Summary: Miss X complained about the Council commissioned care provider’s actions when her mother went missing at the care home. The Council and care provider investigated the concerns, identified faults and put actions in place to prevent the faults recurring. The Council has already apologised to Miss X. In addition, it has agreed to make a payment to Miss X and Miss Y to acknowledge the distress caused by the faults and to ensure its contract monitoring team continue to monitor compliance with the care home’s action plans.

The complaint

1. Miss X complained about the Council commissioned care home, Tower Bridge Care Home’s actions when her mother, Miss Y, went missing and was found later that evening in a locked store room. This left her mother needing hospital treatment and caused Miss X and her mother significant distress.

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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. 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).
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)

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How I considered this complaint

5. I have considered the information provided by Miss X and have discussed the complaint with her on the telephone. I have considered information from the Council in response to my enquiries including records from the care provider and from the Council’s safeguarding investigations.
6. I gave Miss X and the Council the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the final decision with CQC.

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What I found

8. 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
9. 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 the fundamental standards and prosecute offences.
10. The Care Act 2014 sets out a framework for local authorities to protect adults at risk of abuse or neglect.
11. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (Section 42, Care Act 2014)

What happened

12. Miss Y had lived at Tower Bridge Care Home (the care home), run by HC-One Ltd (the care provider) for several years. Miss Y had advanced dementia. She was fully mobile and frequently wandered around the care home and was unable to communicate her needs clearly and intelligibly.
13. In March 2021 staff noticed Miss Y was missing from the care home. The police were called over two hours later, after staff had searched for her. Miss Y was found by police in a locked store room in the home, several hours after she was last seen by care home staff. Care home staff did not tell Miss X that Miss Y was missing until after the police attended the care home. Miss Y was admitted to hospital where it found she was dehydrated with bruising on her head. The police raised a safeguarding concern with the Council. It also received safeguarding referrals from the Ambulance Service and hospital.
14. In late April 2021 Miss Y was discharged from hospital to another care home. Miss Y’s health has deteriorated and she is now cared for in bed and requires full support with all her care needs and with food and fluid.

The care provider’s investigation

15. An Area manager from the care provider investigated the incident, met with Miss X and sent her a complaint response in April 2021. They apologised for the distress Miss X experienced. In the response they noted:
• The police and Miss X should have been called much earlier and the care provider’s missing persons’ policy was not followed in full.
• The care home deputy manager did not interact with Miss X during the search or its aftermath and they should have considered that Miss X needed support and reassurance.
• The only rational explanation for Miss Y entering the store room was that it had incorrectly been left unlocked by care home staff.
• Before the incident, the home had not correctly assessed or mitigated risks to Miss Y’s safety and wellbeing, regarding her weight management, her frequent independent walking and her high risk and history of falling. There were no food and fluid records in place given Miss Y had recent weight loss and her care plan noted she required close monitoring of her food and fluid intake.
• They found the MUST assessment sheet (a malnutrition screening tool) had been rewritten since they first inspected it at the care home. This caused Miss X serious concerns. The Area manager had investigated this and found a staff member had rewritten rather than corrected the sheets following the Area Manager’s feedback at an earlier investigation visit where they had highlighted the sheets were incorrectly completed. This was addressed with the staff member as they acknowledged this could appear to Miss X to be an attempt to cover up previous errors.
• They would have expected the care home to call Miss X regularly to maintain contact and to seek an update after Miss Y’s hospital admission. They apologised this did not occur.
16. They noted actions would be taken including meetings with all staff to go through the incident. This needed to identify lessons to be learnt and areas for improvement. This would include formal supervision with certain staff members, reviewing the charting requirements of all residents and ensuring future use of the ‘Herbert Protocol’ – a nationally recognised system for alerting and recognising a person with dementia who has gone missing.
17. Following the investigation, the care provider produced a 12 point action plan. The recommendations included close monitoring observations to be introduced for all dependent and vulnerable residents, a review of all key operated locks and how keys were held and managed, a full walk-round handover at shift changes and risk management checks for other residents to ensure similar incidents did not occur.
18. Miss X remained unhappy with the outcome and the care provider considered it at the next stage of its complaints’ procedure. It confirmed a robust action plan was in place following the incident and a senior manager had visited the home to confirm the actions were completed. Supervisions were also undertaken with staff.
19. It noted that despite the MUST screening tool being wrongly completed Miss Y was regularly reviewed by a consultant geriatrician and actions were put in place to address weight loss including 1:1 support at mealtimes. It noted staff had lost the original MUST forms and that a staff member completed new forms after being advised the originals had been wrongly completed. It acknowledged these should have been amended rather than redone. However, it considered there was no deliberate attempt to falsify records and the staff member concerned had received further training. It apologised again for the distress caused to Miss X and the family.
20. Miss X remained unhappy and complained to us.

The Council’s safeguarding investigation

21. The police notified the Council’s safeguarding team of the incident in March 2021. The Council allocated a social worker to investigate. They contacted the hospital which advised that when admitted, Miss Y was dehydrated with swelling/bruising to her forehead but she appeared otherwise healthy. The care home did not report the incident as a safeguarding concern until mid April.
22. The social worker spoke with Miss X and with the care provider which provided them with a copy of its investigation report. The care provider also advised the social worker of a recent CQC inspection visit prompted by the safeguarding concern.
23. The Council held a strategy meeting with staff from the hospital, the police and the care home in May 2021. It discussed Miss X’s concerns about the time taken to notify her and the police Miss Y was missing and her concerns about the altered care records. The Council’s contract monitoring team also advised it would continue to liaise with the care home to ensure the action plan was adhered to. The police advised it did not appear to be a criminal matter.
24. The social worker closed the safeguarding investigation in late May 2021. They found neglect which caused Miss Y harm. They noted the Council’s contracts team would continue to monitor the care home, CQC had inspected and the care provider had put measures in place to ensure the incident would not be repeated.
25. Miss X raised further concerns with the Council. She felt her concerns around the falsification of documents were not taken seriously and she had ongoing concerns about care provision at the care home. A manager met with Miss X and following this wrote to Miss X in July 2021. They acknowledged the impact the incident had on Miss X and the family and apologised for this. They noted Miss X said she had not received feedback on the outcome of the safeguarding enquiry and they summarised the actions taken. They agreed to reopen the safeguarding investigation to look again at her specific concerns. The Council allocated an officer to:
• Obtain a clearer picture of what happened on the day of the incident and to consider the wider implications for how the care home monitored vulnerable adults particularly those known to wander
• Understand how its commissioning team planned to monitor the care home
• Understand what controls the care home had put in place to minimise falsification of documents going forward.
26. The officer visited the care home, spoke with the care provider and Miss X and examined the care home’s records. They found when Miss Y went missing there was no clear handover from day to night staff. The handover took place between 8pm and 8.30pm and it was the night staff at the care home who noted Miss Y was missing; the day staff had not noticed she was missing. Risk assessments recorded Miss Y needed close monitoring but this had not happened and CQC were not informed of the incident by the care home until 1 April.
27. They also found the MUST sheets had been updated because a member of staff was told the original document was not accurate. The old form was then misplaced.
28. The care provider advised that:
• It had revised its missing person protocol. If a resident went missing in future, after an immediate search it would inform the police, family members, CQC, the Council’s commissioning department and safeguarding.
• the store room now had a padlock and a key pad requiring a code to enter it.
• it had introduced close monitoring observations of all vulnerable residents who wandered with purpose round the care home and had introduced the Herbert protocol for dementia care units.
• it had since introduced a full walk round handover at shift changes so staff could observe residents first hand.
29. The Council’s contract monitoring team visited the care home in May 2021. It had planned to visit monthly but had not been able to due to staff sickness and shortages. However it was due to visit in September 2021, in particular to look at risk assessments and associated care plans and how they were managed by the care home.
30. The Council closed the safeguarding investigation in October 2021. It noted Miss Y was settled in her new care home. The care home had recognised its mistakes and had learnt from the incident. It had implemented new procedures and completed internal training with staff. The Council provided Miss X with the outcome of the safeguarding investigation.

The CQC inspection

31. Miss X notified CQC about what happened. CQC inspected the care home in April 2021. The report noted the inspection was prompted in part by notifications of recent incidents which included how the provider managed an incident of a missing person and an incident related to staff misconduct. It looked at whether the service was safe and well-led and concluded the care home required improvement in both areas. Within the report it noted it found inconsistencies within risk assessments which created a risk to people’s health and safety which was breach of regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities Regulations 2014.
32. It found the provider had carried out an internal investigation in response to the incident related to Miss Y and that an action plan was in place and being implemented. However, there was a delay by the care home in making a safeguarding referral for this incident and the provider’s missing person’s policy did not make reference to the safeguarding process.
33. It found the care home had not had a permanent registered manager since January 2021 which had impacted on management of the service.
34. Following the CQC inspection the care provider developed an action plan which it monitored on its live action plan tracking system. The actions included:
• For the home manager to discuss the incident reporting and recording procedures with staff at team meetings/supervisions
• All accidents and incidents to be logged on the incident review system within 24 hours with safeguarding referrals and referrals made to CQC where required. This would be monitored by the care provider with appropriate action taken if it did not happen.
• A new care home manager to be recruited and regular team meetings to be held to enable staff to feel supported and well communicated with.
• The Clinical Risk Register to be a guidance on identifying the level of risk for a resident who has fallen, with falls care plans initiated for residents who had two falls in a month.
35. The care provider monitored compliance with the actions, closing them when completed or in some cases it kept the action open to enable three months monitoring so it could be satisfied the action was sustained.

Findings

36. The care provider carried out an investigation into what happened. In the complaint responses to Miss X it accepted it was at fault. These faults included:
• the store room being left unlocked;
• delay in notifying Miss X and the police and in reporting the incident to CQC;
• the handover between day and night staff was not thorough enough;
• Miss X was not closely monitored on the day she went missing;
• risks to Miss Y’s well being and safety related to falls and food and fluid intake were not properly assessed or mitigated; and
• MUST malnutrition screening forms were rewritten and replaced.
37. The Council also investigated the incident under its safeguarding procedures. It found Miss Y was neglected which caused her harm. The Council has acknowledged it failed to properly update Miss X with the outcome of the original safeguarding investigation. This was fault. When Miss X complained that not all her concerns were addressed the Council reopened the safeguarding and considered the issues further. I am satisfied the Council has now properly investigated Miss X’s concerns.
38. The care provider produced a detailed action plan setting out the actions it has taken to address the faults identified. I am satisfied this was appropriate and the care home has taken action to prevent recurrence of the faults identified.
39. Miss X remains dissatisfied with the care provider’s explanation for the changes to the MUST malnutrition screening sheets and for the loss of the originals. The care provider explained this was down to the action of an individual who had wrongly thought they should be corrected. It has carried out supervision to prevent recurrence of the fault. I cannot now establish what happened to the original forms and there is nothing else I can achieve by further investigating this issue.
40. Although the care provider has taken action to prevent recurrence of the faults, the faults caused Miss Y significant distress and these mistakes by the provider led to Miss Y’s hospital admission. Any remedy for injury or harm to health is usually a matter for a court to decide not the Ombudsman. However, I can recommend a payment to acknowledge the impact of faults on Miss Y and have done so in this case. The provider’s faults meant Miss Y did not receive services intended to provide her with protection.
41. In deciding on a remedy for injustice to Miss Y, I have considered the severity of harm and risk of harm, length of time involved, and the vulnerability of Miss Y.
42. The Council and care provider have already apologised to Miss X for the distress caused to her. The injustice of distress cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault.
43. The Council’s contract monitoring team did not monitor the care home monthly as it planned to do. The care provider has demonstrated it has complied with the actions required. However, I would expect the Council to monitor the care provider further to ensure that actions taken have led to sustained improvements in practice.
44. The CQC has also inspected the care home in response to Miss X’s concerns. It identified breaches in the regulations which the care provider was required to address. It is for the CQC to follow up these actions.

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Agreed action

45. 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 provider, I have made recommendations to the Council.
46. Within one month of the final decision the Council has agreed its contract monitoring team will visit the care home to monitor compliance with the action plans.
47. Within one month of the final decision the Council has agreed to pay Miss X £300 to acknowledge the distress caused to her by the faults identified and to pay Miss Y £1,000 to acknowledge the impact the faults caused to her.

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Final decision

48. I have completed my investigation. There was evidence of fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman