Summary: The Council failed to complete a care plan prior to Mr Y’s admission to a care home and failed to respond appropriately to concerns about his wellbeing and the alleged behaviour of a carer. It also failed to keep in touch with Mr X during and after a safeguarding investigation and failed to provide an adequate complaint response.

The complaint

1. Mr X complains about the quality of care provided to his late father, Mr Y. He also complains about the way the Council dealt with his complaint.

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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 discussed it with Mr X;
• considered the correspondence between Mr X and the Council, including the Council’s response to the complaint;
• made enquiries of the Council and considered the responses;
• taken account of relevant legislation;
• offered Mr X and the Council an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
6. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
7. The Care Act 2014 says a council has a duty to safeguard adults. Section 42 of the Act says a council must make necessary enquiries if:

• it has reason to think a person may be at risk of abuse or neglect and
• the person has needs for care and support which mean he or she cannot protect himself or herself.

8. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.

Background

9. This is not meant to be an account of everything that happened. I have focused only on the material issues in the complaint.
10. At the time of the events complained about Mr Y was in his late eighties. He was deemed to have capacity to make decisions about day to day living and able to express his wishes and preferences.
11. Mr X and his sister held power of attorney for Mr Y’s health, welfare, and financial affairs.
12. Mr Y had a property in another Council area (Cheshire East). For many years he lived between his partners house, located in Stockport Council’s area, and his own home. Latterly he lived with his partner but retained his own home.
13. Due to a deterioration in his mental health, Mr Y was admitted to hospital on 26 January 2020.
14. The records show an officer from Cheshire East social services visited Mr Y in hospital on 1 February 2020 to discuss discharge planning. The officer took information from the ward about Mr Y’s health and care needs and completed an initial assessment. Mr Y’s main issue at the time appeared to be his mental health. He had been detained under Section 5 (2) of the Mental Health Act on 31 January 2020. The hospital reported he had been more settled in the previous seven days, but his mental health required close monitering. A hospital ‘therapy report’ reported Mr Y to be “…independently mobile for approximately 30m, steady pace, good balance”.
15. Mr Y’s family requested a short-term residential placement with a view to sheltered accommodation in the longer term. Cheshire East social services identified Bradwell Court Care Home, located in its Council’s area. The care home is registered to care for EMI (elderly mentally ill) residents. Mr X visited the home and accepted the placement.
16. Mr X says there was some dispute between Cheshire East Council and Stockport Council about Mr Y’s ordinary residence. Stockport Council assumed responsibility and placed Mr Y in the identified care home on 17 February 2020. It obtained all relevant information about Mr Y from Cheshire East Council.
17. The Council intended to undertake a detailed assessment of Mr Y’s needs during his stay at the care home.
18. Mr X believes the care home was not provided with a care plan prior to/or on Mr Y’s admission, and that it lacked basic information about Mr Y’s needs, including medication. Mr Y was discharged from hospital with prescribed medications which had dispensing instructions. I have seen no evidence to show the Council completed an interim care plan before or after Mr Y’s admission to the care home.
19. The records show the care home completed a pre-admission assessment. The document is dated 20 February 2020. The care home says the pre-admission assessment was completed before Mr Y moved into the care home but there was a delay in uploading the document onto its database. The document is unsigned. Numerous other assessments were completed shortly after Mr Y’s admission.
20. The falls, mobility assessment and falls risk assessment completed on 21 February 2020 records Mr Y to have had a fall within the previous twelve months. He was reported to mobilise independently using a zimmer frame or walking stick, and that he required no equipment to assist him with standing or sitting.
21. The records show Mr X contacted social services on 24 February 2020 to report his concern about Mr Y’s agitation and mental health. He also reported a carer had treated Mr Y badly. The officer advised Mr X to speak to the care home and to request that the carer in question did not attend to Mr Y. The officer advised Mr X to address Mr Y’s mental health with his psychiatrist. The officer said a worker would be allocated when Mr Y’s respite placement was ‘up for review”.
22. Mr Y spent eight days at the care home, during which he had four falls. Mr X says he was not informed about the first fall, and only discovered this when his daughter visited the care home.
23. After Mr Y’s third fall he sustained a head injury and was taken by ambulance to hospital where he had a brain scan. Mr X was informed, and he went to the hospital to be with Mr Y. The hospital discharged Mr Y back to the care home.
24. Within 24 hours of Mr Y returning to the care home he fell again. Mr Y had urinary urgency and Mr X says he had summoned carers as he needed the toilet, and when carers did not arrive soon enough, Mr Y attempted to manage alone. He was readmitted to hospital and found to have a broken hip. He initially recovered from surgery to repair his hip, but sadly his health deteriorated, and he passed away on 11 March 2020.
25. Mr X reported his concerns to the Council’s social services duty team on 25 February 2020. The duty officer contacted the hospital to enquire about Mr Y’s condition. The hospital confirmed Mr Y had a fractured femur. The officer informed the hospital she would be raising a safeguarding alert. The officer contacted Mr X to inform him.
26. The Council says the care home was in Cheshire East’s area, so it was responsible for dealing with the safeguarding enquiry/investigation. The Council informed Mr X.
27. Mr X contacted Cheshire East Council to ask for a contact number of its safeguarding team. I have had sight of Cheshire East Council’s safeguarding enquiry form, it records Mr X’s concerns and his dissatisfaction with Stockport Council’s handling of the matter, he believed Stockport Council was “passing the buck”.
28. Cheshire East Council contacted the safeguarding team at the hospital to request information about Mr Y’s diagnosis and treatment, the cause of death, and any concerns raised by health professionals. I have had sight of the report from the hospital which stated “I have reviewed this gentleman's notes are there are no concerns raised about his presentation to hospital or the fall he sustained resulting in his fractured Neck Of Femur… During his time in hospital with us, he became unwell and began to deteriorate refusing medical intervention. He also displayed signs of physical aggression towards staff”.
29. Cheshire East Council contacted the care home to notify it of the complaint and to make formal safeguarding enquiries. It was alleged that Mr Y had suffered:

• four falls in one week
• verbal abuse from carer

30. The care home completed a safeguarding enquiry form and returned it to Cheshire East Council the same day. It records Mr Y to have had unwitnessed falls in his ensuite bathroom, it attached incident forms which recorded the falls to have occurred at 22.02pm, 4am & 5.41am. Mr Y alerted staff via his buzzer that he had fallen. In response to the allegation of verbal abuse, it records Mr X to have reported the incident to the care home manager and that he described the carer as ‘huffing and puffing’. The records show the manager spoke to Mr Y the same day and asked him to identify the carer in question. Mr Y gave three different names of carers he believed to be responsible. The carer in question, and other carers present were formally interviewed, and statements taken.
31. A statement was also taken from Mr X’s daughter. She reported she had visited Mr Y on 20 February 2020 and was informed by another resident that Mr Y had fallen in the dining room because the arm of a dining room chair had collapsed. She asked Mr Y if was ok, and he replied he was. During this visit she witnessed a male carer huffing and puffing when Mr Y asked to go to the toilet. A few days later during a telephone conversation with Mr Y, he told her he had pressed his buzzer four times in the toilet the previous evening and when the same male carer attended, he made Mr Y feel like a nuisance. No concerns were reported about any other carers.
32. The care home manager confirmed the fall from the dining room chair had not been formally recorded by carers, and that she would address this in 1-1 sessions with the two carers responsible for completing relevant documentation. She said further training would be given, and that she intended to contact the company’s HR to establish if ‘further steps’ were required. The manager also notified the safeguarding team and the Care Quality Commission (CQC).
33. Because there was an ongoing safeguarding investigation, Cheshire East Council reported Mr Y’s death to the coroner on 13 March 2020. I have had sight of the referral form. It gives a brief overview of the events and details of its initial enquiries. The Police were also informed.
34. The Police sent an email to Cheshire East Council safeguarding team Council on 17 March 2020, to say the doctor that completed Mr Y’s death certificate had not recorded the fall/fracture, or subsequent surgery as a cause of death, therefore the coroner “…has no remit to investigate any further. The son has asked if someone could get in touch with him re the safeguarding investigation please?”.
35. The records show Cheshire East Council contacted Mr X on 18 March 2020 to discuss the complaint.
36. Mr X says he contacted Cheshire East numerous times for updates. It informed him he would be updated when the investigation was concluded.
37. Cheshire East Council made further enquiries of the care home about:

• the manager’s retraction of a previous statement relating to the damaged dining room chair
• the fall in the dining room, the broken chair, and the carers actions.
• contact with GP/Health professionals following the increased falls
• additional equipment was considered to minimise falls risk
• the order date of a high-rise toilet seat
• Mr Y’s medication
• if Stockport Council Adult had provided an assessment or review pre/during Mr Y’s stay

38. Cheshire East Council concluded the safeguarding enquiries on 15 April 2020. The records show an officer from Cheshire East Council telephoned Mr X on 16 April 2020 to discuss the findings. Mr X asked for a full copy of the safeguarding report. The officer advised she would provide a written summary of the outcome and recommendations. Cheshire East Council later refused to provide a full copy of the report, saying it contained personal data about third parties.
39. Mr X received an email from Cheshire East Council on 22 April 2020 detailing the outcome of the investigation. I have had sight of this email. The author explained that “On the balance of probabilities the safeguarding concern is partially substantiated”, because:

• the arms on the dining room chair were known to be loose, therefore placing residents at risk of potential injury.
• completed risk assessments by the care home appeared incomplete.
• the falls risk assessment completed did not take into consideration that Mr Y’s prescribed medication
• aids required in Mr Y’s toilet were not in place
• Mr Y was known to have fallen previously therefore outline measures taken clearly to support Mr Y in minimising his risk of falls
• there is no evidence to show the care home reviewed the risk assessment after the Mr Y’s fall in the bathroom on 23 February 2020, after which he was taken to hospital. Mr Y then had a further fall on 25 February 2020 sustaining a fractured hip

40. In respect of allegations of verbal abuse, the investigation concluded “Carers who have supported [Mr Y] during his stay, all deny being rude to [Mr Y] when supporting him. However the family members view is that the carer who was supporting on 20.02.2020 had poor attitude”. Lessons learnt by the care home were detailed. It confirmed “Action will be taken with the carer and team leader concerned after the outcome of the investigation”.
41. Mr X wanted reassurance that ‘someone’ had been held accountable for what had happened. He asked for information about the action taken as a result of the safeguarding investigation. He says this was not forthcoming from either Council.
42. Mr X contacted Cheshire East Council again on 5 May 2020 to formally complain that Stockport Council had failed to complete a comprehensive assessment of Mr Y’s needs and failed to provide the care home with a care plan. It advised Mr X to contact Stockport Council directly to submit his complaint.
43. Mr X submitted a formal complaint to Stockport Council in July 2020 saying as the funder of Mr Y’s care it had a duty of care to him. He complained about the quality of care provided to Mr Y, and about the way his complaint had been handled.
44. The Council acknowledged receipt of Mr X’s complaint and said he could expect to receive a response by 7 August 2020. Mr X did not receive a response. He says chased the Council on many occasions and was passed from one officer to another. He says some officers were rude.
45. Mr X submitted a complaint to this office in May 2021. We deemed it premature and referred it back to the Council. Mr X heard nothing from the Council and contacted this office again. We contacted the Council on 10 June 2021. It said there had been an oversight and consequently there had been a delay in providing Mr X with a complaint response.
46. The Council completed the complaint response the same day,10 June 2021. I have sight of the letter. The author apologised for the delay in its response. He went on to say “The council agrees that the service fell short of what a reasonable person would expect and accepts that this resulted in a very stressful period for you and your family. For which the council apologises to you. The council also apologises for the delay in responding to you in a timely manner. Though, as you know, we faced enormous challenges over the last 15 months we should, at least, have advised you of the delays and provided an estimate of when you could expect a response. I therefore uphold your complaint and confirm that the cost of the residential placement will be cancelled”.
47. Mr X is dissatisfied with the response. He feels there has been a lack of accountability for what happened to Mr Y and that it has not answered his questions/queries about ‘what the charges were’ and what, if any, ‘sanctions’ were taken against the care home. He is also unsure what cost the Council intends to cancel. He would like clarification if this includes the third-party top payment he paid directly to the care home.

Analysis

48. 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.
49. There are numerous aspects to this complaint: Mr Y’s admission to the care home and how this was managed by the Council, the care provided in the care home, the safeguarding investigation and how the Council responded to Mr X’s complaint.
50. Prior to Mr Y’s discharge from hospital an officer from Cheshire East social services visited Mr Y in hospital to complete an initial assessment. The officer obtained all relevant information and recorded it appropriately. This information was shared with the Council. There is no evidence of fault by the Council here.
51. Mr Y was unable to return home and his ongoing care needs were unknown. The Council planned to do a more detailed assessment of Mr Y’s needs during his stay at the care home. Such practice is not unusual. There is no fault here.
52. However, following the initial assessment, the Council should have completed an interim care plan and provided a copy to the care home. I have seen no evidence that it did so. The Council is at fault here.
53. The care home completed its own initial assessment of Mr Y’s care needs.
54. Mr X contacted the Council to express his concern about Mr Y’s mental health, and that a carer had treated Mr Y badly. The Council’s response was inadequate. Given Mr Y’s history of mental health problems the Council should have contacted the care home to establish the facts and ensure Mr Y’s wellbeing. Any reports about carers treating residents badly should be investigated promptly and robustly. It was wholly inadequate to suggest Mr X contact the care home to request that the carer in question did not attend to Mr Y. This could have left Mr Y and other residents exposed to unacceptable treatment.
55. Mr Y had four falls in eight days, it was only after he was admitted to hospital with a broken hip that the Council acted and a referral to safeguarding was made.
56. The situation was then complicated by the fact that a different council (Cheshire East) completed the safeguarding investigation. I have not made enquiries of this Council, but I have had sight of all the safeguarding documents, (provided by Stockport Council). Mr X can be reassured his concerns were taken seriously and investigated properly.
57. Cheshire East Council informed Mr X of the findings of the investigation.
58. I note Mr X’s dissatisfaction that he has not been provided with a full copy of the safeguarding report by either Cheshire East or Stockport Council. The Council had a duty to inform Mr X of the findings of the investigation and any recommendations arising from it. It was not obligated to provide information which refers to third parties, which the full report did.
59. In the same way Mr X is not entitled to detailed information relating to employees. However, I can share with Mr X that formal action was taken against a carer and a team leader.
60. The Council appears not have appointed a nominated contact for Mr X when the safeguarding investigation had been passed to Cheshire East Council. It would have been good practice to do so. It commissioned the care and had a duty of care to Mr Y. It should have liaised with Cheshire Council and ensured Mr X was kept informed/updated.
61. Mr X was left feeling the Council had little concern about the quality of care it had commissioned for Mr Y, or the events that transpired in the eight days he was resident at the care home.
62. Mr X’s distress and frustration is understandable.
63. The Council’s complaint response letter compounded this. Although the Council upheld the complaint and apologised, its letter lacked any detail or gravitas. There was no reference to Mr Y, the experience he had or the findings of the safeguarding investigation. Neither did it explain if and how the Council had liaised with Cheshire East Council, and what action had been taken to improve the quality of care provided by the care home, and how this would be monitored.

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Agreed action

64. The Council should, within four weeks of the final decision offer Mr X an apology for its failure to:

• complete a care plan prior to Mr Y’s admission to the care home.
• respond appropriately to Mr X concerns about Mr Y’s wellbeing and the alleged behaviour of a carer
• keep in touch during and after the safeguarding investigation
• provide an adequate complaint response.

65. The apology should be delivered in person by a senior officer from social services. In addition, the Council should:

• pay Mr X £250 for his time and trouble pursuing the complaint with the Council and this office
• pay £500 to acknowledge Mr X’s distress and frustration caused by the Council’s failure to respond appropriately to his concerns
• provide evidence of all the above to this office.

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Final decision

66. There is evidence of fault by the Council. It failed to complete a care plan prior to Mr Y’s admission to the care home, failed to respond appropriately to Mr X’s concerns about Mr Y’s wellbeing, and the alleged behaviour of a carer.
67. It also failed to keep in touch with Mr X during and after the safeguarding investigation and failed to provide an adequate complaint response.
68. The agreed action is a suitable way to settle the complaint.
69. It is on this basis; the complaint will be closed.
70. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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Investigator's decision on behalf of the Ombudsman