Summary: Mr C complains about the care Mr F received during the two weeks he spent at a nursing home, which had been arranged by the Council. The Ombudsman found fault with the care Mr F received at the home. The Council has agreed to waive Mr F’s care charge and apologise to Mr C for the distress he experienced.

The complaint

1. The complainant, whom I shall call Mr C, complains on behalf of himself and his (late) father, whom I shall call Mr F. Mr C complains that:
• The Council should not have moved his father during the Christmas / New Year period.
• He raised several concerns with the social worker on 2 January 2018. However, the social worker failed to act on them.
• The care home failed to meet his father’s medical needs properly.
• The Council failed to investigate the concerns he raised (as a complaint) and failed to refer the safeguarding alert to Birmingham City Council (BCC).
2. Mr C told me that, as an outcome of his complaint, he wants an apology from the Council, with a decision to waive the outstanding Council bill for the care (£645.02).

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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. 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, although we found fault with the service of the nursing home, we have made recommendations to the Council.
5. 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)

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How I considered this complaint

6. I considered the information I received from Mr C and the Council. I also considered the findings (report) of an investigation by the local clinical commissioning group (CCG) into the care issues Mr C raised. I shared a copy of my draft decision statement with Mr C and the Council and considered any comments I received, before I made my final decision.

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What I found

7. Before Mr F went into hospital, he lived at home with a care package of three visits a day. He also received support from district nurses who cared for his long-term urinary catheter. On 5 November 2017, Mr F showed signs of a Urinary Tract Infection. Further, the nurse could not replace his catheter. The Out of Hours GP called an ambulance to take Mr F to hospital.
8. From the hospital, Mr F went into a temporary bed at a nursing home, while the Council would arrange a permanent place in a different nursing home. Mr C says he was happy with the support his father received at the temporary home, which was organised and paid for by the NHS.

Mr C’s complaint about the discharge date

9. Mr C moved on into the second nursing home on 28 December 2017. Mr C complains the Council should not have moved his father during the festive season (Christmas – New Year period). His father had complex medical needs, which needed good liaising with local / community health professionals (including his GP). However, these would not be readily available and accessible during the festive season. He said he explained to the Council that this would put his father at risk, but the Council went along with the move anyway.
10. The Council says that:
• The nursing home carried out an assessment on 21 December 2017 to decide whether they could meet Mr F’s care needs. The care home confirmed the following day they could meet his needs and could accept him on 28 December 2017.
• The Council called Mr C on 22 December to tell him of the discharge date and arrange to meet at the home so he could sign the contract. The case recording indicates that all parties agreed the date of 28 December, including the nursing home and Mr C. There is no evidence in the records that Mr C raised any concerns about the proposed discharge date, when the Council made the discharge arrangements. The allocated social worker has also confirmed that this was the case.

Mr C’s complaint about his father care

11. Mr F’s transport on 28 December 2017 was carried out by the local NHS Ambulance Trust. On Mr F’s arrival at the nursing home, it appeared his care records had been lost. This was not due to fault by the Council or the second nursing home. However, Mr C told me this had an impact on his father’s subsequent care, because the nursing home could not see from his records how his care / medication had been provided during the last few weeks. Mr C said this was even more concerning, because his father’s current and previous GP could not be contacted for information either, during the festive season.
12. Mr C complains the care home failed to meet his father’s medical needs properly. Mr C says:
• The home did not have the equipment he needed (catheters, flushing solutions, a catheter stand) and asked the family to get this. Fortunately, the family could get this from his father’s house. The home should not have accepted / admitted his father without this being in place first.
• The home constantly contacted the family, almost daily, to ask for information, and collect his medication.
• Nursing staff could not flush or change his father’s catheter, which had been done regularly by nursing staff at the previous home.
• The staff was slow to involve a GP when his father’s condition declined. A GP only became involved due to the family insisting.
• Staff failed to ensure / monitor that his father received enough fluids. This was very important with his conditions.
13. The home manager told the CCG investigator that the home asked the family to provide the equipment, because it was difficult to get such items quickly, particularly over the holiday period. The investigator concluded that:
• It is expected that if a home accepts a patient with specific needs, including catheters, that enough stocks are readily available before their admission to the home. This was not the case here, which is fault. It is important that all necessary consumables should always be in stock, and the home ensures there is enough stocks for holiday seasons with contingency plans in place.
• The home carried out appropriate actions, including: involving the District Nurse, asking the family to provide the equipment instead, involving the Out of Hours GP and subsequent admission to hospital. The staff appeared to escalate for support in a timely manner.
14. The CCG investigation confirmed the nursing home asked the family to collect medication. The home manager told the investigator the home’s approach was to ask if families were happy to support with such tasks. Only if the family would be unable to do this, would it explore other routes. The manager said the family did not show any concerns at the time with this arrangement. The investigator concluded the home was heavily reliant on the family, irrespective of the time of day or night. This should not be usual practice and it would be important the home ensures that in future, it will no longer be relying on families (as a first line of support) for collecting medication or providing possible consumables.
15. The CCG investigator also found that:
• There were no care plans for continence management, catheter care, maintenance or flushing (if needed).
• There were omissions in details of when staff delivered catheter care, the colour or smell of the urine; and no entries were seen to indicate a flush was carried out.
• The pre-assessment did not record when the catheter was last changed.
• Overall, the pre-assessment could have been more robust, with subsequent care plans put into place and actioned by all staff.
• All fluid intake was recorded on the fluid balance chart. The charts showed Mr F was taking over one litre of fluids a day. However, there was no documentation to state if this was the correct allowance agreed.
• Improved documentation would help to ensure compliance to nutrition instructions (such as adding thickener) and to ensure all staff are aware of individual needs.
16. The home manager told the investigator there were three members of staff at the time, who were trained and skilled to replace catheters. Currently, there were two staff trained to do this, but only if the catheter replacement is uncomplicated. Complex cases should be escalated to the district nurse, GP or the hospital. The investigator concluded the home should put in place links with district nurses, GPs and the local continence service to establish such escalation pathways.
17. Mr F’s condition worsened while at the nursing home, as a result of which he went into hospital on 10 January 2018. Mr F passed away nine days later.
18. The investigator identified a list of recommendation to address the above short comings, which she subsequently discussed with the home manager. The CCG will monitor the implementation of these.

Mr C’s complaint about the way the Council dealt with his concerns

19. Mr C complains that:
• He raised several concerns with his father’s social worker on 2 January 2018. However, the social worker failed to act on them.
• The Council failed to investigate the concerns he raised as a complaint, and failed to refer the concerns to as a safeguarding alert to Birmingham Council.
20. Mr C made a complaint about the above to the Council on 30 May 2018. In its response, the Council said on 13 June 2018 that:
• The above issues were very concerning. As such, the Council recommended to Mr C to contact Birmingham City Council (BCC) to express his concerns. As such, BCC could determine whether a formal adult safeguarding enquiry should be undertaken to investigate the concerns.
• The complaints team said it has alerted BCC to enable them to make their own enquiries.
21. Mr C contacted the Council on 25 June and again on 9 July 2018, to say that he remained dissatisfied with this response, including in relation to the outstanding invoice. However, he did not receive a response to this.
22. The Council told me that:
• Overall, the findings from the CCG report suggests there were some shortfalls in practices. It is unfortunate that the experience of Mr F and his family with the home were unsatisfactory, and we agree this is unacceptable.
• The concerns highlighted will be addressed with the provider through an action plan overseen by the CCG, who will monitor the recommendations to ensure they are being implemented to improve service delivery.
• On this basis, the Council agrees there has been fault regarding the less than satisfactory care Mr F received. The Council therefore accepts Mr C’s proposed remedy and it issue him a formal apology and waive the outstanding care bill of £645.02.

Assessment

23. Mr C says he raised concerns with the Council about moving him during the festive season. He said he also raised concerns about his father’s care on 2 January 2018. However, there is no reference to this in the Council’s records and the social worker involved denies that Mr C expressed concerns at the time. As such, I am unable to conclude that Mr C expressed concerns at the time. Nevertheless, the nursing home should have considered whether it had the equipment, stocks and links with local health services in place, to be able to deal with Mr C’s catheter care during the festive season, or whether it would have been better to delay his admission to the home.
24. The CCG investigation has identified several shortcomings with regards to nursing home’s record keeping, the support Mr F received and the impact this had on the family. The Council has accepted that Mr F’s support fell short and has agreed to provide an apology and waive the outstanding invoice. Furthermore, the Council will coordinate with the CCG to ensure the CCG’s recommendations will be implemented. My view is that this is an appropriate remedy.
25. As the nursing home was in the area of BCC, it would be up to BCC to look into any safeguarding alerts it receives about the home. I did not see evidence that the Council made a safeguarding alert to BCC with regards to Mr C’s concerns. As the Council had commissioned Mr F’s care at the home, and therefore remained ultimately responsible for this, I would have expected that the Council had taken ownership of this and made a safeguarding alert to BCC about the concerns Mr C had raised with the Council, rather than leaving this with Mr C. However, it would also have been open to Mr C to contact BCC directly, when the Council did not do this.

Agreed action

26. I recommended that, within four weeks of my decision, the Council should provide an apology to Mr C and inform him in writing that the outstanding invoice has been waived.
27. The Council has told me it has accepted my recommendations.

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Final decision

28. For reasons explained above, I decided to uphold Mr C’s complaint.
29. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.

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Investigator's decision on behalf of the Ombudsman