Summary: Mr C complained the Council forged his signature to force him out of his home, arranged care placements which provided him with poor quality care, charged him for services he either did not receive or which were badly delivered and overcharged him for his care. The Council delayed resolving an issue with Mr C’s belongings and failed to ensure the care providers kept proper records. One of the homes also lost some of Mr C’s belongings. There is no fault in the remainder of the complaint. An apology, liaison with both care providers to ensure case recordings are improved and a payment to Mr C and his representative are satisfactory remedy.

The complaint

1. The representative for this complaint, whom I shall refer to as Ms B, complained about the care the Council arranged for the complainant, whom I shall refer to as Mr C. Ms B lives outside the country. Ms B says the Council:
• allowed one of its social workers to forge Mr C’s signature to force him out of his home;
• arranged two placements which provided Mr C with poor quality care;
• charged him for services Mr C either did not receive or which were badly delivered; and
• overcharged Mr C for his care.
2. Ms B says fault by the Council meant Mr C received poor quality care, which caused him distress. Ms B also says she has incurred financial costs she should not have had to pay.

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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. 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)
5. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

6. As part of the investigation, I have:
• considered the complaint and Ms B's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
7. Ms 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

What happened

8. Mr C had been living in his own home when he was admitted to hospital. Mr C was discharged to Hilltop Lodge (which I will refer to as Hilltop) in May 2019. At that point Hilltop had little information about Mr C and he did not have most of his belongings with him. The only contact Hilltop had for Mr C’s family was his brother. Hilltop tried, and failed, to contact the next of kin on several occasions. Mr C moved into Hilltop’s long-term unit in June 2019 as it had established he was not safe to return home.
9. Mr C had a fall in June 2019. Hilltop tried to phone the next of kin but did not receive any response.
10. An independent mental capacity advocate (IMCA) visited Mr C in July 2019. Mr C told the IMCA he was happy in the home and the staff were providing for all his care needs. The IMCA noted the room was bare and suggested Hilltop arrange for Mr C’s belongings to be transferred. Hilltop again tried, and failed, to contact the next of kin.
11. In July 2019 the speech and language therapist visited. The speech and language therapist recommended a soft, bite-size diet for Mr C.
12. Hilltop contacted social services in July 2019 because it could not make contact with the next of kin. Hilltop told the Council the request was urgent because it needed to book a dentist appointment for Mr C. Hilltop also told the Council Mr C needed toiletries and clothes.
13. Mr C visited the optician at the end of July 2019. The optician recommended bifocal lenses.
14. Hilltop contacted the Council again at the beginning of August 2019. Hilltop said Mr C needed toiletries, clothes, a dentist appointment and access to his finances to pay for glasses. Hilltop chased the Council later in August 2019.
15. In August 2019 Mr C’s stepsister visited and told Hilltop the person recorded as next of kin had passed away. She provided a telephone number for Mr C’s sister. The home telephoned but could not get an answer.
16. Hilltop contacted the Council again towards the end of August 2019 to discuss the ongoing difficulties it was having accessing Mr C’s belongings. The Council’s social worker agreed to visit to collect some clothes. That visit took place in September 2019, following a meeting. At that meeting Mr C said he was looking forward to staying at the home permanently.
17. Ms B visited Mr C in September 2019 and agreed to purchase some items for him. Ms B had some concerns about the suitability of Hilltop and arranged for Mr C to move to another care home. The move to Beechcroft, the new care home, took place in October 2019.
18. Mr C had a fall at Beechcroft in October 2019. Beechcroft contacted a member of Mr C’s family to tell them. Ms B subsequently contacted Beechcroft to ask for all matters relating to medical needs to be referred to her.
19. Mr C attended an audiology appointment on 6 November 2019. The audiologist could not carry out any work because Mr C needed his ears syringed. That took place at the end of November 2019.
20. Mr C visited a dentist in December 2019 and the dentist relined his dentures.
21. Mr C had new hearing aids fitted in December 2019. He then went on holiday, during which he lost one of the hearing aids. Mr C returned from holiday at the end of December 2019.
22. At the beginning of January 2020 Mr C’s family asked Beechcroft not to use private hearing aids as Mr C had lost one at the airport and the NHS hearing aids were too small. Ms B asked Beechcroft to arrange an appointment for a new hearing aid. Mr C had new hearing aids fitted later that month.
23. Ms B raised some concerns about the home in January 2020, including concerns about oral healthcare for Mr C and the loss of his hearing aids. Ms B also reported Mr C regularly contacted her as he felt hungry. Ms B said she had to have food delivered in the evening at least twice a week. Ms B also raised concerns about Beechcroft not treating Mr C’s cold.
24. Ms B visited the UK at the end of January 2020 and met with Council officers. Ms B said Mr C wanted to move and told the Council she had begun to look for alternatives. The Council began searching for an appropriate placement which could meet Mr C’s cultural needs. Mr C moved to another home in February 2020.

Analysis

25. Ms B says the social worker forged Mr C’s signature to force him out of his home. Ms B says Mr C never agreed to stay in residential care permanently and never said he wanted to release his flat. I do not have a copy of the termination agreement allegedly signed by Mr C. However, the Council says its investigation has confirmed the social worker signed the tenancy termination document, rather than Mr C. I understand Ms B’s concern about that. However, the documentary records show the assessment completed when Mr C went into Hilltop recorded him as saying he wanted to go into long-term care because he could no longer cope at home alone. By September 2019 Mr C was also saying he wanted to stay in residential care permanently. In those circumstances I am satisfied Mr C would have had to give up the tenancy of his property in any case, irrespective of who signed the termination forms. In those circumstances I have no grounds to criticise the Council.
26. Ms B says Mr C’s glasses, hearing aids and dentures were lost in the transition between the hospital and Hilltop. This is something confirmed by Hilltop which has advised it received Mr C with no personal belongings. The evidence I have seen satisfies me Hilltop tried to contact Mr C’s brother, who is the only person it had recorded as the next of kin, to try and locate Mr C’s belongings. When that did not succeed I am satisfied Hilltop contacted the Council. That was in July 2019. Given Mr C did not have any of his belongings and as Hilltop had made clear it was an urgent request for help, I am concerned it took the Council until September 2019 before the social worker visited Mr C’s property to obtain his belongings. That delay is fault and meant Mr C was without his personal belongings for at least two months longer than he should have been.
27. Ms B says Hilltop failed to take Mr C to the dentist or carry out oral hygiene. As I refer to in the previous paragraph, when Mr C moved into Hilltop it had little information about Mr C. I am satisfied though the home arranged for Mr C’s dental care to be moved to a different dentist given the dentist allocated at that point did not have wheelchair access. I am therefore satisfied Hilltop took action in relation to identifying a suitable dentist for Mr C to visit.
28. In terms of oral hygiene, the care plan completed by Hilltop records care staff should monitor Mr C’s oral health. The care plan refers to the need for care staff to remove Mr C’s dentures, clean them and place them in a cleaning solution for 20 minutes at night and then rinse them the following morning. Having considered the daily care records I cannot identify many recordings referring to denture care for Mr C. In those circumstances I cannot confirm proper oral care took place, in accordance with the provision set out in the care plan. Failure to keep proper records is fault and means Ms B is left with uncertainty about whether Mr C’s oral health needs were properly provided for.
29. Ms B says Hilltop refused to arrange for Mr C to be fitted for glasses. Ms B says Hilltop delayed because Mr C did not have any money in his account and this meant Mr C’s glasses were not ordered until September 2019 when she visited. Ms B is particularly concerned about the delay because Mr C could not see properly and he would have been entitled to NHS support for his glasses, which Hilltop should have known.
30. The evidence I have seen satisfies me Hilltop arranged for Mr C to visit the optician in July 2019. It is clear that visit resulted in Mr C needing new glasses. I am satisfied Hilltop tried to sort that out by contacting the next of kin and then the Council. As I said earlier, there were delays in the Council arranging for a social worker to visit Mr C’s property and this also delayed resolution to the finance issue for the glasses. Given Mr C could not see properly without his glasses I am concerned it took until Ms B visited before that matter was resolved. That delay is fault and meant Mr C was left in Hilltop without his glasses for longer than he should have been.
31. Mr C’s representative says Hilltop lost some of Mr C’s clothes in the lead up to his move to a new care home. Ms B says many of those clothes were items she had purchased for Mr C recently and which she had to purchase again. Hilltop acknowledges some of the clothes Mr C’s family bought for him went missing. Hilltop says though Ms B found the missing clothes in the laundry room. That is something Ms B strongly refutes. There is no documentary evidence referring to the missing clothes. However, given Ms B has kept receipts to show the original clothing she bought and the additional clothing she had to buy when Mr C moved to a new care home I consider it likely, on the balance of probability, clothes were lost at Hilltop and not retrieved. I therefore consider Ms B has suffered a financial loss as she has had to buy new items of clothing when she should not have had to do so.
32. Ms B says Hilltop failed to carry out proper hygiene care for Mr C’s ears. Ms B says this resulted in a wasted appointment with an audiologist as Mr C had a build up of wax that needed to be removed. Ms B is concerned about that because it led to a delay in Mr C receiving his hearing aid. The documentary evidence shows when Mr C attended and audiology appointment on 6 November 2019 he needed his ears syringed. The documentary evidence shows Mr C then received new hearing aids on 13 December. I cannot reach a safe conclusion about whether poor hygiene care resulted in Mr C needing his ears syringed. Nor can I reach a safe conclusion about whether poor hygiene care caused any delay in Mr C receiving his new hearing aids.
33. Ms B says Beechcroft failed to treat Mr C for a cough/cold for 10 days in January 2020. The documentary evidence does not record any issues identified with Mr C’s health leading up to 24 January 2020 when Ms B mentioned in an email to Hilltop her concerns about it not providing Mr C with paracetamol to treat his cold. The only other entry is an entry on 28 January 2020 when the GP checked Mr C’s chest and gave the all clear, advising the home medication was not required. There is an issue here with the lack of documentary evidence, particularly in relation to medication. Failure to keep proper documentary records is, in itself, fault. It does mean however I cannot reach a safe conclusion about whether Hilltop was aware of and failed to treat a cold before 24 January 2020.
34. As with the previous home, Ms B says Beechcroft failed to soak Mr C’s dentures at night. I have considered the documentary records provided by Beechcroft. Those records show 11 occasions when Mr C’s dentures were not soaked. As the risk assessment Beechcroft completed clearly identified the need to soak the dentures overnight failure to do that is fault.
35. Ms B says Beechcroft lost Mr C’s hearing aids twice which meant she had to replace them. The only documentary evidence I can find in relation to missing hearing aids relates to January 2020. At that point it is clear Mr C had lost one of his hearing aids when returning from holiday. The documentary records show he lost his other hearing aid in the home but the home subsequently found it. There is also evidence in the documentary records to record the family asking the home in January 2020 not to use the NHS hearing aids as they were too small which would result in them falling out. Given the lack of documentary evidence I cannot reach a clear conclusion about whether fault by the home resulted in the loss of Mr C’s hearing aids.
36. Ms B says when an audiology appointment was arranged for Mr C in November 2019 the family arranged for somebody to go with him. Mr C says because Beechcroft took Mr C to the audiology appointment before the family member arrived it resulted in a wasted appointment because Mr C did not have with him the items he had been asked to bring. There is nothing in the documentary records I have seen to confirm Beechcroft knew of a family member attending to take Mr C to the audiology appointment. I consider though that is likely because the documentary records are not comprehensive given communications from Ms B confirmed the family member had telephoned Beechcroft to advise they were stuck in traffic and would be late. Failure to either wait for the family member or ensure checks were made about what Mr C needed to take with him to the appointment is therefore fault and resulted in a wasted appointment.
37. Ms B says Beechcroft failed to contact family members when Mr C experienced health issues, including falls. The documentary records provided by Beechcroft show it notified a family member on five occasions between 30 October 2019 and 1 December 2019 when there was a medical issue. On all but one of those occasions the home contacted another family member, rather than Ms B. However, the documentary evidence also shows Ms B had asked in October 2019 for any contact following medical issues to be made with her. Failure to do that is therefore fault, although I could not say the home had failed to tell the family about medical issues given the records show contact with a family member.
38. Ms B says before Mr C moved into Beechcroft it said it could provide cultural meals but then failed to do so. As I understand it, Ms B chose Beechcroft as a suitable home for Mr C to move into as she was unhappy with the care provided at Hilltop. There is no documentary evidence though detailing any discussion about cultural meal requirements until January 2020 when Ms B raised it as one of the issues. Given the lack of documentary records I cannot say Beechcroft had committed to provide culturally appropriate meals to Mr C, particularly given the risk assessment completed by Beechcroft did not identify any cultural dietary requirements.
39. Beechcroft says it offered to arrange meals to be delivered from a local provider which it says Ms B declined. Ms B disputes that. Beechcroft accepts there is no documentary evidence to show this happened. In those circumstances I consider it unlikely, on the balance of probability, the offer was made. Taking into account the risk assessment did not identify any cultural dietary requirements, the fact Ms B chose the home and as the Council began looking for a more suitable home for Mr C when Ms B raised concerns, I do not criticise the Council here.
40. Ms B says staff at Beechcroft failed to check on Mr C during the night of 29 January 2020. Ms B says this meant Mr C spent most of the night out of his room and nobody noticed. Beechcroft has provided a copy of documentation detailing nightly checks while Mr C was in the care home. This shows regular checks throughout the night of 29 January 2020. On each of those occasions Mr C is recorded as being in bed. In those circumstances I have no grounds to criticise the Council.
41. Ms B says both Hilltop and Beechcroft failed to apply appropriate creams to Mr C’s skin. In relation to Hilltop, the care plan records Mr C was prescribed lotions to help maintain skin integrity. The care plan says those creams should be applied as and when required. Beechcroft has been unable to provide the medication chart for Mr C to show what was prescribed from the pharmacy. There is evidence of creams being applied on three occasions in 2019 but there are no records of creams applied for the other dates. I have seen nothing though to suggest there was a problem with Mr C’s skin integrity while he was at Hilltop or when he transferred to Beechcroft. In those circumstances I do not intend to pursue the point further.
42. Ms B says both Hilltop and Beechcroft failed to wash Mr C’s hair with specialist shampoo. For Hilltop, I said earlier that when Mr C moved into the home it had little information about him or his needs. It is not surprising in those circumstances Hilltop would not have identified the need for specialist shampoo at the outset. The documentary records I have seen though do not provide any clarity about whether specialist shampoo was provided once it was identified as being necessary. Failure to keep full records is fault and means Ms B is left with some uncertainty about whether Mr C received the specialist shampoo he should have received while he was at Hilltop.
43. For Beechcroft, there are again gaps in recording. Although Beechcroft records show care staff provided personal care to Mr C, including washing his hair, the records do not say whether specialist shampoo was provided. Failure to keep full records is fault and this again leaves Ms B uncertain about whether Beechcroft used the specialist shampoo.
44. As with Hilltop, Ms B says Beechcroft failed to address Mr C’s oral health needs. Having considered the documentary records I am satisfied Beechcroft arranged for visits to the dentist in December 2019 and January 2020. Beechcroft also completed a mouth care plan and mouth care chart. I am therefore satisfied Beechcroft acted to address Mr C’s oral health needs, with the exception of the soaking of dentures which I refer to earlier.
45. Ms B says both Hilltop and Beechcroft failed to carry out checks on Mr C during the night. As I said earlier, there is evidence Beechcroft carried out regular checks throughout the night on 29 January 2020. Beechcroft has also provided documentary records showing regular checks throughout the night on the other dates Mr C was living there. Hilltop it has also provided evidence of checks during the night. I therefore have no grounds to criticise the Council here.
46. Ms B says the Council has overcharged Mr C for his care. Having considered the documentary records I am satisfied the Council carried out financial assessments for the 2019/20 and 2020/2021 financial years. I am therefore satisfied the Council has based Mr C’s contribution on his income. I therefore could not say the Council overcharged Mr C for his care. In reaching that view though I recognise Ms B questions whether Mr C should be responsible for the full costs of his care given the concerns the family raised about the care provided. Nevertheless, for both care homes Mr C was resident in those homes and received care. I have set out in this statement the areas where I have found fault in how that care was provided but there is no question care was provided to Mr C by both homes. I therefore cannot criticise the Council for charging Mr C for his care. I will set out later in this statement what I consider an appropriate financial remedy to reflect the areas where I have found fault.
47. I now have to consider what remedy is appropriate for the faults I have identified in this statement which have caused an injustice to Mr C and Ms B. As I have made clear, although there were shortcomings in the care provided to Mr C at both care homes a lot of that relates to the failure to document provision made, creating uncertainty about whether it was in place. I therefore cannot make any recommendation about a refund of care home fees for the two homes as that would be disproportionate to the injustice I can establish as a result of the fault. The exception to that is with the delay obtaining Mr C’s belongings when he moved into Hilltop. That delay meant he was without his belongings for longer than he should have been. That included his glasses and hearing aids. I consider that a significant injustice and recommended the Council apologise to Mr C and pay him £400. The Council has agreed to my recommendation.
48. It is also clear Ms B has suffered an injustice as she has had to go to time and trouble to pursue her complaint. The Council has offered £400 to reflect that time and trouble. That is in line with what the Ombudsman would recommend and I therefore consider that an appropriate remedy in terms of Ms B’s time and trouble. However, I also consider Ms B has experienced financial loss as a result of Hilltop losing some of Mr C’s clothes which meant Ms B had to buy new ones. As Ms B has receipts both for the original clothes she bought for Mr C and for those she had to replace when he moved to Beechcroft I recommended the Council refund to Ms B the amount she spent to replace lost clothing. To do that I would expect Ms B to provide the Council with receipts. The Council has agreed to my recommendation.

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Agreed action

49. 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 Hilltop and Beechcroft, I have made recommendations to the Council.
50. Within one month of my decision the Council should:
• apologise to Ms C and Mr B;
• pay Ms B £400; and
• pay Mr C £400.
51. Within two months of my decision the Council should discuss with both homes the findings from this investigation in relation to case recordings and ensure that ongoing monitoring visits for both homes covers the quality of case recordings.
52. Once Ms B has provided the Council with evidence of the additional expenditure she made when replacing Mr C’s lost clothing when he moved to Beechcroft the Council should reimburse the amount she paid.

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Final decision

53. I have completed my investigation and found fault by the Council in part of the complaint which caused Ms B and Mr C an injustice. I am satisfied the action the Council will take is sufficient to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman