk and potential level of harm.
• Practitioners visited the home and established [Mrs Y] had not come to any harm.
• From this the safeguarding practitioner recommended that the matter should be addressed via care management, due to the risk level being low.

23. The social worker visited Mrs Y again on 28 July 2023 and noted her ongoing concerns about the quality-of-care Mrs Y was receiving.
24. The records show a discussion between Mrs X and the social worker in which Mrs X expressed her view that Mrs Y had come to harm due to the neglect in care practices, which had led to a deterioration in Mrs Y’s condition. The social worker agreed with Mrs X, and recorded her views, “…that the lack of care and neglect that [Mrs Y] has suffered have lead to her deterioration”.
25. The social worker sent an email to the Council’s safeguarding team with the findings from her review. She (social worker) detailed her ongoing concerns about the care provided to Mrs Y and said “[Mrs Y’s] mental and physical health has deteriorated since being at Hesslewood… I feel that this safeguarding needs to be looked into further- the concerns re [Mrs Y’s] care have not been fully resolved. Hesslewood have had 2 opportunities to make appropriate changes and have failed to do so”. The social worker said she was looking to move Mrs Y to a different care home.
26. Two further safeguarding concerns were raised on 31 July & 1 August 2023. The first related to an unprofessional comment a carer made to Mrs Y. The safeguarding team contacted the manager of the care home to discuss the allegation.
27. The August safeguarding referral related to concerns about care provision, some of which were a repeat of those raised in July. The concerns included:

• Mrs Y’s weight not being monitored;
• food charts not completed;
• too long a wait for call bells to be answered;
• medication issues;
• Mrs Y being over mobilized, causing exhaustion;
• allegations of rough handling by a staff member;
• care home not addressing previous issues.

28. The Council says it raised the issues with the care home, but the findings from the safeguarding enquiry were that “…abuse could not be substantiated and the investigation was closed to that team, but intelligence was passed to the contracts and quality assurance team mentioned above for additional monitoring”.
29. Mrs X contacted the social worker on10 & 16 August 2023 to report Mrs Y was still in bed at 11:45am, that she had not been offered a drink or breakfast or support to get up to use the toilet, and that her condition had deteriorated further.
30. Mrs Y moved to a different care home on 21 August 2023. She sadly passed away in hospital on 30 November 2023.
31. Mrs X submitted two formal complaints to the care home. I have had sight of the stage 2 response letter dated 11 November 2023.
32. The author of the letter acknowledged failings and/or delays in some areas of care provided to Mrs Y; including:

• Physiotherapy;
• information relating to a safeguarding incident;
• application of prescribed skin cream;
• treatment for medical condition;
• personal hygiene & continence care;
• lost clothing.

33. The author set out the action taken to address the failings. No apology was offered to either Mrs Y or Mrs X.
34. The Council says Mrs X submitted a complaint directly to the care home, so it was unaware of any formal complaint until it received notification from this office. It says “…work has taken place with the provider under increased monitoring where the Council has been provided assurances regarding the delivery of care within the home”.

Analysis

35. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them.
36. People have a right to expect safe, effective, and appropriate care that meets their needs. This is not what happened here.
37. The social worker allocated to oversee/review Mrs Y’s care, responded promptly and diligently in addressing concerns about the care provided to Mrs Y. She raised matters directly with the care home and sent timely referrals to the Council’s safeguarding team. She made unannounced visits to monitor the situation, and to check Mrs Y’s wellbeing.
38. The Council’s safeguarding team instigated enquiries about all the referrals received, however, this extended only to raising the issues with the care home. Given the social worker had already done so on numerous occasions the Council should have taken a more robust approach to the consistent failures highlighted.
39. The safeguarding investigation concluded no harm had come to Mrs Y; this contradicts the findings of the social worker who saw Mrs Y regularly. The evidence I have seen shows the poor care had a significant impact on Mrs Y’s wellbeing. This must have caused both her and Mrs X distress and worry.
40. Whilst the Council may not have been aware of the formal complaint Mrs X submitted to the care home, it was aware of the complaints about the quality of care provided to Mrs Y, which were well documented. When alerted by this office it had the opportunity to review the complaint.
41. Sadly, Mrs Y has passed away, so it is not possible to remedy her injustice. Where a person has died, we will not normally seek a substantive remedy in the same way as we might for someone who is still living.
42. However, Mrs X also suffered injustice, she was witness to the poor care Mrs Y experienced which impact on her. She (Mrs X) was put to significant time and trouble pursing the matters with the care home, the Council, and this office. For this a remedy is required.

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Agreed action

43. The Council should, will within one month of the final decision:

• provide Mrs X with a sincere written apology for the failings above and make a payment of £500 in acknowledgement of her distress, and her time and trouble pursuing matters with the care home, the Council, and this office. Evidence of which should be provided to this office.
• provide this office with evidence showing the monitoring of the care home in the last 12 months, as set out in paragraph 34 above;

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Final decision

44. Mrs Y experienced poor care in a care home acting on behalf of the Council. A safeguarding investigation into this was insufficient and failed to acknowledge the impact the poor care had on Mrs Y’s wellbeing.
45. The recommendations above are a suitable way to settle the complaint.
46. It is on this basis; the complaint will be closed.
47. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman