Summary: The care provider did not act promptly to report safeguarding concerns about Mr X. It failed to treat Mr X with dignity. The care provider will now take steps to review its procedures and offer a sum in recognition of the injustice suffered.

The complaint

1. Mrs B complains the care provider failed to safeguard her elderly vulnerable father (Mr X) against abuse by another resident; failed to provide the proper care and treatment for him and attempted to conceal an assault on him. She also complains the care provider did not notify her of a CQC inspection.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I considered all the information provided by Mrs B and the care provider. I spoke to Mrs B. Both Mrs B and the care provider had an opportunity to comment on an earlier draft of this statement, and I considered their comments before I reached a final decision.

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What I found

Relevant guidance

5. 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.
6. The guidance says (Regulation 13) that systems must be established and operated efficiently to prevent the abuse of service users. It also says staff must be aware of and act in accordance with local safeguarding procedures to ensure allegations are investigated.
7. The guidance also says (regulation 10) that service users must be treated with dignity and respect.
8. The guidance also says (regulation 12) that medicines must be administered accurately.

What happened

9. Mr X, who is 87 and has dementia, was resident in an extra care housing scheme at Saxon House: he funded his own care which was provided by the Hales Group care workers and consisted of four care calls every day, to assist with personal care and hygiene, medication administration and meal preparation. Mrs B held power of attorney for him.
10. The care provider says, “[Saxon House] provides independent living for people with onsite care to meet their commissioned care visits under a domiciliary care contract. Hales are contracted to have one staff member on site outside of commissioned care hours to provide an emergency response such as fire or flood evacuation, emergency support due to a fall or illness of a tenant and provide care whilst awaiting emergency services. This does not constitute regular or patterns of increasing care needs outside of a commissioned care package.”

11. Mrs B lives several hundred miles away and says she visited her father every six weeks or so before the incidents described here.
12. Mrs B says there were difficulties in establishing proper communications about her father with the new manager who took up post in 2017. She says she only discovered in October 2019, on a visit to Saxon House, that her father had been assaulted by another resident on 14 September. She says the witness told her Mr X had been dragged from his room by the other resident and the management had to call the police and the mental health crisis team to attend. She says this was not recorded in her father’s daily care notes.
13. Mrs B says she also then discovered her father had been allegedly sexually assaulted by the same resident later in September. She says there was no record of the alleged assault in her father’s notes.
14. Mrs B complained formally to the care provider on 16 October 2019. She said she had stayed longer than planned on the visit after hearing of the incidents which had taken place, so she could ensure her father’s door was locked at night to prevent another incident as the same resident remained in her flat a few doors away from Mr X. She expressed concern that the management had deliberately concealed serious incidents from her.
15. Mrs B complained again to the care provider on 29 October. She said the resident who had assaulted her father remained in a flat near to him, and staff told her they could not do anything to prevent her entering her father’s flat despite the assault. She said she had also, by virtue of her close contact over the last two weeks, seen at first hand the poor care given to her father – for example the poor administration of medication (half-dissolved tablets were left in a glass next to him) and failure to meet his oral hygiene needs (she found his toothbrush dry on at least three occasions after staff were supposed to have cleaned his teeth, and he was noted to have halitosis by independent witnesses).
16. Mrs B said she intended to take her father away from his flat until the complaint investigation was complete. She said she held the Hales staff responsible for failing to provide the statutory notification for safeguarding.
17. Mrs B also disputed some of the care charges.

The care provider’s records

18. The care provider has provided me with its daily care records for the relevant dates. The daily records are computer-based and consist of a list of tasks from Mr X’s care plan which the care worker ticks to show completion. There is room for free text. There is no reference to the incident on 14 September although the care worker completed the free text box to say Mr X was in the corridor when he arrived. There is no reference to the alleged incident on 24 September either.
19. The care provider investigated Mrs B’s complaints. It found there was an “Anonymous post-it note claiming (the other resident) dragged (Mr X) from his room on the 14th of September & on the 24th of September”. It found on 15 September “Carers … attended the care call at 19:30 to find (the other resident) in Mr X’s bed. Nothing states Mr X was in the bed too. (The other resident) was walked back to her flat. Around 20:45 carers return and (the other resident) grabs (a carer) by the arm. (Mr X) is taken to the staff room and the hales manager, the police and crisis team are contacted. (The manager) states the police were coming straight out, but there are no further notes about what happened next”.
20. There were multiple other records of expressions of concern about the other resident’s behaviour towards not just Mr X but generally. The records showed that from May 2019 the other resident’s social worker had been involved in discussions about the suitability of Saxon House as the right environment for her and whether she should be moved, as she was getting into other residents’ rooms, and had attacked residents and a visitor.
21. The first record of a contact with the local safeguarding team was on 28 October 2019 after another incident in which the police and crisis team had to be called out after the other resident attacked Mr X again: “System notes confirm: “Have phoned safeguarding this morning, the lady took details said there was no one to talk to, she said that someone would phone back today” There are no notes to confirm a call back was received”
22. The investigation concluded that although the incidents were not recorded in the daily care notes or communicated to Mrs B, there had been no deliberate attempt at concealment as they had been properly reported to the police and crisis team. It said ‘clear discussions were had to state the environment [the other resident] was in was unsuitable and the housing provider, social services, mental health team were all aware.’ It said there was no evidence Mr X had been sexually assaulted.
23. The care provider says the decision not to record particular incidents in Mr X’s care records kept them confidential from other care staff who were not involved but did not mean they were not appropriately reported.
24. In terms of Mrs B’s complaints about the care provided to her father, the care provider said although the care-workers did not specify each individual task completed, they completed the form to show the personal care had been undertaken. The care provider pointed out Mrs B had only mentioned one instance of poor medication administration but implied in her complaint there were many examples.
25. The care provider says the complaints about Mr X’s oral hygiene were only brought to its attention after Mrs B began to oversee his care in September 2019. It says oral hygiene was not always noted separately in his care daily notes but would have been included in his general personal care.
26. In respect of reporting incidents to the local safeguarding team, the care provider says it did raise concerns with the safeguarding team between September and October 2019, but prior to that it “raised concerns directly with the Social work and mental health teams who advised they were liaising with Safeguarding”.
27. The care provider noted in the investigation report to Mrs B “Safeguarding and CQC notifications have been retrospectively raised in relation to incidents & concerns between 14th September and 16th October. Any further incidents on site in Saxon House, whomsoever they involve, have been notified formally in a timely manner in line with Hales Homecare’s obligations. Additional guidance and training have been provided to management staff in relation to their obligations relating to formal notification processes”.
28. The care provider says it has made financial redress to Mrs B after her queries about invoicing. It says “Hales Group have repeatedly attempted to ensure that (Mr X) ’s family understand the limitations of a care provider in relation to tenancy and commissioning challenges which were outside our control. We would also like to reassure (Mr X)’s family that we have ensured that staff training and development in relation to areas that could be improved: Complaint Management, Statutory notifications, Supporting dementia and MH, have all been addressed in order that a similar set of circumstances does not reoccur.”
29. The care provider points out there was no evidence to corroborate the allegation of sexual assault. It says Mr X was not in the room at the time the other resident was found in his bed; the other resident was fully clothed at the time, and this was also the conclusion of the police investigation.

Analysis

30. The care provider did not act promptly to notify the local safeguarding team of the incidents which occurred. Although the police and mental health services were alerted to the incidents involving the other resident, there should also have been (as the care provider now acknowledges) a formal safeguarding alert raised. That system has now been put in place.
31. There was no attempt to conceal information deliberately. There is ample evidence of the care provider’s involvement of and discussion with other agencies about the issues concerning the other resident.
32. There was however a failure to treat Mr X with dignity. Care staff were aware of and witnessed the way in which he was treated by the other resident but there was insufficiently robust action taken (as specified in paragraph 29) which might have led to a prompter resolution of the matter.
33. There was one recorded instance where medication was not given properly. That was fault and a breach of the regulations although it is doubtful whether one instance caused any injustice to Mr X.
34. The care provider argues the difficulty of its position as a care provider within a setting which was not in its own control (where tenancy matters depended on another body). Nevertheless, staff and management were clearly aware of the incidents which were occurring but failed not only to notify Mrs B (Mr X’s nearest relative who had power of attorney for him) and the landlord company, but also relied heavily on its position as care provider, not landlord. The care provider was not the only agency with responsibility here, but there was fault which caused injustice and as a result Mr X was left in a vulnerable position longer than he might otherwise have been.
35. The care provider was not obliged to notify Mrs B of the impending CQC inspection.

Agreed action

36. Within one month of my final decision the care provider will provide me with details of the training undertaken to ensure proper procedures are followed in terms of safeguarding alerts;
37. Within one month of my final decision the care provider will review the way in which it communicates with relatives about incidents involving its service users and let me know what it intends to put in place going forward;
38. Within one month of my final decision the care provider will let me know what steps it takes to ensure medications are properly administered;
39. There were other stakeholders involved in the circumstances surrounding these complaints. However, this investigation is only concerned with the care provider. It agrees that within one month of my final decision it will offer the sum of £500 to recognize the avoidable distress which was caused to Mr X.

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Final decision

40. I have completed this investigation on the basis that the actions of the care provider caused actual injustice to Mr X, and distress and uncertainty for Mrs B.

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Investigator's decision on behalf of the Ombudsman