Summary: Mrs X complained the Council failed to properly assess her mother before placing her in residential care, forced her mother into a second placement, delayed responding to safeguarding concerns, excluded Mrs X from meetings and failed to act on the concerns she raised. The Council failed to include relevant professionals in assessing Mrs Y, failed to involve Mrs X in meetings and failed to consider safeguarding concerns about the home properly. That has caused Mrs X distress and uncertainty. An apology, payment to Mrs X and reminder to officers is satisfactory remedy.

The complaint

1. The complainant, Mrs X, complained the Council:
• failed to properly assess her mother (Mrs Y) before placing her in a residential care home which failed within hours;
• forced her mother into a placement at Springfield Grange without her family’s consent and against Mrs X’s wishes as Power of Attorney;
• delayed responding to safeguarding concerns;
• excluded Mrs X from meetings and failed to consider her evidence; and
• failed to act on Mrs X’s concerns about Springfield Grange.
2. Mrs X says the Council’s failings caused her pain and sorrow as well as impacting on her mother.

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The Ombudsman’s role and powers

3. 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)
4. 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)
6. 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

7. As part of the investigation, I have:
• considered the complaint and Mrs X's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
8. Mrs X and the organisation 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

What should have happened

9. A Council must carry out an assessment for any adult with an appearance of need for care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must also involve the individual and where appropriate their carer or any other person they might want involved. (Care Act 2014, section 9)
10. The Council’s conversation model guidance provides guidance for social care assessments. It says the conversation record should include:
• basic information about the person and information about why the conversation is taking place;
• a record of the conversation as it happened;
• a record of additional issues such as risks, self-neglect or other safeguarding concerns;
• discussions held with others such as carers, family members and other professionals;
• the agreed actions and who is completing them, along with timescales;
• the professional judgement of the person completing the assessment.
11. 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)

What happened

12. Mrs Y had a diagnosis of Alzheimer's and lived at home with her husband with care support. Mrs X contacted the Council in May 2023 as Mrs Y’s presentation had changed as she had become more aggressive. Mrs X asked for some respite support as her father was struggling to cope.
13. A duty social worker visited Mrs X and her mother in May 2023 and agreed to look for a respite placement. Mrs X said she would look for care homes but felt Mrs Y needed a permanent placement rather than respite care.
14. A further social work visit took place later in May. Following that meeting Mrs X confirmed she believed her mother needed a permanent care home placement.
15. On 8 June Mrs X told the social worker about a placement she had found for her mother. A representative for the care provider visited Mrs Y in June 2023 and completed an assessment. Following that the care provider told the Council it could provide a room for Mrs Y. Mrs Y moved in on 16 June. However, the placement broke down later that day and Mrs Y was admitted to hospital.
16. While Mrs Y was in hospital the Council’s social worker explained the challenge of finding a suitable placement as Mrs Y now needed EMI nursing. Mrs X's father listed the areas he would like considered. The Council looked for placements in those areas. Due to difficulty identifying a placement the Council suggested a placement slightly further away. The family declined that.
17. Mrs X identified a nursing home she considered suitable. However, that nursing home had an £80 top up charge, which the family could not afford. The Council said it could not fund the top up charge as it had identified two homes in the family’s preferred areas. One of those homes was Springfield Grange (the care home). Mrs X visited the care home on 7 July and raised some concerns about the suitability of the placement. Mrs X also explained the things that needed to be in place for Mrs Y to go there. Mrs Y moved into Springfield Grange on 12 July.
18. Mrs X contacted the Council on 18 July to raise concerns about whether Springfield Grange was providing Mrs Y with basic care. Mrs X also raised concerns about interactions with another resident. The Council treated that as a safeguarding referral. A social worker carried out an unannounced visit to Mrs Y on 21 July and discussed the case with care home staff on 24 July. The Council asked the care home to provide some documentation.
19. Mrs X raised further concerns about hydration and nutrition on 13 September. Later in September Mrs X also raised concerns about the medication dosage given to her mother.
20. The Council visited the care home to get the outstanding documentation on 19 September.
21. On 26 September a meeting took place at Springfield Grange to discuss Mrs X’s concerns. The Council decided it could not substantiate Mrs Y had experienced abuse and noted the other resident had moved to another part of the care home. The Council noted the documentation showed the amount of hydration offered and taken and meals offered and taken and that the issues with weight would be carried forward. Springfield Grange accepted at times it could have done better. Springfield Grange explained it would have daily flash meetings and would respond to families in a timely manner.
22. On 2 October Springfield Grange told the Council it had received a visit from pharmacy about a covert plan for medication for Mrs Y. Springfield Grange explained it needed to be discussed with the GP.
23. On 11 October Mrs X raised further concerns about her mother experiencing constipation and dehydration. The Council began a safeguarding investigation.
24. Mrs Y went into hospital on 17 October. The hospital raised a safeguarding referral due to concerns about Mrs Y’s weight loss.
25. The Council met with Springfield Grange on 15 November to discuss the new concerns. Because of the Council’s enquiry the following outcomes were agreed:
• staff should identify and follow health concerns and escalate it to the registered nurse and medical team when identified;
• regular supervision of staff should take place regarding documentation and follow-up
• daily Emar (medication) checks should be looked at for any refusals and any drug concerns;
• oversight to ensure correct recording and ordering of medication, followed by daily flash meetings by senior departments.
26. By the time the safeguarding enquiry had completed Mrs Y had sadly died.
27. When responding to a complaint from Mrs X the Council identified some learning and development which included:
• understanding the legal requirement to involve and engage with those with lasting Power of Attorney;
• the role of the lasting Power of Attorney in relation to decision-making;
• checking and supporting robust recruitment documentation for care staff;
• checking and supporting overseas staff to ensure they have had the appropriate English exams and training before employment;
• checking and supporting care homes to ensure all staff have appropriate training, development and supervision to ensure safe delivery of care to residents;
• robust quality assurance and contract monitoring checks, working closely with CQC and other partners to ensure residents are safe and well.
28. To address that the Council:
• has provided additional support and training with the relevant team to help them understand and recognise the Council's responsibility to work alongside those with lasting power of attorney (LPA) and explaining the available options to them to support their decision-making;
• is reviewing its safeguarding function and how this works, in particular around processes when two officers are involved as that can result in a lack of clarity and coordination which can lead to delay.
29. Springfield Grange has since closed.

Analysis

30. Mrs X says the Council failed to properly assess her mother’s needs before placing her in a residential care home. Mrs X says because the Council did not consult the medical professionals involved in her mother’s care it failed to identify she needed a nursing home placement rather than residential care. Mrs X says if the Council had carried out the assessment properly it would not have placed her mother in the first care home she entered. Mrs X says she and Mrs Y suffered distress because that residential care home placement failed within hours.
31. The Council accepts when assessing Mrs Y it failed to consult the care provider already in place. Failure to do that is fault. In those circumstances, and because the placement failed so quickly, I can understand why Mrs X would believe the Council would not have placed Mrs Y in the first residential care home if it had assessed the case properly.
32. Having considered the documentary evidence though, I note the Council completed the assessment with the intention of placing Mrs Y in respite, rather than permanent residential care. The documentation I have seen suggests the Council intended to complete a more detailed assessment during the respite period to decide what type of placement Mrs Y required long term.
33. I am also satisfied the assessment the Council completed relied on what Mrs X and her father told the social worker about Mrs Y’s needs. There is also evidence in the assessment of Mrs X saying her mother’s presentation had improved following changes in her medication. In addition to that assessment the care home Mrs Y entered also completed its own assessment. That assessment also concluded the residential care home was an appropriate placement for Mrs Y. Added to that, I note the care home Mrs Y initially entered was one Mrs X had identified and visited and was a care home experienced in dealing with residents with dementia.
34. In those circumstances I could not say, on the balance of probability, if the Council had completed a more detailed assessment at the outset it would not have placed Mrs Y in the care home. However, I consider Mrs X has suffered an injustice as she is left with some uncertainty about whether the situation would have been different. As part of the remedy for this part of the complaint I recommended the Council remind officers completing assessments for residential and nursing care to ensure input is obtained from any carer agencies and medical professionals already involved in the service user’s care. The Council has agreed to my recommendation.
35. Mrs X says the Council forced her mother into a placement at Springfield Grange without her consent and without consulting her. The Council accepts it approached Springfield Grange and arranged an assessment without consulting Mrs X, who held lasting Power of Attorney for Mrs Y. Failure to consult Mrs X about the placement before making the approach to Springfield Grange is fault.
36. I could not say though the Council forced Mrs Y to go to Springfield Grange. The evidence I have seen satisfies me Mrs X visited the home before her mother entered it. I am also satisfied the Council told Mrs X it could seek a different care home outside the area Mrs X and her father had identified as suitable, explaining the difficulty finding a suitable placement within the distance Mrs X and her father had set. I am also satisfied the Council told Mrs X it had identified alternative placements if Mrs X and her father could pay a top up. The evidence I have seen satisfies me Mrs X made clear she did not want a placement outside the area she and her father had identified and that they could not pay an additional top up. Given those options were presented to Mrs X though I could not say the Council forced Mrs Y to go into Springfield Grange.
37. Mrs X says the Council delayed responding to the safeguarding concerns she raised about Springfield Grange in July 2023. I am satisfied the Council began a safeguarding investigation promptly. However, the Council accepts when Springfield Grange did not provide the documentation the Council had asked for it did not act by visiting the home until September 2023. That delay is fault and is unlikely to have reassured Mrs X the Council was taking her concern seriously.
38. The Council also accepts it concentrated on the issue relating to the other resident in the home rather than the concerns Mrs X raised about the standard of care provided to Mrs Y. In addition to that, the Council accepts it should not have closed the safeguarding referral when Mrs X had raised further concerns in October 2023. All of that is fault. The Council says it is reviewing its safeguarding processes, partly as a result of the learning from this complaint. As part of the remedy I recommended the Council provide the Ombudsman with details of the action it has taken. The Council has agreed to my recommendation.
39. Mrs X says the Council excluded her from meetings and failed to consider her evidence. I am satisfied the Council invited Mrs X to the safeguarding meeting which took place in September 2023. There is no evidence though the Council involved Mrs X in meetings which took place following the second safeguarding investigation. That is fault. That is unlikely to have satisfied Mrs X the Council was taking her concerns seriously.
40. Mrs X says the Council failed to act when she raised concerns about the care her mother received in Springfield Grange. I have found no evidence of fault here. I say that because I note the Council visited the home and inspected its records as part of its consideration of the safeguarding referral. I am also satisfied those concerns were discussed at the safeguarding meeting which took place in September 2023. I am satisfied that safeguarding meeting set some actions for the home to take. In addition, the Council visited the home again in November 2023 to investigate the further safeguarding concerns. Following that meeting the Council again set some actions for the home to take. I therefore could not say the Council failed to consider the concerns Mrs X raised.
41. I understand Mrs X’s concern about the actions of the placement at Springfield Grange though, particularly in terms of how Springfield Grange monitored Mrs Y’s fluid and food intake. Having considered the documentary records there is a lack of recording around whether carers supervised Mrs Y when eating and drinking or whether they encouraged her to eat and drink. That is fault. Given Mrs Y lost a lot of weight at Springfield Grange it is hardly surprising Mrs X believes this was due to lack of appropriate care.
42. There is also evidence Springfield Grange wrongly transcribed the dosage for one of the medications Mrs Y received when she was discharged from hospital. The home also failed to provide Mrs Y with stimulation. As the Council arranged the placement at Springfield Grange it is responsible for the failures in care that took place. Given the care home has now closed I cannot make any recommendations for the Council in terms of its monitoring of the home.
43. Mrs X has raised further concerns about the care provided to her mother at Springfield Grange on which I have not found evidence of fault. For Mrs X’s concern about Springfield Grange not putting in place covert medication I am satisfied the care home took advice from the pharmacist who then made a referral to the GP. While that was not followed up on and there was delay, which is fault, I cannot criticise Springfield Grange for not putting in place covert medication as that would require a medical professional to recommend it.
44. For Mrs X’s concerns about Springfield Grange’s failure to provide a sensor mat, the evidence I have seen satisfies me this was not put in place as on further consideration the home did not consider it was necessary. I appreciate that may be a decision Mrs X strongly disagrees with. However, it is not my role to comment on the merits of that decision given it was reached after the home completed a risk assessment.
45. I have found no evidence of fault in how the care home dealt with illnesses. There is also evidence of Springfield Grange contacting the relevant medical professionals and obtaining medication to deal with a bladder infection, although on some occasions that was promoted by Mrs X.
46. For sores, the documentary evidence shows Springfield Grange kept records of management of Mrs Y’s skin, including provision of creams. However, Mrs X has also provided a photograph showing a sore which could be as a result of inadequate drying.
47. In relation to Mrs X’s concern about whether the carers dealing with her mother could speak English, I am satisfied that is a matter the Council checked with the care provider. Following that the Council was satisfied the care provider had procedures in place. I therefore have no grounds to criticise it.
48. Mrs X has raised the specific concern about whether Springfield Grange was honest when it cancelled the meeting Mrs X had attended. Mrs X says Springfield Grange told her the meeting had to be cancelled because another resident had a cardiac arrest. Mrs X says that is untrue because a nurse on site told her there had not been a cardiac arrest. I do not have any documentation in relation to what happened for this meeting and Springfield Grange is now closed. I therefore cannot reach a safe conclusion about whether staff at Springfield Grange gave Mrs X wrong information.
49. Mrs X says the Council, when responding to her complaint, grouped various complaints together. Mrs X says this means she could not identify which parts the Council had upheld. It is not unusual for councils to summarise complex complaints or group various complaints about similar matters together. That is not fault, although the Council would need to ensure when responding to the complaint all matters were covered.
50. Having considered the Council’s complaint response I am satisfied the Council provided an explanation for each grouped complaint heading to explain why it had upheld or partially upheld the complaint. I am therefore satisfied the Council was clear about where it had upheld the complaint.
51. As Mrs Y has sadly died I cannot seek a remedy for the injustice she experienced. However, I consider Mrs X has experienced some uncertainty as well as distress because of the failures in this case. As remedy for that I recommended the Council apologise to Mrs X and pay her £500. The Council has agreed to my recommendations.

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Action

52. Within one month of my decision the Council should:
• apologise to Mrs X for the distress and uncertainty she experienced due to the faults identified in this decision. The Council may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet;
• pay Mrs X £500;
• send a reminder to officers completing adult social care assessments for residential or nursing care about the need to ensure all those involved in a person’s care are included in an assessment;
• provide evidence to the Ombudsman of the measures the Council has taken to address the safeguarding failings in this case.
53. The Council should provide us with evidence it has complied with the above actions.

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Final decision

54. I find fault causing injustice. Subject to further comments from Mrs X or the Council, I intend to complete my investigation.

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Investigator's decision on behalf of the Ombudsman