Summary: We have not found evidence of fault by the Council in its response to Mrs A’s concerns about the care provided by a care home to her late husband. The Council has apologised for its delayed response to her complaint.

The complaint

1. The complainant whom I shall refer to as Mrs A, complains about the quality of care given to her husband by the care provider, a residential care home. The care home was commissioned by the Council. Mrs A complains that Mr A had several falls while in the care home, carers left him coughing with bread in his mouth, bent his arm when he had a broken shoulder and did not change his colostomy bag correctly. Mr A passed away two weeks after one of the falls. Mrs A experienced distress. She would like service improvements.

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What I have and have not investigated

2. I have considered the care home’s response to Mrs A’s complaint and the Council’s response to Mrs A’s safeguarding concern and complaints.
3. Part of Mrs A’s complaint appears to be that the care home has been negligent. Deciding about whether an organisation has been negligent usually involves looking rigorously, and in a structured way at evidence as only the court can to make its findings. In addition, only a court can decide if an organisation has been negligent and so should pay damages. We cannot recommend actions or payments that ‘punish’ the organisation. I cannot decide whether an organisation has been negligent and have no powers to enforce an award of damages. So, I would usually expect someone in Mrs A’s position to seek a remedy in the courts. I do not consider there is any exceptional reason why Mrs A cannot do this and so I do not propose investigating this part of her complaint.

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The Ombudsman’s role and powers

4. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. If we are satisfied with an organisation’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

6. I have discussed the complaint with Mrs A and considered the complaint and the copy correspondence she provided. I have made enquiries of the Council and considered the comments and documents the Council provided. Mrs A and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Safeguarding

7. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. 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).

Care Quality Commission

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that 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

9. Mr A had dementia and required care and support. He moved into the care home in 2020. He also had a diagnosis of terminal cancer.
10. In May 2021 Mr A had two falls. As a result of one of the falls Mr A fractured his shoulder. He attended accident and emergency and was discharged back to the home. The home started to use a sensor mat so that carers would be alerted if Mr A stood up.
11. The care home notified the Council’s safeguarding team regarding the fall. The Council considered the safeguarding alert. It visited the home and checked its records. The Council considered the home had taken appropriate action, and it had introduced measures (sensor mat) to alert staff if Mr A moved.
12. In mid July 2021 Mr A had another fall. Mrs A complained to the care home about the fall, and regarding other concerns she had about his care.
13. Mrs A also reported concerns to the Council’s safeguarding team regarding the care provided by the home.
14. Mr A sadly passed away in late July 2021.

The care home’s response to Mrs A’s complaint

15. In August 2021 the care home responded to Mrs A’s complaint.
• Mrs A had complained that on the day Mr A fell in July, carers should not have left Mr A alone in his room sitting in his chair. The home replied carers had transferred him from his bed to his chair as normal. Mr A had been able to get out of his chair and make his way to the corridor. Staff were alerted by the sensor mat, but when they arrived they found him on the floor. The GP believed the fall was likely due to Mr A’s irregular heartbeat. The care home’s notes showed that Mr A had been left alone for only five minutes.
• Mrs A said that carers left Mr A on the floor after his fall for two hours and people stepped over him. The home replied that carers did not move Mr A from the floor while it waited for the ambulance, because the emergency services advised them not to move him.
• Later the same day of his fall, Mrs A complained she found Mr A alone coughing with bread in his mouth, and around his mouth. The care home responded that Mr A’s care plan recorded he needed assistance with eating because of his broken shoulder, but not that he had difficulty swallowing. The care home’s food and fluid charts did not show concerns.
• Mrs A complained that problems seemed to occur at weekends when more agency staff were on duty. A manager said she would try to allocate permanent members of staff to care for Mr A at weekends. In response the care home said there was not a higher percentage of agency staff on weekends.
• Mrs A complained that a carer changed Mr A’s stoma bag without cleaning the area. The care home responded that the carer had received appropriate stoma care training and staff, residents and relatives had not reported any concerns regarding the carer.
• Mrs A said that the same carer bent Mr A’s arm when dressing him despite his fractured shoulder, causing pain. The care home had promised it would move this carer to a different floor. However, despite this within two weeks the home had allocated the carer back to support Mr A. In response the care home said it had addressed the concern about the carer bending Mr A’s arm with the carer immediately. The care home said it had explained the carer would be supporting other residents where possible. But it had not found evidence the carer was at fault, and it was not appropriate for the carer to work elsewhere as the home needed to provide consistency of care for all residents.

The Council’s safeguarding enquiry

16. The Council’s considered the safeguarding concerns Mrs A raised as a section 42 enquiry, under the Care Act 2014. The safeguarding officer visited the care home twice in October 2021, interviewed staff and considered the home’s records.
17. Mrs A’ councillor chased a response to her safeguarding concern in March 2022. The Council apologised for its delay. It explained that the original officer had left the Council and there had been a Covid outbreak in the service.
18. The Council sent Mrs A the outcome of its section 42 enquiry at the beginning of April 2022. It said that it had not found evidence of abuse or neglect. In response to the concerns it said:
• Regarding Mr A being left alone in his room and the carers not reaching him in time to prevent the fall, Mr A had fallen in the corridor despite the sensor mat. While the Council did not find neglect or abuse, it considered there was delay by the home in updating Mr A’s care plan and falls risk assessment.
• Regarding a carer reportedly changing Mr A’s colostomy bag without cleaning the area, the Council considered the carer had received appropriate training.
• Regarding Mrs A’s report that the same carer bent Mr A’s arm to dress him when he had a broken shoulder, and the carer returned to caring for Mr A. The Council did not find evidence of abuse or neglect. But it recommended the care home should have advised the family in writing the carer may return to caring for Mr A.
• Regarding Mr A being left alone with bread in his mouth when carers should have assisted him with meals, the Council said that there was a lack of correct documentation and recording by the home. This was because a care plan was updated in early July to advise that “after meals or medication staff should check [Mr A’s] mouth for debris, and remove any deposits.” This was a discrepancy in the timeline of the home’s records as it had not recorded any incident that led to this change in the care plan.
• Regarding Mrs A’s complaint that many of the problems with Mr A were on weekends when more agency staff worked and did not know him well, the Council did not find evidence to support that there were a higher percentage of agency staff at weekends.
19. While the Council did not find evidence of abuse or neglect by the home, it said it would report the care home’s recording issues to its Quality Team via a Notification of Concern. It explained the Quality Team’s role was to look at concerns relating to a service or provider as a whole and to work with the provider to improve those. The Quality Team carried out monitoring visits to assess the service provider and create an action plan for improvement.

Mrs A’s complaint to the Council

20. Mrs A complained to the Council that she was dissatisfied with the Council’s safeguarding response and its delay in sending her its findings.
21. The Council responded in May 2022. In its key responses the Council,
• Apologised again for its delay in responding to Mrs A’s safeguarding concern.
• Repeated that in relation to Mrs A’s concern about food being left in Mr A’s mouth, there was no evidence of neglect or abuse. But there were questions about the timeline of home’s documents.
• Noted Mrs A said the safeguarding officer stated in a telephone call to her about food left in Mr A’s mouth “why would you leave someone like that?” The Council said it could not comment on whether this was said or not, but it said it would remind officers about the importance of remaining impartial when considering safeguarding concerns.
• Noted Mrs A’s concern regarding the way a carer assisted Mr A to dress when he had a broken shoulder. It did not consider there was evidence of abuse by the carer. However, it found there was delay of nearly seven weeks updating risk assessments and care plans to reflect Mr A’s earlier falls.
• Noted Mrs A’s photo showing the sensor mat was not in place. But it said it could not prove or disprove this concern. It commented that the mat could have been moved when staff were not present.
22. In conclusion the Council said it felt it had carried out a thorough safeguarding enquiry and followed the correct procedure in referring matters to its Quality Team.
23. Mrs A had an opportunity to take her complaint to the Council’s second stage, but she decided that she would bring her complaint to the Ombudsman instead.
24. In its response to my enquiries the Council provided evidence its quality team followed up the recommendations that it made about monitoring. The Council provided a copy of the care home’s response showing it had implemented improvements such as reviewing residents’ care plans monthly and auditing these and ensuring family members are kept up to date via meetings and email updates.

Analysis

25. I have considered the Council’s safeguarding enquiry and the actions it took in response to its findings. In my view the Council has carried out an appropriate investigation which considered the reports raised, relevant evidence and guidance. I have not found fault here.
26. While it did not find evidence of abuse or neglect by the care home the Council identified poor record keeping by the care home, and also noted the home should have advised the family in writing that the carer may return to supporting Mr A. The Council has now provided evidence its Quality Team received a response from the home about improvements it had implemented. I am satisfied the Council has ensured service improvements in relation to the home’s poor record keeping and communication.
27. There was delay by the Council in responding to Mrs A’s safeguarding concern. The Council has explained the reasons for this which it says were outside its control. While I note the reasons for the late response, I consider there was avoidable delay by the Council in completing and providing the outcome of its investigation. However, I consider that the Council has provided an appropriate remedy as it has apologised to Mrs A for this delay.
28. I note that Mrs A says there were unanswered questions about why Mr A was left alone in his room in his chair. Mrs A said the care home’s routine was to dress him and take him to breakfast. The care home’s evidence indicates that Mr A was left alone for five minutes. The Council said Mrs A’s original concern was that Mr A should not have been left in his chair alone. The Council noted that Mr A required the assistance of two carers to transfer to and from the chair and that the sensor mat was put in place as a preventive measure to alert staff. The Council also states that individual providers may sometimes change their routines or schedules due to medical emergencies or personal care taking longer than usual. I have not found evidence of fault here.
29. Mrs A remains concerned that she saw a carer bend Mr A’s arm when dressing him despite his fractured shoulder. The Council considered this report but did not find there was sufficient evidence to support a finding of abuse or neglect. I have not found evidence of fault here.

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Final decision

30. I have not found fault by the Council. I have completed my investigation and closed the complaint.

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Investigator's decision on behalf of the Ombudsman