Summary: Ms X complains her father, Mr Y, was the victim of abuse and neglect by four carers at Ringway Mews Care Home and the Council left her dealing with this on her own with little or no support. There is no dispute over the fact Mr Y was the victim of abuse and that this should have been reported to the Council as a safeguarding concern. If this had happened Miss X could have been better supported. The Council needs to apologise for the failings and the distress they caused.

The complaint

1. The complainant, whom I shall refer to as Ms X, complains her father, Mr Y, was the victim of abuse and neglect by four carers at Ringway Mews Care Home (the Care Home) and the Council left her dealing with this on her own with little or no support.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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, sections 30(1B) and 34H(i), 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, section 25(7), as amended)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Miss X;
• discussed the complaint with Miss X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Miss X and the Council, and invited comments for me to consider before making my final decision.

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What I found

6. Miss X’s father, Mr Y, lives in the Care Home, which is run by HC-One Oval Ltd (HC-One). The Council funds his placement. Miss X has power of attorney for her father’s health and welfare.
7. When Miss X was visiting her father on 22 December 2018, she asked staff to help him to the toilet, but they said they were busy. After 30 minutes she asked again but the staff said Mr Y would have to wait as it was mealtime and company policy was not to take people to the toilet during mealtimes. Miss X raised her concerns with the Nurse on duty who confirmed this was abuse (not company policy) and advised her to report it to a Manager. The Nurse arranged for staff to help Mr Y to the toilet. Miss X says the incident left her father fearful of asking to go to the toilet.
8. Both the Council and HC-One accept the Care Home should have reported this incident to the Council as a safeguarding concern. The Care Home has also accepted its mistake.
9. On 23 December Miss X registered a complaint about “institutional abuse and very poor practice” via the HC-One website. HC-One acknowledged this the next day.
10. HC-One tried calling Miss X on 27 December and left a message for her. It spoke to her on 31 December. Its record of the conversation says she was overall happy with the Care Home but had concerns about what happened on 22 December. She said she was happy for HC-One to deal with her concerns and update her once completed.
11. On 10 January the Council visited Mr Y at the Care Home to review his needs. The Social Worker’s record of the meeting says Miss X mentioned “recent issues that she has addressed personally with the project manager and others. She has dealt with issues as and when in regards to problems that have occurred. All the issues are sorted. Daughter is generally happy with the care home and all is going well”. Miss X disputes this account. She says she told the Social Worker she had been happy with the Care Home up to 22 December and did not know the outcome of HC-One’s investigation, but her father was unsettled. The Social Worker told her he was leaving, but a duty officer would get in contact.
12. On the same day HC-One wrote to Miss X. It said it:
• had completed a full investigation;
• apologised for the way staff treated her father on 22 December;
• would address this with the staff concerned;
• did not have a policy saying residents could not go to the toilet during mealtimes.
13. On 18 February Miss X made a further complaint via the HC-One website about the time taken to confirm any disciplinary action. She said it had told her the legal team were dealing with the issue, but she had been waiting weeks to hear the outcome. She said this was unacceptable as it concerned institutional abuse. Miss X had concerns about the carers involved in the incident still working with her father.
14. HC-One wrote to Miss X on 21 February. Miss X says she only recently received a copy of this letter. It apologised and said the lack of compassion, kind care and treatment were completely unacceptable. It also apologised for the time taken to deal with her concerns. It said it could not share its treatment of individual staff with her. However, it said:
• all staff had had a formal supervision with the Care Home Manager to reflect on their practice;
• the Manager had raised the issue in a daily meeting;
• it had carried out spot checks and spoken to residents and relatives;
• it was arranging dignity and respect training with staff;
• it had re-shared policies and procedures on personal care with staff.
15. On 16 April Miss X called the Council. She said she was having recurring problems with one of the carers at the Care Home, who had been involved in a complaint which resulted in disciplinary measures, including dismissal, against other workers. She said the carer rudely told her to get out of her father’s room so she could do her work. She said she had raised several issues with the Care Home, including the incident on 22 December, which led to the disciplinary action. She said she did not want to move her father, but this may have to happen if she did not get some support. The Council left a message for Miss X, saying it would assign her father’s case to another officer, but this may take a few weeks.
16. On 24 April Miss X told the Council she had arranged a meeting at the Care Home for 16.00 on 25 April. The Council told her a Manager would attend the meeting.
17. At the meeting on 25 April Miss X said staff had been hostile to her following the disciplinary action over the incident on 22 December. She also mentioned the incident she reported to the Council on 16 April. The Care Home said staff believed the family was “out to get rid of them all”. They discussed the possibility of Mr Y moving to another unit at the Care Home. Miss X agreed to discuss this with her father. After doing this Mr Y moved to the other unit at the Care Home where he has settled.
18. In June the Council undertook a performance review at the Care Home to check policies and staff training.

Is there evidence of fault by the Council which caused injustice?

19. There is no dispute over the fact that:
• Mr Y was the victim of abuse when staff at the Care Home refused to help him to the toilet; and
• the Care Home should have reported this to the Council as a safeguarding concern.
20. These are faults for which the Council is accountable (see paragraph 4 above). The former caused injustice to Mr Y, as he was left waiting too long for the help he needed. The latter caused injustice to Miss X as it left her feeling unsupported.
21. There was no fault in telling Miss X information could not be shared with her about disciplinary issues relating to individual members of staff. Such matters are confidential and cannot be shared with third parties. However, it is clear from the meeting on 25 April that Miss X was subject to some hostility from some staff at the Care Home. That should not have happened. The Care Home should have taken steps to prevent this from happening, given that it knew staff believed Mr Y’s family was “out to get rid of them all”. The Council needs to apologise for the distress this caused.

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Agreed action

22. 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 I found fault with the actions of the Care Home, I have made recommendations to the Council.
23. I recommended the Council within four weeks writes to Miss X apologising for the failings and the distress they have caused to her and her father. The Council has agreed to do this.

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Final decision

24. I have completed my investigation as the Council has agreed to take the action I recommended.

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Investigator's decision on behalf of the Ombudsman