Summary: the complainant complained about the poor quality of care, commissioned by the Council at Tanworth Court Care Home, Tanworth Lane, Solihull and the Council’s handling of a safeguarding investigation. The Council says it took suitable action, but recognised faults in its handling of the safeguarding investigation. We found the Council at fault for the standard of care and in the conduct of the safeguarding investigation. The Council has agreed a remedy.

The complaint

1. The complainant, whom I refer to as Mrs X complains the Council as commissioner of the late Ms Y’s care failed to ensure she received good quality care when it commissioned care at Prime Life’s Tanworth Court Care Home, Tanworth Lane, Solihull (the Care Home). Mrs X says the Council failed to properly investigate safeguarding concerns and complaints about Ms Y’s care.
2. Mrs X says Ms Y’s family felt ignored and the Council failed to protect Ms Y’s health and preserve her dignity causing both Ms Y and the family anxiety. The family want the Council to improve supervision of care and safeguarding investigations.

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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 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. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. 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

7. In considering this complaint I have:
• Contacted Mrs X and read the information in her complaint;
• Put enquiries to the Council and studied its response;
• Researched the relevant law, guidance, and practice.
8. I shared this draft decision with Mrs X, the Council and Care Home. I have considered comments received before reaching this my final decision.

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What I found

9. A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (Section 42, Care Act 2014)
10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.

What happened

11. Following an assessment of Ms Y’s care needs and time spent in a hospice Ms Y moved into the Care Home in February 2020. The Council believed the Care Home could offer care that met Ms Y’s care needs. It says the Care Home’ s location meant Ms Y would be near to her family so they could visit regularly. The Care Home opened in January 2020 and so had no history with the CQC or the Council. The Council says it worked with the care home and agreed it could ask for a pause in admissions as part of its phased opening.
12. Between February and May 2020, the family raised concerns with the Council about the care Ms Y received. Following her admission into hospital in August 2020 Ms Y entered a hospice and sadly passed away the day after.
13. The family say while in the Care Home Ms Y did not receive support with her personal care and toileting needs leaving her soiled. The staff did not ensure she sat with her legs raised, even when her legs became swollen. A resident often wandered into Ms Y’s room took and wore her clothes and intimidated her. The food did not meet the standard the family expected. The family says the Care Provider and Council failed to properly monitor Ms Y’s care. The family say that Ms Y complained of being cold, hungry, and afraid but despite their complaints the family says the Care Home and Council did not act swiftly enough to prevent continued suffering. Ms Y, the family say felt ignored and afraid.
14. Ms Y’s Care and Support Plan detailed the care she needed including full personal care, and support with nutrition, eating and mobility.
15. The Council says following concerns raised in February 2020 about suitable clothing, food, and timing of Ms Y’s morning shower it carried out an investigation. The Council found defects in the Care Home’s record keeping. The Council found the Care Home had served unsuitable food to residents. It set out the remedial actions the Care Home needed to take. The Care Home asked for a pause in admissions in February. Council officers made follow up visits during February and March 2020 to check on progress with those actions.
16. Records show Care Home staff noted food and fluid intakes. They record visits by Ms Y’s GP and by the practice nurse to deal with abdominal pain, confusion, digestion, and skin care. In May 2020 the records show staff discussed with Ms Y’s medical team Ms Y’s increased anxiety and how to manage it. The Care Home reviewed the care plan to ensure staff oversaw Ms Y’s clinical condition and cognitive powers.
17. Mrs X says the family complained about the failures in care because they felt Ms Y’s treatment affected her dignity, comfort, and security. They say they often saw the resident who wandered into Ms Y’s room wearing Ms Y’s clothes taken from her wardrobe. The Council says in its response to my enquiries the Care Home fitted a gate to prevent entry to Ms Y’s room. However, Mrs X says staff did not close or secure it, thus the resident gained further entry.
18. Mrs X says staff rarely helped in the dining room and so Ms Y had to manage without help despite her care plan showing she needed help with feeding. Mrs X says the care plan issued by the hospice when discharging Ms Y from respite care recommended carers keep her legs raised. The hospice’s discharge letter given to the Care Home does not include this requirement. However, Mrs X says staff did not raise Ms Y’s legs even when they became swollen and they should.
19. In responding to my enquiries, the Council says it met with Ms Y’s family in February to address their concerns. A review of the care in May 2020 did not result in the family expressing any other concerns so the Council believed the care met Ms Y’s needs with no continuing concerns.
20. On admission to hospital in August 2020, the medical team assessed Ms Y as dehydrated and suffering sepsis. The family say this is from an infection they had reported several times to the Care Home, but staff took no action. The Council says it first heard of these conditions on Ms Y’s admission to hospital. The Council says there may be medical reasons for them rather than poor care.
21. The CQC raised a safeguarding concern about the Care Home. A Section 42 safeguarding enquiry followed resulting in no finding of neglect. However, the enquiry recommended improvements. The Council also imposed a pause on new nursing admissions to the Care Home during March 2020 to address concerns.
22. The family say the Chair handled the safeguarding meeting in October 2020 poorly leaving them little time to present their evidence. The Council apologised for the rushed meeting. The Council also apologised for the four-week delay in sending out the minutes of the safeguarding meeting.
23. As part of its quality control procedures the Council usually carries out four -weekly contract review meetings giving it oversight of any concerns about quality, safeguarding or complaints. The Council’s appointed care quality monitoring officer for the Care Home had frequent contact with the Care Home and clinical lead. The Covid-19 pandemic and associated controls resulted in limited site visits. Therefore, the Council undertook video conferencing with the Care Home and reviewed digitally provided records until able to visit in person.

Analysis – was there fault leading to injustice?

24. My role is to examine how the Council oversaw and responded to quality issues at the Care Home it commissioned. If it acted with fault, I must decide what impact that had and what the Council should do to put that right.
25. Records show care quality concerns arose from Ms Y’s entry into the Care Home. The Council responded to those concerns rapidly and followed them up with the Care Provider. While the Care Provider put in place the recommended measures quality concerns continued. The family says Ms Y continued to experience poor quality care and remained fearful. The Council says the care provided did not always meet expected standards and the voluntary and imposed pauses in admissions allowed the Care Home to address concerns. The CQC later rated the Care Home as ‘Good’ in all areas.
26. It is clear the Care Home did not meet all the quality measures expected by the Council on Ms Y’s entry to the home. That led her to suffer the indignity of another resident intimidating her, taking, and wearing her clothes more than once even after fitting the mesh gate intended to stop others gaining access. Ms Y experienced fear and lacked on occasion proper personal care. I find the Care Provider and Council at fault for the failings in this commissioned care.
27. The Council upheld complaints about the safeguarding enquiry. The faults resulted in the family feeling the Council had ignored or dismissed their concerns. They felt the Council had not listened to Ms Y’s concerns and experience. They felt justified when the CQC investigated a report from a whistle blower. For the public to have confidence in the safeguarding procedure councils need to ensure staff follow the procedure and address concerns raised. I find the Council failed to properly conduct its safeguarding enquiry leading to avoidable distress to the family.
28. We try to place people in the position they would have been but for the faults identified in an investigation. Where that is not possible, we may recommend a symbolic payment in recognition of the injustice. Under our ‘Guidance on Remedies’ we usually recommend between £100 and £300 for avoidable distress and time and inconvenience a complainant has been caused in making a complaint.

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Agreed action

29. 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 find the Care Provider at fault, I have made recommendations to the Council.
30. To address the injustice caused to Mrs X and the family in witnessing the poor care experienced by Ms Y the Council agrees to within four weeks of my final decision:
• Apologise to the family for the failings identified;
• Pay Mrs X £200 in recognition of the avoidable distress caused;
• Share this decision with staff including chairs of safeguarding enquiries to strengthen learning from the complaint.

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Final decision

31. In completing my investigation, I find the Council at fault for the failures in its commissioned care and its handling of the safeguarding investigation.

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Investigator's decision on behalf of the Ombudsman