Summary: There was no fault in the way the Council placed Mr X’s mother Mrs Y in a care home. The Council commissioned care home was at fault of the delay in changing Mrs Y’s GP. The Council has agreed to apologise and make a payment to acknowledge the uncertainty and frustration this caused and to remind the care home to change GP registrations as soon as possible.

The complaint

1. Mr X complained the Council, in October 2024, arranged an inappropriate placement at the Grange Care Home for his mother Mrs Y which could not meet her needs. Mr X complains the Council then delayed moving her somewhere more suitable which meant her condition deteriorated and which caused him frustration and distress.

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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 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)
3. 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)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended). iN this case the council commissioned the care home so we consider the care home was acting on behalf of the Council.
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(1), as amended)

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How I considered this complaint

6. I considered evidence provided by Mr X, the Council and the Grange Care Home (the care home) as well as relevant law, policy and guidance.
7. I gave Mr X, the Council and care provider an opportunity to comment on a draft of this decision. I considered any comments before making a final decision.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

9. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
10. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision. An assessment of someone’s capacity is specific to the decision to be made at a particular time. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests.
11. Under the Mental Health Act 1983 (MHA), when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained in hospital against their wishes. The purpose of detention under section 2 of the Mental Health Act 1983 is for assessment of a patient’s mental health and to provide any treatment they might need. Patients can be detained under section 2 for a maximum of 28 days.

What happened

12. The following is a summary of the key events relevant to this complaint.
13. Mrs Y lived at home with her husband Mr Y. In late September 2024 Mrs Y was admitted to hospital due to concerns about her behaviour and lack of self-care. The hospital completed behaviour charts. They noted Mrs Y sometimes declined drinks, medication and personal care. She was sometimes calm and settled and sometimes unsettled and agitated. On one occasion Mrs Y was very agitated and lashed out and on one occasion she attempted to throw away her breakfast tray.
14. A social worker visited Mrs Y in hospital to conduct a mental capacity assessment. They concluded Mrs Y had fluctuating capacity but at the time was not able to make a decision about her care and accommodation. The Council requested an assessment by a discharge assessment nurse to confirm the level of care Mrs Y required due to the concerns highlighted regarding her behaviour.
15. In early October 2024 the Council’s notes record a discharge assessment nurse assessed that Mrs X had no evidence of nursing needs.
16. The following day the Council arranged a multi-disciplinary team meeting which Mr X and other family members attended alongside social work staff and nursing staff. The meeting discussed the option of Mrs Y returning home with a care package or a short term care home stay. The meeting agreed Mrs X should be discharged to a dementia residential care home for 28 days to assess her needs.
17. The Council’s care navigation team identified two care homes including the Grange Care Home. The care home requested sight of the behaviour charts completed at the hospital and with agreement from Mr X, it agreed to accept Mrs Y.
18. Mrs X was transported to the care home. The social worker spoke to the care home manager on day one who reported Mrs Y was hitting out and agitated, she was kicking doors and hitting staff. They were concerned that Mrs Y had been discharged with such behaviours and no medication to help with these behaviours. The Council noted the care home said Mrs Y’s medication needed looking at. It noted the care home said Mrs Y may be physically well and fit for discharge but mental health wise she needed involvement to help settle her. The Council advised the care home to contact the hospital about any medication.
19. Three days later the Council’s notes record Mr X had spoken with the ward and Mrs X was refusing her medication but was settled. The care home’s records show Mrs Y regularly refused her medication and any support with personal care and spent most of the time in her room.
20. Five days after Mrs Y entered the care home it noted family visited. It noted it informed the family Mrs Y’s GP would need moving and the family requested Mrs Y stay at her own GP as she may not be staying long term at the care home as they were looking to move her closer to them. The care home noted it advised the family it did not think the care home was the right place for Mrs Y and they would be contacting the social worker.
21. The care home noted it spoke with the social worker. This conversation is not noted in the Council’s records. The care home noted it told the social worker Mrs Y was very verbal and agitated and refused all medication. She needed more care than it had anticipated and it could not meet her needs. The social worker asked if the care home could get the District Nurse to assess Mrs Y’s health needs. The care home noted the District Nurse said this was for the social worker to do. It noted ‘spoken with family and informed them that I would have to change [Mrs Y’s] GP over to ours so that urgent referrals could be done to the CMHT [Community Mental Health Team]’.
22. The care home’s records show Mrs Y continued to be very vocal and agitated when staff entered her room, to refuse personal care and medication. Staff left food in her room. Mrs Y would eat small amounts and would sometimes throw the remainder out of the window.
23. The care home noted it spoke to the family about changing the GP and noted the family agreed to this. This was 12 days after she entered the care home.
24. The care home contacted the Council, the following day and advised that Mrs Y was refusing medication and drinks and was verbally and physically aggressive. It considered she needed readmission to hospital. The Council told the care home to contact the Rapid Intervention and Treatment team (RITT- a specialist older adult mental health multi-disciplinary service). The Council considered Mrs Y was too unwell to be assessed from a social care perspective and needed a medical review. The care home said Mrs Y’s records were in the process of being transferred from her old GP surgery to their GP. This should be completed by the next day and it would refer Mrs Y to the RITT. The care home also raised concerns that Mrs Y was not taking her medication. The Council advised this was also the GP's remit.
25. Two days later the Council spoke to the care home which said Mrs Y remained aggressive and staff could not get near her to provide personal care but placed food on trays on the side. It said the registration with the GP was nearly complete and it would prioritise a referral to the RITT. The social worker contacted the GP who confirmed Mrs Y was registered with them that day.
26. 16 days after Mrs Y entered the care home it contacted the GP and requested an urgent RITT referral. It also noted they discussed covert medication but given Mrs Y’s poor diet and throwing food out of the window this may not work.
27. Three days later the RITT visited Mrs Y. It updated the Council that it was unable to assess Mrs Y due to her aggression and refusal of treatment. Later that day Mrs Y’s mental health was assessed following a referral from the RITT. This found Mrs Y was not able to consent to her care and treatment and she was a significant risk to herself through self-neglect and to others through her aggression. This recommended a section 2 admission under the Mental Health Act for assessment.
28. The following day, 21 days after entering the care home, Mrs Y transferred to a mental health hospital.
29. Mr X complained to the Council that Mrs Y was discharged to an inappropriate placement. The Council responded in late February 2025. It said the multi-disciplinary team decided where Mrs Y should be discharged to and the social worker acted appropriately. It noted there was a delay in the care home registering Mrs Y with their GP or referring her to the mental health team. The care home told the Council it did not raise it immediately as behaviours can be temporarily escalated due to a change. It also said the family had asked it not to pursue registration with the local GP. It accepted it should have insisted on her transferring to its GP immediately.

Findings

30. When Mrs Y was fit for discharge from hospital the Council arranged for her to be assessed by a Nurse to determine if she had any health needs. It then arranged a multidisciplinary team meeting. As Mrs Y did not have any health needs all parties agreed Mrs Y, in her best interests, should be discharged to a short term residential dementia bed for a period of assessment. There was no evidence of fault in the way the way the Council arranged Mrs Y’s hospital discharge.
31. The Council, through its care navigation team consulted care homes. The Council provided the Grange Care Home with information on Mrs Y’s needs and provided behaviour charts from the hospital. There was no fault in the initial information the Council provided to the care home.
32. The Council arranged a short term care home stay so that Mrs Y’s needs could be appropriately assessed and Mrs Y left the care home after three weeks. The care home sought to support Mrs Y and to meet her needs. The behaviour records from the hospital showed Mrs Y had periods of agitation but were not so suggestive that a residential care home for those with dementia could not meet her needs. Mrs Y’s behaviour deteriorated during her time in the care home. I could not say, even on balance, that would not have occurred had she moved to a different care home.
33. When Mrs Y first arrived at the care home it raised concerns about her behaviour and whether it could meet her needs. In response to Mr X’s complaint it said it did not take action straightaway as sometimes behaviours could be temporarily escalated by a change in environment. This was not fault.
34. However, Mrs Y’s behaviour did not improve and it delayed arranging to transfer Mrs Y’s GP. This delay was fault. The care home records show a staff member spoke to the family five days after she entered the care home. The family initially did not wish to change GPs but agreed to this later that day. Further care home records show a similar conversation the following week. It is unclear why the care home did not take action to change Mrs Y’s GP earlier.
35. After the transfer of Mrs Y’s GP, the care home acted appropriately to make urgent referrals for support. Had it transferred GP’s straightway it is likely Mrs Y would have received support at least a week earlier. I cannot say, even on balance, that had a GP transfer occurred straightaway, the outcome would have been different. However, the delay is likely to have caused Mr X frustration and uncertainty over whether things may have been different.

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Agreed Action

36. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care home and so made recommendations to the Council.
37. Within one month of the final decision the Council has agreed to:
1. apologise to Mr X and pay him £200 to acknowledge the frustration and uncertainty caused by the care home’s delay in transferring Mrs Y’s GP.
2. remind the care home of the importance of signing new residents up to their GP as soon as possible.
38. The Council should provide us with evidence it has complied with the above actions.

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Decision

39. I found fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman