Summary: Mr B complained about the care given to his late mother (Mrs C) in two care homes. He said she and the family were caused distress and uncertainty. We found fault in the way the Council communicated to Mr B regarding CCTV footage of his mother and the Council agreed it failed to carry out a monitoring visit of one of the homes or inform the family of the outcome of the safeguarding investigation. The Council has already apologised and offered to pay £300. It has also agreed to pay a further £200 (the total of £500 to be offset against the outstanding bill).

The complaint

1. Mr B complains that his late mother (Mrs C) received poor care and supervision from two care homes in the months before she died. He says she was assaulted by another resident in one home and in the second she developed sores on her feet, was dressed in other residents’ clothes, was unnecessarily sedated and was not fed or hydrated properly. This caused significant distress and uncertainty for the family as to how much these events contributed to their mother’s deterioration.

Back to top

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, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

4. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. Mr B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

5. Mrs C had a number of health conditions including dementia which affected her capacity to make decisions and caused confusion.

Home Z

6. Mrs C went to a care home (Home Z) for respite care at the end of May 2019. Her care needs assessment and care plan from May 2019 noted that she could get around indoors with assistance from one person: she needed reassurance as she was frightened of falling and very anxious. She had fallen twice in the preceding 12 months.

Safeguarding policy

7. Home Z’s safeguarding policy says it will contact the police if a resident is at immediate risk of harm. In cases of alleged harm, the Home’s management will discuss the issue with the safeguarding team and the police to determine if a joint investigation is required. It also notes that in dealing with incidents of potential harm, people have rights which must be respected and which may need to be balanced against each other.
8. It says Home Z will work in partnership with other agencies to ensure that concerns or allegations of abuse are appropriately referred for investigation to the most appropriate agency.

What happened

9. One evening, soon after she had arrived at the home, Mrs C got up from the lounge unaided and walked into the corridor. A member of staff (staff D) came down the corridor and found Mrs C with her lower clothing around her knees and another resident behind her touching her bottom. Staff D moved the other resident away from Mrs C, assisted Mrs C to the toilet following her request and then to sit down in the lounge. She reported the incident to senior staff. Staff D said Mrs C seemed fine in herself and she had a good night’s sleep. Home Z reported the incident to the safeguarding team at the council in which Home Z was situated. Home Z provided one to one supervision for the other resident, sought medical advice and reviewed his care needs.
10. Home Z informed Mrs C’s family, who removed Mrs C from the Home the following day. The family also called the police (who took no further action) and contacted the Care Quality Commission (CQC).
11. The safeguarding team concluded that the incident did not meet the threshold to investigate further because the resident was not deliberately targeting Mrs C and his actions were the result of dementia. The team also contacted the Council to inform it of the incident and the fact it would not be taking any further action. It said the Council agreed with this outcome.
12. Neither Council informed the family of the outcome of the safeguarding referral.

Complaint

13. Mr B made a formal complaint to Home Z about the incident. He was concerned how Mrs C made her way to the corridor on her own as she could not walk without assistance. He also questioned why Home Z had not called the police and requested to view the CCTV footage.
14. Home Z replied to the complaint in July 2019. It explained that, while Mrs C was assessed as needing assistance to mobilise, this did not mean she could not get up unaided if she chose to do so. She did not require one to one supervision and no member of staff saw her leave the lounge. Home Z further explained that it did not call the police because it had notified the safeguarding teams of both Councils and they felt the matter had been dealt with proportionally. Home Z felt it may have been upsetting for both residents as they lacked capacity.
15. In respect of the CCTV, it said Mr B could see the CCTV but it would have to be released through the correct channels and after getting permission from the other residents who may be on the CCTV. It also said that there was no CCTV covering the area where the incident took place, only footage showing Mrs C leaving the lounge after speaking to another resident in the doorway.
16. Home Z said in response to our enquiries that Mr B had never made a formal request for the CCTV footage. It confirmed it had saved the footage. I asked to see it, but the Home was unable to provide it in an appropriate format. Instead, it sent several stills showing Mrs C leaving the lounge unaided and passing another resident in the doorway.
17. Mr B was not satisfied with the response and complained to the Council. The Council responded in September 2019. It had reviewed the information from Mrs C’s assessments and Home Z and concluded that Mrs C had got up and walked into the corridor unaided. It said the safeguarding team at the other council had concluded the case did not meet the threshold for a full investigation because the resident’s behaviour was out of character, no previous allegations had been made about him and prior to the incident he did not appear to pose a risk to female residents. Home Z, in agreement with the other council, had ensured the resident had one to one supervision at all times.
18. The Council’s own safeguarding team was satisfied with the action Home Z and the other council had taken and agreed no further action was required. It said it did not always inform family members of the outcome in such cases but accepted it could make improvements to its procedure in this respect.
19. In respect of the CCTV, it said there was no footage of the area where the incident took place and so there was nothing to view independently. It said it could not establish why Mr B had been told there was CCTV.
20. The Council was satisfied that appropriate action had been taken by all parties.

Home Y

21. Mrs C moved to a second care home (Home Y) in early June 2019. She stayed there until 6 July 2019 when she was admitted to hospital. She did not return to the home. She died in October 2019.
22. Mr B said he was concerned about the standard of care at Home Y. He said when Mrs C went into hospital she was severely dehydrated, with a UTI, a chest infection and pressure sores. He felt she had not been fed properly. Mr B was also concerned that she was dressed in other resident’s clothes, her hearing aid was broken and he wondered if she had been sedated.

Complaint

23. Mr B complained to the Council about Home Y. The Council responded in September 2019. It said the hospital confirmed the pressure sores were not serious enough to meet the criteria for a safeguarding referral and the hospital did not consider they had arisen as a result of neglect.
24. In respect of the other issues regarding the standard of care at Home Y, the Council said it would refer these to its quality monitoring team to carry out further investigation and he would receive feedback when the process was complete.
25. In response to our enquiries, the Council has provided records from Home Y. These show that Home Y carried out a detailed assessment of Mrs C when she arrived at the home, including details of her medical conditions and medications, her communication and need for reassurance, her toileting needs and possible confusion, her mobility needs and fear/risk of falling, as well as her nutritional needs and risk of malnutrition (zero on admission).
26. The daily care records show that staff monitored Mrs C’s fluid and food intake, her sleep, showering, and wellbeing. They also contacted the GP, the district nurse service and other external organisations regarding medication for an infection and sore skin, fixing her hearing aid, her hearing, blood tests, possible dehydration and blisters on her feet. On 6 July 2019 the home rang NHS Direct for advice as Mrs C was lethargic and not eating or drinking and it advised to call an ambulance.
27. The Council has said its Quality Monitoring Team did not visit Home Y due to an oversight. It apologised for this and reviewed its process for allocating work. It has also offered a £300 reimbursement of the costs incurred between 6 and 13 July 2019 after Mrs C left Home Y.

Analysis

Home Z

28. I cannot identify any fault with the actions of Home Z leading up to the incident in the corridor. There was no evidence that Mrs C required one-to-one supervision at all times or that she could not walk unaided. There is no evidence to support Mr B’s view that poor care led to Mrs C being in the corridor. As the Council concluded it is likely she got up unaided and walked to the corridor herself, which is supported by the stills from the CCTV footage.
29. There was no evidence that the resident involved in the incident had any history of such behaviour or that any other allegations had been made against him. Home Z followed its procedure in supporting Mrs C after the incident and taking steps with the resident to minimise risks to other residents.
30. Home Z correctly referred the incident to the council in which the Home was situated and I cannot find fault with the way in which the referral was dealt with. Given the lack of evidence of further risk and the medical conditions of both Mrs C and the other residents it was a reasonable conclusion to take no further action. The Council has acknowledged that it should have informed the family of this outcome. It has apologised for this omission and improved its procedures for the future.
31. Home Z has explained why it did not call the police and I cannot find fault with that decision. I also note that the police decision was to take no further action following contact from the family.
32. However, I do consider there was confusion over the issue of the CCTV, which caused Mr B some frustration and distress. Home Z explained that there was no CCTV footage of the actual incident but that there was one camera on the route Mrs C took to the corridor. It correctly explained to Mr B that this showed Mrs C leaving the lounge unaided after speaking to another resident in the doorway. It said Mr B could request sight of the CCTV through the usual channels as it would need to gain consent from other residents in the footage. I assume Home Z was referring to a Subject Access Request under the General Data Protection Regulations. It said it did not receive a request from Mr B but neither did it explain what he needed to do to obtain the footage. This was fault.
33. The confusion was exacerbated by the Council saying in its complaint response that there was no CCTV for Mr B to view, which contradicted the earlier response from Home Z. I think the Council was referring to the fact that there was no CCTV of the incident, but this did not acknowledge that Home Z had saved footage of Mrs C’s journey to the corridor which Mr B wanted to see. This could have been resolved at that point through the complaints process, if the Council had properly understood the situation.

Home Y

34. From the documents provided I cannot identify any fault in the actions of Home Y. The Home carried out a detailed assessment of Mrs C when she arrived, monitored her on a daily basis and took appropriate advice when concerns were noted about her condition, such as a reluctance to eat and blisters on her feet in early July. I cannot reach a conclusion on the inappropriate clothing Mr B noted, as there is no evidence to explain how that occurred. But neither is there any evidence to say it was a recurrent problem.
35. The Council has acknowledged it should have carried out a monitoring visit as it promised in its complaint response. It has apologised for the failure to do this and offered £300 towards the outstanding bill for Home Y.

Agreed action

36. I welcome the apology and offer of £300 from the Council regarding the failure to carry out the monitoring visit of Home Y. However, in recognition of the confusion over the CCTV I asked the Council (within one month of my final decision) to pay Mr B an additional £200.
37. The Council has agreed to my recommendation. Mr B has requested that the whole amount(£500) be offset against the outstanding bill.

Back to top

Final decision

38. I consider this is a proportionate way of putting right the injustice caused to Mr B and I have completed my investigation on this basis.

Back to top

Investigator's decision on behalf of the Ombudsman