Summary: Mrs B complains about the quality of care her mother, Mrs C, received at a residential care home placement arranged by the Council (The Elms Care Centre, Ibstock). We uphold the complaint finding various examples of poor practice by the Care Provider. We also find the Council did not adequately monitor the placement or respond properly to all Mrs B’s concerns. These faults caused distress to Mrs C and Mrs B, as well as resulting in frustration and time and trouble to Mrs B. The Council accepts these findings and at the end of this statement we explain action it has agreed to take to remedy this injustice.

The complaint

1. I have called the complainant ‘Mrs B’. Her complaint centres on the care provided to her mother, ‘Mrs C’, between July 2017 and March 2018 when she lived at the Elms Care Centre, Ibstock. The Council arranged for that placement. Mrs B makes complaints about the quality of care Mrs C received from the Care Provider including that it failed:

• To seek prompt medical attention on 4 September 2017 when Mrs C experienced a fall which caused a broken wrist. It then sought to recover money from Mrs B for the cost of taking Mrs C to hospital for an x-ray and treatment on 5 September 2017.
• To properly manage Mrs C’s diet and continence care. Mrs B says that Mrs C became incontinent while living in the care home. She says this is due, in part, to a failure by the Care Provider to ensure Mrs C followed a coeliac diet.
• To maintain Mrs C’s skin integrity. Mrs B says when Mrs C moved away from the care home she had dry patches on her legs which bled when touched.
• To provide suitable activities for Mrs C. Mrs B says the Care Provider promised Mrs C a wide range of activities including opportunity to play the piano. But the Care Provider failed to provide these and Mrs B says Mrs C lost mobility while in the home.
• To help Mrs C maintain her personal appearance. For example, in supporting her with hair and nail care. Also, in ensuring she wore clean clothing.

2. Mrs B further suspects Mrs C was hit while living in the care home. She says Mrs C flinched when Mrs B went to brush her hair and said she feared being hit. Mrs C also repeatedly said “don’t hurt me” when care workers began supporting her after she moved away from the care home. The Council considered this matter as part of a safeguarding investigation begun in response to Mrs B’s complaint made in April 2018.
3. A third part of Mrs B’s complaint concerns the Council’s management of her mother’s care. Mrs B says the Council failed to respond appropriately to concerns she raised about her mother’s care, including the events of 4 September 2017.
4. Mrs B says as a result of the poor care Mrs C experienced she suffered distress and did not get the care she should. Mrs B, who has power of attorney over Mrs C’s financial affairs does not consider she should have to settle in full an outstanding bill for Mrs C’s charges while at the care home. Mrs B also says she suffered her own distress from the events described.

Back to top

The Ombudsman’s role and powers

5. 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, section 25(7), as amended)
6. 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)
7. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe fault has not caused injustice to the person who complained or the injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended)
8. If we are satisfied with a council’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)

Back to top

How I considered this complaint

9. Before issuing this decision statement I considered:

• Mrs B’s written complaint to the Ombudsman and any supporting information she provided, including that gathered in a telephone conversation with her.
• Information provided by the Council setting out how it responded Mrs B’s complaint before we began our investigation. Further information it then provided in response to our specific enquiries.
• Relevant legal and procedural matters as set out in the text below.
• Reports undertaken by the Care Quality Commission (CQC) into care standards at The Elms Care Centre.
• Comments made on a draft decision by Mrs B and the care provider. The Council only commented on the draft decision to confirm that it accepted the proposed findings.

Back to top

What I found

Relevant Legal and Administrative Considerations

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the ‘fundamental standards’ which all care providers should meet in delivering care. We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
11. Of relevance to this complaint are the following:

• Regulation 9 – “Person-centred care”. This Regulation is to ensure those who use care services receive care personalised specifically for them. Care should follow an assessment of their needs and preferences. Accompanying guidance says assessments of people's care needs should include all their needs, including health, personal care, emotional, social, cultural, religious and spiritual needs. Assessments and care plans should be regularly reviewed and a plan should contain a review date.
• Regulation 12 – “Safe care and treatment”. This Regulation aims to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment. Guidance says providers must do what is reasonably practicable to mitigate risks. Incidents that affect the health, safety and welfare of people using services must be reviewed and thoroughly investigated by competent staff. Outcomes of investigations into incidents must be shared with the person concerned and, where relevant, their families, carers and advocates.
• Regulation 14 – “Meeting nutritional and hydration needs”. Providers must ensure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. People must have their nutritional needs assessed and food must be provided to meet those needs. Nutritional needs assessments should “as a minimum” include consideration of dietary intolerances among other matters. The provider should regularly review the nutrition and hydration needs of users of its services.
• Regulation 17 – ‘Good governance’. This regulation requires providers have systems and procedures in place to meet other regulatory requirements. Systems and procedures should assess, monitor and mitigate any risks relating to the health, safety and welfare of people using services. Providers must also maintain accurate, complete and detailed records for each person using the service.

12. Regulation 18 of the CQC (Registration) Regulations 2009 says care providers must report all incidents to the CQC which result in serious injury to a service user.
13. Regulation 19 of the CQC (Registration) Regulations 2009 covers notice of fees payable to care providers. This regulation should ensure providers give timely and accurate information about the cost of their care and treatment to people who use services. To meet this regulation, providers must make written information available about any fees, contracts and terms and conditions, where people are paying either in full or in part for the cost of their care, treatment and support.
14. The Council also has a legal responsibility to safeguard adults. In any case where the Council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
15. The aims of adult safeguarding are to:
• prevent harm and reduce the risk of abuse or neglect to adults with care and support needs;
• stop abuse or neglect wherever possible;
• safeguard adults in a way that supports them in making choices and having control about how they want to live;
• promote an approach that concentrates on improving life for the adults concerned;
• raise public awareness so that communities as a whole, as well as professionals, play their part in preventing, identifying and responding to abuse and neglect;
• provide information and support in accessible ways to help people understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or well-being of an adult; and

• address what has caused the abuse or neglect. (Care and Support Statutory Guidance, 14.11)

16. Local authorities have a duty to arrange care and support for those with eligible needs (Care and Support Statutory Guidance 8.4). In care homes, the local authority cannot pay for the cost of care if the user of the service has resources above the capital limit, currently £23,250. For those who do not have capacity to arrange their own financial affairs the Council should work with anyone with legal authority to act on their behalf. For example, someone holding power of attorney or acting as a Court appointed deputy. If there is no-one with such powers the Council must arrange and pay for the care needed until someone obtains such powers.

Chronology of events

Background

17. The beginning of events covered by this complaint is June 2017. Before this time Mrs C lived at home. She received no care from the Council. She suffered a fall at home resulting in her admittance to hospital. On discharge she went to the Care Provider. This was at first for four weeks respite care. Subsequently, Mrs C remained at the care home as a short-stay resident. From her arrival there was discussion between Mrs B and the Council about Mrs C moving to another area closer to Mrs B’s sister. Mrs C went on to move in early March 2018. Since then Mrs B’s sister has arranged care for Mrs C.
18. In June 2017 Mrs C had capital above the capital limit (see paragraph 16). However, the Council did not consider Mrs C had capacity to manage her financial affairs. So, it agreed to pay for Mrs C’s care while Mrs B sought legal authority to manage Mrs C’s financial affairs. It confirmed this arrangement in a letter sent to Mrs B at the end of July 2017.

The Care Provider’s care planning

19. When Mrs C arrived at the care home, the Care Provider undertook some care planning. It has provided a copy of a ‘short stay care plan’ dated 31 July 2017 and reviewed monthly after that but not amended. The care plan provides brief comments in answer to various questions. For example:

• Q: Toileting/Continence Management; A: [Mrs C] is continent.
• Q: Preferred bathing and showering arrangements? A: [Mrs C] refused a bath or shower when asked.
• The plan comments that Mrs C’s “skin is intact” and her “feet are fine”.

20. The plan provides a description of Mrs C’s preferred daily routines. There is no mention of preferred activities except that she enjoys looking out of her window into the garden. There is a paragraph explaining that Mrs C was “very disruptive” in the afternoons often wanting to leave the care home. A section asking about Mrs C’s life story or “past hobbies” is blank.
21. In a section of the plan headed “mobility/prevention of falls” the care plan notes Mrs C is independent and does not need carers to support with transfers. An undated hand-written note refers to Mrs C “having a fall today but no serious injury” and provides a brief description of the event.
22. In the section of the care plan headed “food/dietary needs”, the plan says only that Mrs C “eats well and has no likes or dislikes”. The care plan noted Mrs C had epilepsy, vascular dementia and hypertension. The form lists only one medication taken by Mrs C; lorazepam which can cause drowsiness.
23. The Care Provider carried out separate risk assessments for Mrs C’s skin integrity and risk of falls. It completed the skin integrity risk assessment in early August 2017 and reviewed it without making changes at monthly intervals between September and November 2017. The assessment recorded Mrs C having healthy skin and complete continence. It scored her at no risk of having pressure sores.
24. There are two falls risk assessments; one dated 4 July and one dated 4 September 2017. Neither has Mrs C’s name on it with the space for the name left blank. Two sheets, also missing Mrs C’s name, show reviews of the risk assessments. One says reviews took place in August and on 4 September 2017 and on both occasions the risk assessment was “still reflective” of Mrs C’s risk. The other sheet says reviews took place on a different date in August and in late September and October 2017. Again, the comment records the assessment “still reflective” of risk.
25. Both assessments recorded Mrs C at low risk of falls. The assessment dated 4 July refers to Mrs C having a previous history of falls. It does not record her having vascular dementia even though this is a risk factor marked on the form. It records Mrs C being “fully co-operative” in her care. It refers to there being no side effects with her medication.
26. The 4 September assessment records Mrs C having unpredictable or variable moods. It notes she has vascular dementia. But records her having no history of falls. It does not note any side effects associated with her medication.

Events on 4-5 September 2017

27. On 4 September 2017 Mrs C suffered a fall at the care home. On 5 September an x-ray at a local hospital found she had fractured her wrist. Mrs C then went to another hospital to have the injury set in plaster. Mrs B says when Mrs C went to hospital her fingers had swelled and she needed rings cutting off.
28. An incident report kept by the Care Provider recorded Mrs C falling from her chair when reaching for her purse she had dropped on the floor. It said at 11:00am Mrs C was “vocalising pain” and had bruising/discolouration and swelling. The form says care home staff spoke to the GP surgery at 11:45am and received advice “to have it checked out at hospital in case [Mrs C] had done something because her hand was hurting”. The form says the Care Provider told Mrs B of the incident at 9:30am on 5 September. The form also says the fall was non-anticipated and that “one member of staff now remains on the floor at all times and to monitor [Mrs C] when she is on the move”. A section headed 'possible reasons for the fall’ is incomplete.
29. As required by law the Care Provider sent a notice of the incident to the CQC. This says the Care Provider “made an appointment” for Mrs C to attend a local hospital for x-ray.
30. The Care Provider also kept a running daily care log. This says: “Doctor has been out to check on [Mrs C] and is arranging for her to have a x-ray at local hospital”. The daily care log says Mrs C received a cold compress and pain relief in the afternoon of 4 September.
31. There is fourth record of potential relevance, which is a separate log of contacts the Care Provider maintained when Mrs C needed medical care. However, I have seen no entry for 4 or 5 September 2017.
32. Mrs B says it was a nurse practitioner who went to the care home. She understands they told the Care Provider to take Mrs C to hospital and the care home only delayed until the following day because of staff shortages. She also understands the nurse practitioner told the Care Provider to remove rings worn by Mrs C because of her hand swelling.
33. When Mrs C attended hospital on 5 September, a member of the care home staff accompanied her. Mrs B went to visit her later in the day following Mrs C’s return to the care home. The Care Provider then asked her to pay £102 to cover its costs of accompanying Mrs C to hospital.
34. The Council’s safeguarding investigation (see below) obtained confirmation for this. The member of staff accompanying Mrs C said a manager told her to bill Mrs B for “miles driven, petrol costs and the costs of having another carer cover her shift”. Mrs B refused to pay and the Care Provider dropped its demand. It later said its Manager’s actions were contrary to policy.
35. In February 2018 Mrs C suffered a further fall at the care home. Notes say she “had got up cross legged and fell on her bottom”. The care home recorded speaking to the GP surgery which advised it to carry out checks on Mrs C and let it know if she reported any loss of movement in her legs, bowel or bladder. Three days later it called the GP who visited and advised on pain medication “if pain is still an issue”. There is no record of the care home telling Mrs B about this fall.

The Council safeguarding investigation

36. In April 2018 Mrs B complained to the Council about its actions in this case and the care Mrs C received (as summarised in paragraphs 1 to 3). The Council said it would investigate the complaint as a safeguarding matter. It commissioned a social worker whose investigation began in May 2018 and completed in October 2018.
37. The investigating social worker visited the Care Provider and inspected records. They also sought some information from Mrs C’s GP. There was delay because Mrs C had moved to another practice area and her current GP reported delay in receiving her notes. As part of their investigation the social worker also spoke to Mrs B twice to gather information, including to seek her view on whether Mrs C would potentially recall her time at the care home.
38. The investigation obtained information about:

• The events surrounding Mrs C’s fall on 4 September 2017 as I have summarised, including the attempt to charge Mrs B for the Care Provider’s staff accompanying Mrs C to hospital. It also found out there is no detail on Mrs C’s medical notes to confirm the advice given to the Care Provider on 4 September. This included whether the Care Provider received advice to remove Mrs C’s rings as her hand swelled.
• That a pharmacist had “attempted to prescribe” aqueous cream to Mrs C but the Care Provider told them it was “not required”. A care worker told the Council that Mrs C did rub such cream on her legs. But the Care Provider probably rejected the prescription as Mrs C had a big tub of cream that lasted a long time.
• There were no records of Mrs C having coeliac disease. Medical records referred to past prescriptions for coeliac dietary products until May 2016. They were stopped on guidance from a named individual, who would appear to be a pharmacist.

39. The Council closed its investigation reaching the following findings:

• That it could not find out what advice the Care Provider received from the GP when Mrs C fell on 4 September 2017. So, it could not say if this resulted in delay in getting the x-ray or Mrs C’s rings being cut off later.
• That the Care Provider had no awareness of Mrs C needing a coeliac diet.
• That risk assessments completed by the Care Provider showed Mrs C’s skin intact.
• That due to the time elapsed the investigation could not substantiate that Mrs C suffered any physical abuse.

40. The Council communicated these findings in writing to Mrs B in October 2018. She then contacted the Council in December 2018 about the safeguarding investigation. The Council replied offering more explanation for its findings and apologised for how long the safeguarding investigation took. The reply signposted Mrs B to the Council complaints team if unhappy with the reply.

Other records

41. There is no record of the Council visiting or assessing Mrs C’s needs at any point after she entered the care home. It has records of various contacts from Mrs B. Mostly these concern discussions around the cost of Mrs C’s care and arrangements for paying it. There were also various communications around Mrs B’s efforts to obtain authority to deal with Mrs C’s financial affairs and arrange her move away.
42. However, on 5 September 2017 the Council recorded contact from the Care Provider which reported Mrs C’s fall at the care home. The Council recorded brief details of the incident. There is no record of any further consideration given to it. It has no record on its notes of contact from Mrs B about this incident.
43. However, Mrs B provides a copy of an email she sent on 7 September 2017 which refers to an attached “report on the incident”. Her email says the incident provides “even more reason to get Mum [moved] before anything else happens”. Mrs B addressed her email correctly to a social worker she contacted several times before and afterwards. I note no other email sent by Mrs B which is not on the Council’s records.
44. As part of this investigation I considered all daily care logs kept by the Care Provider of Mrs C’s stay. I noted these were in two parts. One a commentary on Mrs C’s general well-being (‘the running care notes’) and one referring only to activities (‘the activity log’). In the running care notes there are frequent mentions of Mrs C’s mobility, with her often described as walking around the home. There are no mention of any falls other than those I mentioned above. Staff refer many times to Mrs C toileting independently with only occasional references to her needing any assistance. A note kept in February 2018 said Mrs C forgot to change her underwear and staff should monitor this. But there are other comments on Mrs C looking smart. The notes describe Mrs C looking after her personal care except when bathing when staff would help. They describe Mrs C experiencing frequent agitation and anxiety, especially when wanting to leave the care home. Notes refer to the Care Provider having deprivation of liberty safeguards in place for Mrs C (authorising it to prevent her leaving the care home), but I have not seen a copy of these.
45. The activity log usually comprises two to three brief daily entries. It often describes Mrs C as chatting or watching television. It also reports her listening to music, sometimes reading newspapers or completing puzzles. There is evidence of occasional wider activities at the care home such as sing-alongs or quizzes.
46. A CQC report issued in September 2018 and based on an inspection in July 2018 found among other matters that:

• Care plans were basic and lacked the detail to support staff to provide person-centred care.
• The Care Provider did not consistently maintain systems to monitor the quality of care and effectiveness of the service.
• People’s access to activities in and out of the home was limited.

47. However, the report also found the Care Provider’s service satisfactory in other regards. It said the Provider considered people’s health care and nutritional needs appropriately. It also consulted health practitioner’s appropriately. Its staff had a good understanding of the need to safeguard adults from harm.

My findings

Care Mrs C received from the Care Provider – the fall on 4 September 2017

48. I begin by considering events around 4 September 2017 when Mrs C fell from her chair. I consider there is evidence of fault in the care given to Mrs C in two key regards.
49. First, the Care Provider failed to seek suitable prompt medical treatment for Mrs C. There are conflicting reports of what the Care Provider did to provide Mrs C with help. One record says it telephoned the GP surgery. Another refers to a GP visit. One record says the Care Provider received advice to take Mrs C to hospital. Another, that it received advice to book an appointment for Mrs C to have an x-ray. While a third record says it was the GP surgery that booked an x-ray. This is symptomatic of poor record keeping by the Care Provider, a theme I return to below.
50. But whatever advice the Provider received I find that by lunchtime on 4 September it had clear evidence of Mrs C being in pain with signs of injury. It knew, as a minimum, that Mrs C needed an x-ray. I can see no reason it should not have tried to obtain that x-ray the same day, consistent with its duty to provide safe care to Mrs C. Even if understood Mrs C would receive an x-ray the following day by appointment there was nothing to stop it acting more urgently and taking Mrs C to an A&E Department.
51. Second, the incident highlights the Care Provider’s poor practices around record keeping. I have already noted the contradictions between the Council’s incident report, running care notes and CQC incident report. But there is also no record of the Care Provider’s discussion with the GP where it usually kept note of such consultations. All of this suggests a chaotic approach to how it records falls incidents and its response to the same.
52. I find this conclusion reinforced by the confusing trail that surrounds the falls risk management for Mrs C. Neither risk assessment provided is fit for purpose. Neither contains Mrs C’s name. Both contain omissions. The first failed to mention Mrs C’s vascular dementia and described her as co-operative with her care, a statement contradicted by much other evidence. While the second, even though dated the day of Mrs C’s fall, did not mention her having any falls. Neither considered if Mrs C’s prescription of lorazepam put her at risk of falls, while there is no record of whatever other medication Mrs C received in her care plan.
53. I am doubtful about the veracity of these records given the inconsistency in dates when the Care Provider reviewed the risk assessments. But even if I accept those reviews took place, I note they inexplicably stopped three months before Mrs C left the care home. Those reviews were also clearly not fit for purpose if they failed to pick up on the obvious errors highlighted in the paragraph above.
54. Further, the initial care planning undertaken by the care home for Mrs C was inadequate in several regards. This included its failure to record a history of falls, a consequence of which resulted in Mrs C moving into residential care. The further hand-written note of a fall on the care plan makes no mention of when or how this happened.
55. The incident report suggested the Care Provider reviewed practice in trying to prevent Mrs C having another fall. But there is nothing in the risk assessments to reflect this. The comments are also not reflected in the care log notes which do not suggest the sort of constant watchful care the Care Provider referred to.
56. It is also not clear how the Care Provider responded to those other falls Mrs C had at the care home. I have not seen incident reports for those episodes. Nor what review of falls management took place.
57. Taking account of these factors, the only finding I can make is that the Care Provider was at fault for its management of Mrs C’s falls risk. I do not consider it complied with the fundamental standard in Regulation 12 to provide safe care and treatment to Mrs C. It neither carried out a proper assessment of Mrs C’s risk of falls nor a meaningful review when she experienced a fall. This catalogue of poor care planning must also call into question whether the Care Provider met the standards of good management set out in Regulation 17, another fundamental standard. Its poor record keeping alone would justify a finding of fault.
58. It was then further fault when the Care Provider failed to tell Mrs B promptly of her mother’s fall. The Care Provider’s own records support Mrs B’s account she did not know until the following day. This too reveals a hole in the Care Provider’s care planning. Nowhere in the care plan is there any statement about contact with Mrs C’s family if she fell ill or had an accident. There is no record of the Care Provider speaking to either Mrs C or her family as part of its care planning, which appears based on cursory observations made when Mrs C first moved into the home. I note the CQC raised concerns about the quality of the Care Provider’s care plans when it inspected a few months after Mrs C left its care.
59. A further fault then followed when the Care Provider asked Mrs B to pay for its staff accompanying Mrs C to hospital. This was wrong first because the Care Provider had no contract with Mrs B to provide Mrs C’s care. Its contract was with the Council. But even if it had a contract with Mrs B it would need to have clearly explained her liability for any charges in advance to be compliant with Regulation 19 of the CQC (Registration) Regulations 2009. I have not explored whether any charge could be lawful at all. Although I think that doubtful given the Care Provider’s duty to provide safe care and treatment which must involve ensuring its residents attend urgent medical appointments.
60. These faults cause injustice to both Mrs C and Mrs B. In Mrs C’s case I am satisfied she will have experienced unnecessary distress in the delay waiting for medical treatment on 4 September and having rings cut off. While I consider there were wider failings in the Care Provider’s management of Mrs C’s care planning and risk of falls I consider any further distress from this limited. Because even though Mrs C experienced up to two further falls at the care home the evidence suggests any injury from these limited. Further, I am conscious that even scrupulous care planning cannot cut out the risk of falls.
61. Mrs B’s injustice will be that of distress also, knowing her mother suffered unnecessarily for 24 hours. She also experienced her own distress in the delay in the Care Provider telling her of the fall and wrongly asking her to pay money to it.

Mrs C’s diet and continence care

62. I have highlighted above the inadequacy of the Care Provider’s care planning for Mrs C. However, I find no grounds to suggest the Care Provider ignored any problems with Mrs C’s continence care on her entering the care home.
63. Both the Care Provider and Mrs B agree Mrs C was continent when she entered the care home. I find there are then multiple (almost daily) mentions of Mrs C having no care needs in this regard after that in the Care Provider’s running care records. There are occasionally references to Mrs C needing help with toileting, one mention of her not changing her underwear and occasional references to stomach upsets. But there is nothing in the papers that suggests Mrs C developed a need for continence care during her stay with the Care Provider.
64. Mrs B says that while Mrs C was in the Care Provider’s care she had to purchase incontinence pads. This would contradict the Care Provider’s records. However, even while this would suggest a need for continence care it would not provide evidence of the Care Provider failing to meet such a need. Nor that poor care caused Mrs C to become incontinent. So, while I accept Mrs B’s account and what she found when Mrs C left the care home I do not have sufficient evidence to find fault here.
65. I find the Care Provider at fault for the limited care planning it did around Mrs C’s dietary needs. The single line in its care plan does not suggest any proper consideration of this matter. I reiterate the care plan does not appear to have involved either Mrs C or her family. Had it done so, then Mrs B could have alerted the Care Provider to her understanding that Mrs C needed a coeliac diet and the Care Provider could have checked that accordingly.
66. However, given what the Council later found during its safeguarding investigation I do not consider it would have received confirmation Mrs C needed such a diet. Nor do I find evidence in the papers of Mrs C having persistent digestive problems brought on by her diet at the care home. So, while I consider there was further fault in the care planning, I do not consider on this occasion it caused injustice to Mrs C.

Mrs C’s skin integrity

67. The Care Provider’s care records appear deficient. Nowhere in Mrs C’s care plan or supporting papers is there any suggestion Mrs C suffered sore skin. So, on the surface, its management of this issue appears satisfactory.
68. But I note the Care Provider failed to keep its record up-to-date. It provides no record of reviewing Mrs C’s skin integrity after November 2017.
69. I also note the evidence obtained by the Council’s safeguarding investigation that Mrs C used aqueous cream, a treatment for dry skin conditions. She had a long-standing prescription for this, not recorded in her care plan.
70. That is a fault which again questions the Care Provider’s ability to comply with Regulations 12 and 17 of the CQC fundamental standards.
71. In terms of injustice, I see no reason to doubt Mrs B’s account of the condition of Mrs C’s legs when she left the care home. It is reasonable to consider therefore that Mrs C again experienced some distress because of the Care Provider’s failure to adequately monitor this issue.

Mrs C’s activities and mobility

72. The running daily care notes provide enough evidence that on balance I am satisfied Mrs C preserved mobility while living at the care home. If Mrs B noted a deterioration then I could not say that was down to the Care Provider limiting Mrs C’s ability to mobilise.
73. But when it comes to activities at the care home, I question the Care Provider’s description of some items in these terms. I assume matters such as chatting and watching television an essential ingredient of daily living. But on their own these ‘activities’ are not enough to show a varied, stimulating environment. I consider this is what Mrs B envisaged when Mrs C entered the care home and what she had in mind when making her complaint. She refers in particular to her mother having opportunity to play the piano; something not referenced in the Care Provider’s notes.
74. Unfortunately, the care plan is yet again lacking in recording any hobbies or activities Mrs C might have enjoyed. There is also no biographical detail in there which would help staff engage with Mrs C; especially during times of agitation and anxiety which Mrs C experienced. So, the evidence suggests the Care Provider did not provide enough activities as part of its care for Mrs C. It should also have tried harder to record her individual preferences. That is a fault. This finding is also reinforced by the findings of the CQC inspection which took place soon afterwards.
75. I consider the injustice which arises is that of some limited distress to Mrs C in the form of uncertainty. I cannot say that a more varied and personalised programme of activities would have limited Mrs C’s anxiety triggered by moving to a care home environment and her dementia. But it is not unreasonable for Mrs B to consider that it might have done.

Mrs C’s personal appearance

76. I again find the Care Provider’s care plan lacking in detail. For example, in explaining Mrs C’s habits or preferences when it comes to receiving chiropody or hairdressing services. These are usually matters which fall outside the scope of any contract for care and I note further no discussion of these matters in communications between the Council, Mrs B and the care provider. I consider it would have been helpful therefore had the Council given more attention to these matters in advance.
77. However, I do not find on balance that I can uphold this part of Mrs C’s complaint. Because while I recognise what Mrs B found when Mrs C left the care home, I do not find overall the evidence supports that Mrs C’s needs were not met in these areas.

The complaint Mrs C may have been hit while living in the care home

78. I understand why Mrs B has concerns in this area. But it is speculative to link Mrs C’s flinching and comments with any specific incident in the care home. There is no other evidence which would suggest any incident where Mrs C suffered physical abuse while living there. Consequently, I cannot uphold this part of the complaint.

The Council’s safeguarding investigation

79. I consider it flows from what I have said above that I have concerns about the adequacy of the Council’s safeguarding investigation. I can make no criticism of the finding there was no evidence that Mrs C suffered physical abuse while living in the care home.
80. But I am concerned that in the areas of falls risk management, dietary assessment and skin integrity the Council did not pick up on the deficiencies in the Care Provider’s records. The Council has a duty to consider the wider implications of any safeguarding investigation it undertakes. In this case I consider the Council should have been more conscious of the need to consider others at the home whose needs may have been similarly poorly assessed. The implication of such poor falls risk management in another case could have far more serious consequences.
81. I also find no evidence the Council looked to see how the Care Provider would avoid a repeat of its inappropriate attempt to bill Mrs B for Mrs C’s hospital appointment. The Council should have alerted the CQC and/or the Council’s contract monitoring team to the Provider’s practice.
82. I find fault therefore with the safeguarding investigation. I do not consider any direct injustice results to Mrs C from this as she was in a place of safety before the investigation began. Nor do I consider Mrs B suffers injustice from these faults although I comment further below on the Council’s overall handling of her concerns, where injustice resulted.

The Council’s case management

83. It was not part of the safeguarding investigation remit to consider the Council’s own awareness of Mrs C’s case when the events Mrs B complains about took place. However, it is still part of Mrs B’s complaint. I have therefore considered the Council’s records of its contacts with Mrs B and Mrs C while she stayed with the Care Provider.
84. The first point I note here is the lack of direct engagement between its social worker and Mrs C. I find it unacceptable the Council carried out no assessment or review of Mrs C’s needs after she moved to the care home. Having located the placement and arranged Mrs C’s care the Council needed to ensure it could meet her needs satisfactorily. It could not do that without assessing her. The failure to review the suitability of Mrs C’s placement was therefore a fault.
85. The second point I note is the Council missed an opportunity to consider the Care Provider’s response to Mrs C’s fall in September 2017 at the time it happened. I am unsure why the email from Mrs B should be missing from its records. But even without that, the Council knew of the fall and Mrs B’s injury. Yet it took no action. It did not check on the Care Provider’s management of the risk of Mrs C suffering falls. This finding links to that made above as this was an opportunity for the Council to review Mrs C’s placement.
86. The Council’s fault here results in further injustice to Mrs C and Mrs B. A review may not have led to the Council deciding Mrs C’s placement was unsuitable. But it could have picked up on the poor care planning practices I have highlighted. It could have sought Mrs B’s views and ensured her involvement in planning for Mrs C’s care moving forward. It could have brought about some improvements in Mrs C’s care and reduced some of the injustice highlighted above. It would have lessened some of Mrs B’s time and trouble in pursuing her complaint.

The Council’s complaint handling

87. Finally, I have considered the Council’s response to Mrs B’s complaint received in April 2018. I make no criticism of the decision to begin a safeguarding investigation into some of Mrs B’s concerns. However, that could not encompass all the concerns Mrs B had about Mrs C’s care. For example, her concerns expressed about Mrs C’s activities at the care home. It was fault therefore for the Council not to consider how it should investigate these. It was also fault for the Council not to consider its own management of Mrs C’s case when replying to Mrs B.
88. Further I note the response Mrs B received after the safeguarding investigation offered no linkage to the Council’s complaint procedure. It did not signpost Mrs B to that nor to this office if unhappy with the response. While the Council’s later correspondence invited Mrs B to get back in touch with its complaints service I query if that was appropriate given the letter flowed from Mrs B’s complaint in April 2018. It could have signposted Mrs B to this office at that point.
89. This causes some further injustice to Mrs B. I consider the fault in the handling of her complaint will have added to her frustration, time and trouble.

Agreed action

90. In paragraphs 60, 71, 75 and 86 I have identified where fault by the Care Provider (acting on behalf of the Council) or by the Council caused injustice to Mrs C. In paragraphs 61, 86 and 89 I identify where fault by the Care Provider or the Council caused injustice to Mrs B. 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. So, where we recommend action to remedy a complaint it is the Council that we ask to provide that remedy.
91. The Council has agreed that within 20 working days of a decision on this complaint it will:
1. Give an apology to Mrs B and Mrs C accepting the findings of this investigation.
2. Write off 10% of the outstanding charges for Mrs C’s care in view of the distress resulting from those faults identified above.
3. Pay Mrs B £500 in recognition of her distress, time and trouble.
92. In addition, the Council has agreed to learn lessons from this complaint. Within three months of this decision it will ensure it has:
1. Given clear advice to its social work staff about its expectations of them in assessing and reviewing the suitability of care home placements it has arranged. This could be by way of a regular staff briefing; one-off briefing or written advice. Any written advice should cross-refer or be linked to any existing procedure or advice given to staff.
2. Given clear advice to its social work staff about its expectations when they are alerted to residents experiencing falls in care settings (or other potential concerns). This should include what records should they keep of their consideration of such incidents and whether this should trigger a safeguarding referral, a review of the placement or some other action. This could be by way of a regular staff briefing; one-off briefing or written advice. Any written advice should cross-refer or be linked to any existing procedure or advice given to staff.
3. Undertaken a review of the care planning records of any residents for whom it has arranged or is paying for care and who are living in the Care Provider’s care home, to ensure they are satisfactory. It should also have undertaken or scheduled a review of those resident’s assessment of care needs to ensure the placement remains fit for purpose.
4. Given clear advice to its social work staff undertaking safeguarding investigations about its expectations when investigations highlight poor practice in care planning or charging (even if individual concerns are not upheld). This could be by way of a regular staff briefing; one-off briefing or written advice. Any written advice should cross-refer or be linked to any existing procedure or advice given to staff.
5. Reviewed how in future it can ensure a more effective response to complaints that result in safeguarding investigations. For example, in ensuring those investigating safeguarding matters refer those raising concerns back to the complaint procedure when setting out their findings. Or in introducing a system to keep in touch with those who have made a complaint which results in a safeguarding investigation.

Back to top

Final decision

93. For reasons set out above I uphold this complaint. I find fault by the Council and the Care Provider acting on its behalf causing an injustice to the complainant and her mother. The Council has agreed action that I consider will satisfactorily remedy this complaint. So, I have completed my investigation satisfied with its actions.
94. 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 our final decision with CQC.

Back to top

Investigator's decision on behalf of the Ombudsman