• The complaint
• The Ombudsman’s role and powers
• How I considered this complaint
• What I found
• Final decision

The Ombudsman's final decision:

Summary: Mrs B complained in respect of her mother Mrs C about the actions taken by a Care Provider supported by the Council, when Mrs C’s behaviour escalated on two occasions. She complains that Mrs C was in effect evicted from the Care Provider’s care home and spent 40 days in hospital unnecessarily. We find some fault in the Council’s actions and it has agreed to pay Mrs B £350 for the injustice caused.

The complaint

1. Mrs B complained in respect of her mother Mrs C, that the Care Provider (HC-One Ltd commissioned by Cheshire West & Chester Council – the Council) inappropriately called the police due to Mrs C’s behaviour, did not promptly inform her family it had also called an ambulance and after a second incident, refused to accept Mrs C back. This caused distress to Mrs C and her family and Mrs C spent 40 days in hospital for social reasons rather than a medical need.

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

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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. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

5. Mrs C had dementia. She was living at home with support until her condition deteriorated and in February 2019, she moved into a care home (the Home).
6. The Council carried out a review of her care needs in November 2019. The Mental Health Team (MHT) informed the social worker that Mrs C’s medication had been increased due to her agitation. MHT had also referred Mrs C to the Advanced Dementia Team (ADT) to carry out a dementia care mapping exercise. They would visit Mrs C at the Home to observe her routine, identify staff training needs and offer distraction techniques. MHT had also discussed with the Home setting up a daily walking group as Mrs C liked walking outdoors. The Home’s manager (HM) said she had already done this and noted Mrs C became agitated when she went back inside. HM said she was happy for Mrs C to stay at the Home.
7. The dementia care mapping visit was done in December 2019 and the report shared. Mrs C’s stress and distress care plan was updated in January 2020. In February 2020 the Home updated Mrs C’s risk assessment to include climbing on to windows. HM had an email exchange with the ADT regarding a training session for staff in managing distress and agitation.
8. HM contacted the ADT on 17 February 2020 expressing concerns about Mrs C’s level of agitation and requesting a medication review as the distraction techniques were not working. HM said Mrs C was hanging out of the window, screaming for police and telling other residents she will slit their throats. ADT said it was aware of the medication review and suggested referring Mrs C to the Council for a review of her care needs.
9. The care record says that on 4 March 2020 at 3.15 pm Mrs C was very agitated, shouting out of the windows, crying and asking for her daughters. At 3.25 staff heard screaming and shouting coming from the lounge, residents were running out of the lounge asking for help. A staff member found Mrs C in the lounge trying to smash the window with a book end, which other residents were trying to take off her. The Home considered Mrs C and other residents were in danger, so it called the MHT and the Police who came straightway. The Police also contacted Mrs C’s daughter. The care record says the police and MHT decided it was in Mrs C’s best interests to go to hospital.
10. The incident report contains similar information. It said Mrs C also climbed onto the window ledge and tried getting out, screaming ‘get my daughter’, ‘get the police’ while banging on the window. Other residents were visibly shaken and scared. It says staff tried to calm Mrs C down, but she was just getting worse, so they called the police, who arrived. The report states that the Home then called MHT and Mrs C’s daughters (this was incorrect – the Police contacted the family).
11. The hospital records say that by the time a doctor saw Mrs C several hours after she arrived at the hospital, that she was calm and settled. The doctor recommended that Mrs C’s medication should be changed and they faxed an urgent prescription through to her GP, with follow-up by the MHT. The doctor considered there was no reason to admit her to hospital.
12. The hospital discharged Mrs C later that evening. Her daughters brought her back to the home and settled her in bed. The care record says she had a very unsettled night.
13. The Council’s social work records show that Mrs B’s sister telephoned the Council on the morning of 5 March 2020 to express concern about the incident the previous day. The Council said it was looking to support Mrs C with her future care and support needs and if these were to change it would look for an appropriate setting.
14. The Council’s duty social worker (DSW) also spoke to HM on 5 March 2020 who was concerned about Mrs C’s behaviour being similar today. DSW advised HM that if Mrs C became that distressed again, HM should call the police and ambulance and tell the paramedics that the Home cannot take her back again. HM had also contacted the MHT.
15. The MHT explained to the Home that they would get the new medication for Mrs C and try this before considering a hospital admission.
16. The care records says that Mrs C had a very unsettled day again and was very agitated from the start. After lunch she started shouting, banging windows with her walking stick, pacing the Home and entering other residents’ rooms. Staff contacted the GP who agreed to prescribe extra medication and the MHT were on their way to pick it up. But then Mrs C got very angry, hitting out and pulling another resident by the arm, so the Home called an ambulance and informed Mrs B and her sister.
17. HM spoke to the Council during this incident, expressing concern about Mrs C and the other residents and saying that the Home could no longer manage Mrs C’s care needs. MHT recommended that the Council look for nursing care for Mrs C. HM updated the Council that she had called an ambulance and Mrs C was on her way to hospital. The Council spoke to the hospital to confirm that the Home could not take Mrs C back as it could no longer meet her needs as she was a risk to herself and other residents.
18. The same doctor saw Mrs C later that night and again considered there were no medical reasons to admit Mrs C to hospital. But given the time he agreed that she could stay overnight and return to the Home in the morning with a view to implementing the medication change. The doctor said to the MHT that it was an extremely inappropriate use of A & E by the Home.
19. On 6 March 2020 Mrs B contacted the Home to say she was unhappy with the events the previous day and said they were going to send Mrs C back to the Home.
20. The Council also spoke to the hospital, which said it was deciding whether to admit Mrs C, but if it did, it would be a ‘social admission’. The Council disagreed saying that Mrs C had been taken into hospital due to a deterioration in her mental health which was posing a risk to herself and others. The hospital disagreed, saying Mrs C’s medication had been increased and she settled after 10 to 15 minutes. The Council said this had not been the case on the previous two days. The Council also confirmed to MHT that the Council had advised the Home it would not support a move back if the Home could no longer keep Mrs C and the other residents safe.
21. The hospital admitted Mrs C as a social case.

Complaint

22. On 8 March 2020 Mrs B made a complaint to the Home that it had made Mrs C homeless and the hospital said the Home’s actions were highly inappropriate. She said Mrs C had been sent in the ambulance alone with no coat and no walking aid. She said MHT had done a full review and put together a new care plan on the morning of 5 March 2020. A mental health nurse was on her way to pick up the new medication and deliver it to the home only to find Mrs C had been sent to hospital. She said the hospital admitted Mrs C for social reasons because the Home refused to accept her back into their care.
23. She considered Mrs C had been treated more harshly than other residents who also banged furniture and windows on occasion. She said the Home had not explained its reasons for refusing to accept Mrs C back or for refusing to accept the professional medical advice to implement the care plan put in place by the senior psychiatrist and mental health team.
24. On 9 March 2020 Mrs B forwarded a copy of the complaint to the Council. The complaints team referred the complaint to the safeguarding team. Safeguarding confirmed the Home had already let them know about the incident and they were not going to take any further action as it appeared to be an accident.
25. The Care Provider responded to the complaint on 14 April 2020. It detailed the events which had led to the complaint. It noted that in February 2020 the Home had contacted the ADT expressing concerns about Mrs C’s behaviour and agitation and requesting a medication review. It also noted an incident where Mrs C had entered another resident’s room unsettling them. It detailed the incidents and the reasons why the Home had called an ambulance. On 10 March 2020 the Care Provider had offered Mrs C a nursing bed at a different home to allow an assessment to take place in the community. The family refused this preferring to wait for a hospital assessment. The home carried out a telephone assessment two weeks later but did not offer Mrs C a place, due to her requirement for 1:1 nursing care and her physical behaviour.
26. Mrs C was medically fit for discharge on 19 March 2020 and was discharged to a nursing home on 22 April 2020 for a continuing healthcare (NHS funded) assessment.
27. The Care Provider said Mrs C’s condition and behaviour had been deteriorating in the months before the incidents, evidenced by the Home’s referral of Mrs C to the MHT, the GP and other professionals for advice and support. It said since she had been in hospital Mrs C’s escalating behaviour had recurred indicating a progression of her condition.
28. It explained that the Home had given Mrs C the correct medication on 4 March 2020 but the medication chart had been incompletely photocopied when she returned home from hospital. It apologised for not informing the family when Mrs C went to hospital on 5 March 2020. It also apologised for inadequate communication with the family over Mrs C’s care and for the failure to send her stick with her in the ambulance. It agreed it would have been preferable for Mrs C to have been accompanied to hospital, but it was not possible without compromising the care of the other residents. It said it would review current practice in the Home and improve procedures for transfer of information between the Home and the hospital.
29. Mrs B was unhappy with the response. She had also obtained copies of the Home’s records and hospital notes for 4 and 5 March 2020. She highlighted a number of inconsistencies and considered one of the incident reports had been altered to reflect that staff had tried to take Mrs C outside to de-escalate the situation.
30. The Care Provider responded on 12 June 2020. It explained the discrepancies highlighted by Mrs B and concluded that transfer back to the Home would have been inappropriate due to the progression of Mrs C’s condition and her assessed need for nursing care.
31. Mrs B complained to the Ombudsman.

Analysis

32. There is evidence that Mrs C’s condition was progressing prior to March 2020 with increasingly agitated behaviour. The ADT had carried out an assessment, the Home had requested a medication review and the MHT advised the Home to request a care needs review.
33. However, before these could take place, the first incident occurred on 4 March 2020. I cannot identify significant fault with the way the Home dealt with the situation on that occasion. Mrs C’s behaviour appears alarming and was affecting other residents. I have no reason to dispute that the Home tried distraction techniques which were unsuccessful. Mrs C was shouting for the police to be called and she appeared to calm down to some degree when they arrived and again when she arrived at the hospital. There was a positive outcome to the hospital visit in that the doctor suggested a medication change and arrangements were in place to start this the following day. The Home has apologised for not informing the family and for sending Mrs C to hospital without her walking aid.
34. But I have concerns about the Council’s actions the following day: In the morning it said to Mrs B that it would support Mrs C with her care and support needs and if they were to change then it would look for an appropriate setting to meet her needs. Given the incident the previous day and the events leading up to it, I consider the Council should have taken steps as a matter of urgency to review Mrs C’s needs.
35. But on the one hand while giving Mrs B a commitment to support Mrs C’s needs in the future, the Council then gave the Home, on the same morning, an unequivocal direction to call the ambulance and not accept Mrs B back if her behaviour deteriorated. It reached the view that the Home could not meet Mrs C’s needs without carrying out any assessment, talking to Mrs C’s family or discussing the case with MHT who were on their way with new medication. I consider this view was premature and contributed to the difficult situation which transpired later in the day. This was fault.
36. I also consider it was premature to declare, once the second incident had happened, that Mrs C could not return to the Home. It should have waited for the medical view of her condition before reaching the decision that Mrs C could not go back to the Home. The Council assumed Mrs C’s condition had deteriorated to the point where she would have to be admitted to hospital. However, the medical view was very different, and the hospital favoured trying the medication change as it did not consider there was any medical need to admit her. While this was a difference of professional opinion and it is not for me to say which view was right, I do think the Council reached its view too quickly and without sufficient information. This was fault. The hospital was left with no option but to admit her causing distress to Mrs C and Mrs B.
37. But I do not agree that these actions definitely led to Mrs C spending an unnecessary time in hospital. Her behaviour while in hospital was agitated and the hospital did not consider she was medically fit for discharge until 19 March 2020. The MHT and the Council concluded on 6 March 2020 that she needed a nursing placement. So even if she had been sent back to the Home on 6 March 2020, it is difficult to conclude she would definitely not have gone back to hospital at some point. But I do think the decision to move her to a new placement could have been made in a more ordered and thorough manner, decreasing the resulting distress and uncertainty.

Agreed action

38. In recognition of the injustice caused to Mrs B and Mrs C by these events I asked the Council (within one month of my final decision) to pay Mrs B £350.
39. The Council has agreed to my recommendations.

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Final decision

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

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Investigator's decision on behalf of the Ombudsman

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