Summary: Ms C complained about the support her mother-in-law received at a care home arranged by the Council. The Ombudsman finds fault with the Council and the care home acting on the Councils behalf for some of the care Mrs M received and for failing to record and report safeguarding concerns. The Council has agreed to pay a financial remedy and work with the care home to improve how it records and reports safeguarding incidents.

The complaint

1. The complainant, whom I shall call Ms C, complained to us on behalf of her mother-in-law, whom I shall call Mrs M. Ms C complained that:
• The Council should not have moved her mother-in-law into a particular unit (hereafter called ‘Unit A’) at Care Home A, because this unit was not suitable to meet her needs. Her mother-in-law needed a dementia nursing care placement, which this was not.
• Her mother-in-law once mentioned during a phone call with a family member that some of the men “bash her about”. At this point, a male care worker took the phone from her and said the GP had arrived to see her. The family member asked if he could say goodbye and was told that he couldn’t.
• She has been told that, during time when there was Covid-19 within the unit, her mother-in-law was restricted with food and fluid intake.
• The staff at the home failed to spot that a chair they had given to her mother-in-law, was clearly too small for her.
• Her mother had a clear bruise on her face on the day she moved to a new care home. The care home did not record, investigate or refer this to the Council’s safeguarding team.
• The manager of the home failed to attend a Best Interest Meeting shortly before her mother-in-law was moved to another care home. She arranged another staff member to be present, who was however unable to provide any useful input.

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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 the actions or proposed actions of the Council, 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 considered Ms C’s complaint and information she provided. I also considered information from the Council and from the two care home’s Mrs M lived in.
6. I considered comments from the Council and Ms C on a draft of my decision.

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What I found

The complaint about Mrs M being moved into Unit A

7. Mrs M’s assessment states she suffered from Vascular Dementia and self-neglect in the areas of nutrition, medication, personal hygiene and appearance. This was due to her lack of insight into her needs and circumstances. Mrs M was resistant to care and support.
8. On 17 November 2020, the Complex Case panel considered an application for a S117 dementia nursing placement at Hilton Park. This was approved by the CCG and social care and Mrs M moved into Unit A in November 2020.
9. Ms C says that:
• The Council should not have moved her mother-in-law into Unit A, because this unit was not suitable to meet her needs. She said her mother-in-law needed a dementia nursing care placement, which this was not.
• The family were led to believe the Unit was a dementia unit, and that staff were trained in dementia care. However, this was not the case.
10. The Council has since recognised that it should have carried out a care review after 6 to 8 weeks, which did not happen. Mrs M should have been under a care coordinator to ensure this would happen. However, I have not seen evidence she had a care coordinator at the time.
11. The Council has said that, during this time, a Specialist Mental Health Practitioner was in regularly contact with the care home. It says they spoke to different staff members on Unit A who stated Mrs M was doing well. It added that, throughout this involvement, the Practitioner shared his professional knowledge with the home about how best to support Mrs M.
12. The care home (a nurse) reported to the Community Mental Health Team (CMHT) on 12 and 15 February 2021 that Mrs M was fine. Her food and fluid intake were good but ''it depends on her mood''. She would sometimes refuse her medication but was settled with little or no management problems.
13.  
14. A week later, Ms C reported some concerns to the CMHT, saying Mrs M looked physically unwell, pale, appeared to have lost weight and she was in pain, during a recent zoom call. The CMHT called the manager and said if food and fluid intake remained poor, they should refer to the dietician. The manager did not believe Mrs M was in pain. The home reported on 2 March the GP would review Mrs M about her weight loss and then refer to the dietician if needed. The GP felt that her poor intake was due to her low mood due to the covid restrictions and not seeing her family.
15. At the end of April 2021, the home reported to the CMHT there were no changes, and they did not have many problems about Mrs M’s care.
16. At a Multi-Disciplinary Team meeting at the end of May 2021, it was decided to have a best interest meeting for Mrs M.
17. A student social worker contacted the care home in May 2021 to say she was going to do a care review of Mrs M. She visited the care home, reviewed care notes and care plans and spoke to Ms C. The social worker tried to have a meaningful conversation with Mrs M but could not due to her advancing dementia. The records show the care review was not completed. The Council has said the student social worker did not record or raise any concerns about the placement being inappropriate. 
18. When the lockdown and restrictions related to Covid-19 were lifted, the family could visit Mrs M again. This resulted in them raising concerns with the Council about Mrs M’s living environment, especially related to her being isolated and a perceived lack of personalised support with eating and drinking (preferences). The records showed the Council raised these with the care home, investigated them. The Council organised several meetings to review whether it would be in Mrs M’s best interests to move her to a more specialized dementia care setting, because it said her dementia had deteriorated.
19. A consultant psychiatrist carried out a review of Mrs M’s mental health and medication in June 2021. He recorded that:
• There had not been a significant deterioration in her mental health and there had been no increase to her psychiatric medication.
• The unit may not be the best match between her needs and the unit's profile (very mild dementia). 
20. A record from 15 July 2021 states the care home’s Senior General Manager reported to the CMHT that they have assessed their residents and identified some of them were not appropriately placed. This included Mrs. The manager said they were going to close down Unit A for refurbishment and would relocate the residents there. The manager added that Unit A was not a ''special mental health unit''.
21. The minutes of a best interest meeting in August 2021 stated the care home’s clinical lead said that Unit A was a delirium unit that also had some dementia patients. The record of the meeting states that:
• “(…) staff do not have dementia training. This raises the issue of the appropriateness of the placement as Mrs M is being funded for dementia care”. The clinical lead said that staff can manage mild dementia but not at the level of Mrs M’s needs.
• The priority would be to make sure Mrs M would be safe and that her basic needs were being met. Her situation would need to be escalated with management as Mrs M had been nine months in a unit that was not dementia as contracted. The family confirmed they felt Mrs M was safe for now where she was but that her dementia care needs were not being met.
22. The safeguarding enquiry into Ms C’s concerns found that:
• The Council sent an outdated care plan to the care home on 9 November 2020. However, the home knew at the time that she had dementia.
• At the time of Mrs M’s admission, the care home was registered for Nursing Dementia. Mrs M lived in a mixed community for elderly and frail residents, with a separate area designated for residents living with dementia or other cognitive impairment. This showed that an appropriate placement was sourced and commissioned. However, the care home is not specifically a specialist dementia care facility.
23. Mrs M moved to another care home in September 2021. Ms C reported soon after that:
• Mrs M seemed much happier and looked well.
• There had been regular contact with the staff of the new home.
• Mrs M was washing/showering every day, changing her clothes twice a day (for day and night) and spending a lot of time out of her room in the lounge or dining room. This did not happen at the previous home.
24. In response to my enquiries, the Council told me that:
• It assessed Mrs M in hospital in October 2020. This identified her needs as nursing dementia. The care home was registered as accommodation for persons who need nursing, caring for adults over 65 and mental health conditions.
• The placement was monitored by the Community MHT who reported it was going well.
• It is the Council’s conclusion that this was an suitable placement for Mrs M at the time. The care home is registered to care for people with nursing and Mental Health needs. The provider refers to it as a mixed community for elderly frail residents who are living with dementia.
• It increased monitoring visits to the home and developed an action plan with the provider to address any areas of improvement it had identified. The Council decided in March 2022 that significant improvements had happened.

Analysis

25. In response to my draft decision, the Council has since clarified the information given at the best interest meeting was incorrect, and that staff did receive dementia training as part of their induction.
26. The care home has not been able to explain why its clinical lead did not believe staff had dementia training. However, it is clear from the records the clinical lead at the time did not believe the placement to be able to meet Mrs M’s needs.
27. There was a delay by the Council and the care home realising the placement was not suitable for Mrs M, especially about support she needed for her dementia.
28. This could have been picked up earlier if the Council had carried out the required 6-8 weeks care / placement review, and if Mrs M would have had a care coordinator at the time.
29. Once the Council realised that Mrs M’s placement was unsuitable, it took the appropriate steps to move Mrs M to another home.

The complaint about what happened and was said during a phone call.

30. Ms C said:
• Mrs M mentioned during a phone call that some of the men “bash her about”.
• At this point, a male care worker took the phone from her and said the GP had arrived to see her. The family member asked if he could say goodbye and was told that he couldn’t.
31. I asked for evidence to show the care home investigated the concern in relation to Mrs M’s comment that she was being bashed about. In response, the care home said that:
• Ms C stated in her letter dated 11 October 2021 that Mrs M “gets confused and words muddled and is known to say ‘bash her’ when meaning something else.”
• The General Manager from the home spoke with her and shared the findings with her.
• We do take allegations of harm against residents very seriously and the then General Manager of the home did undertake an investigation into this allegation. It is understood the General Manager spoke with all male members of staff employed at the Unit and found no evidence to support the allegations that had been made.
32. In response to my question, the Council said the home did not raise this concern with the Councils safeguarding team. The Council would expect an allegation of this nature to be reported to its Safeguarding Team.

Analysis

33. While the care home says it carried out an investigation at the time, there is no recorded evidence of this. This is fault. The Council has also confirmed the home failed to inform the Council’s safeguarding team of this allegation.

Ms C’s allegation about food restrictions

34. Ms C says she has been told that her mother-in-law was restricted with food and fluid intake during a Covid-19 outbreak in Unit A,
35. The care provider responded by saying it investigated this concern and shared the findings with Ms C in a letter in January 2022. It confirmed that staff did not restrict Mrs M’s food and fluid intake.
36. The records indicate that Mrs M food intake reduced when visits were not allowed due to Covid-19. As a result, the care home involved the GP who said this was due to Mrs M’s mood having deteriorated as she was no longer able to meet her family during this time.

Analysis

37. There is no evidence to conclude that staff restricted Mrs M’s food intake during a covid-19 outbreak on the unit.

Ms C’s complaint about the chair in Mrs M’s room

38. Ms C complained that staff at the home failed to spot that a chair they had given to Mrs M was clearly not suitable for her.
39. Ms C said that a social worker immediately spotted during her first visit that the chair Mrs M had been using for eight months was too small for her. The social worker discussed this at a meeting on 29 July 2021. It was only then that the care home provided a suitable chair to her.
40. The record of the visit referred to above states: “Chair provided for Mrs M in her room appears to be on the small side and looks uncomfortable”. Once the social worker had raised this issue, the care home immediately provided a recliner chair.
41. The care provider has said that, since then, it has introduced a procedure whereby the nurse in charge will involve the occupational therapist in all placements. This is to ensure that each resident has the right equipment to meet their needs. The home will also ensure there will be daily spot checks of equipment in use. Additionally, the Quality Improvement and Regulation Team coordinator and regional manager will visit weekly to complete thorough checks of the home and equipment.

Analysis

42. The care home is responsible for having a mechanism in place to ensure the chairs it provides to its residents in their bedrooms are suitable for its residents. I have not seen evidence of such a procedure in place at the time, or how/that this was followed at the time of Mrs M’s admission. Further, the social worker established the chair Mrs M had been given was too small and therefore uncomfortable. This is fault.
43. However, the care home took immediate action when the social worker identified this issue. It has also identified the correct action to take to try and avoid a reoccurrence in the future.

Ms C’s complaint about the bruise on her mother’s face

44. Ms C said her mother had a clear bruise on her face on the day she moved to a new care home. She said the care home had not recorded her bruise or investigated how this happened before or after she raised this as a concern. Ms C said the home did also not tell the Council’s safeguarding team.
45. Ms C said that a family member noticed clear bruising on her face on the day Mrs M moved to another home. It was clearly not a new bruise as it was yellow. She said the family member asked a member of staff about it, who said they did not know how this had occurred. She said she herself spoke to a member of staff and the assistant manager the next day, who both denied knowing anything about the bruise.
46. Ms C sent me a photo she took on the day Mrs M moved. The photo shows a clear yellow mark on Mrs M’s forehead.
47. In response, the care home has said it was unaware of any bruising and there is no evidence to show Mrs M’s family raised this concern at the time. It said that, given the passage of time and the staff changes within the home, it was difficult to look into this now. It has found no evidence in its records about an accident or incident shortly before Mrs M’s move to another home.

Analysis

48. I have no reason to doubt that Mrs M’s family raised the above concern at the time of her move, as referred to above. Further, the mark on Mrs M’s forehead is clearly visible and, as such, the care home should have already taken action to investigate this even before Mrs M’s family raised this concern.
49. In response to my draft decision, the Council queried when the bruise had occurred. I contacted the new care home which received Mrs M after she left the previous care home. The new care home provided evidence the bruise was on her face when she arrived from the previous care home. The evidence indicates Mrs M had the bruise on her face when she left the previous care home, and the care home where it occurred did not record or investigate the incident. The care home where the bruise occurred failed to investigate this matter before and after Mrs M’s family raised this concern. This was fault by the care home.
50. The Council has also confirmed the home failed to inform the Council’s safeguarding team of this concern / injury, which is fault.

Ms C’s complaint about the best interest meeting

51. Ms C complained the manager of the home failed to attend a Best Interest Meeting shortly before her mother-in-law was moved to another care home. She said the manager arranged another staff member to be present, who was however unable to provide any useful input. The manager only attended the last ten minutes.
52. The home said the General Manager was not present as she had to manage a critical matter involving the health of another resident. However, she ensured a senior member of the home’s staff was able to attend in her absence, and joined herself later on. The manager apologised to Mrs M’s family for her late attendance at the time.

Analysis

53. There is no evidence the general manager acted inappropriately, or the above issue resulted in any significant injustice that needs to be remedied.

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Agreed action

54. 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.
55. Within four weeks of my decision, the Council has agreed to:
• Apologise to Ms C and Mrs M for the faults identified above and the distress this resulted in.
• Pay Mrs M £1,000 for the injustice Mrs M experienced as a result of the fault identified in paragraph 23.
• Pay Mrs M £200 for the injustice she experienced as a result of having to sit in a chair that was unsuitable and uncomfortable for her.
• Pay Ms C £400 for the distress she experienced, as a result of the above faults.
• Work with the care home to review the way in which it records and investigates incidents and if/when it refers incidents to the Council’s safeguarding team, identifying any training needs along the way if needed.
• Share the lessons learned above with the care home and the Council’s adult social care staff.

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Final decision

56. I have now completed my investigation. I uphold Ms C’s complaint about the care her mother received in the care home, and the Councils consideration of these concerns.

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Investigator's decision on behalf of the Ombudsman