Summary: Mrs X complained Mancroft Healthcare Ltd failed to safeguard Mr Y and tried to cover up what happened when he was assaulted. There was no fault in the way Mancroft Healthcare Ltd cared for Mr Y. However, it was at fault for failing to make a safeguarding referral promptly, and for failing to tell Mr Y’s family about the incident.

The complaint

1. Mrs X complained on behalf of a relative, Mr Y, that Mancroft Healthcare Ltd, Wolverhampton (the care provider) failed to safeguard Mr Y and tried to cover up what happened when he was assaulted.
2. Specifically, Mrs X complained:
• The care provider and the Council placed an unsuitable new resident in the care home without carrying out proper assessments.
• The care provider failed to properly supervise Mr Y, leading to an attack by the new resident.
• The care provider failed to inform the family about the incident, or the fact Mr Y sustained injuries and was hospitalised.
• The care provider failed to notice Mr Y also suffered a hip injury, leading to a further hospital visit several days later where Mr Y sadly passed away.
3. The events caused Mrs X stress and worry.

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The Ombudsman’s role and powers

4. 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)
5. 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)
6. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
7. 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)
8. 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)
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

10. Mrs X and the Council now have an opportunity to comment on my draft decision. I will consider their comments before making a final decision.

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What I found

Assessments and care planning

11. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
12. Where the care planning process has determined a person’s needs are best met in a care home, the council must provide for the person’s preferred choice of accommodation, subject to certain conditions.
13. Councils must also ensure the accommodation is suitable to meet a person's needs.

Safeguarding

14. Everyone has a responsibility to raise an alert if they have concerns for the welfare of a vulnerable adult. Concerns should be raised immediately with the person responsible for dealing with safeguarding alerts.
15. In care homes, the decision to make a safeguarding referral is usually made by the care home manager. The Ombudsman will consider whether commissioned care providers acted quickly enough.
16. 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)

What happened

17. I have summarised below some key events leading to Mrs X’s complaint. This is not intended to be a detailed account of what took place.
18. Mrs X’s complaint relates to the actions of a third party, who was a resident at the care provider for a short time while Mr Y lived there. I have referred to this third party as Resident A. I cannot include all relevant information about Resident A because some information is confidential, and I do not have their consent.
19. On 2 April 2022, Resident A pushed Mr Y over, causing him to suffer a fractured and dislocated shoulder.
20. According to the care provider’s records, at the time of the incident Mr Y was sitting in a chair in the resident’s lounge. Resident A walked over to Mr Y and pushed him off his chair without warning and for no apparent reason.
21. Care provider staff who witnessed the incident removed Resident A from the resident’s lounge.
22. Mr Y complained of pain to his shoulder. The care provider telephoned an ambulance, but there was a wait of several hours. Mr Y was instead taken to hospital by taxi.
23. The hospital x-rayed Mr Y’s shoulder and fitted a cast. Mr Y left hospital the same day and returned to the care home. The care provider did not notify Mr Y’s family about the incident.
24. The care provider reports Mr Y ate and drank as normal when he returned and did not complain about any other pain.
25. The care provider spoke to Resident A’s social worker on 4 April and told them about the assault.
26. The care provider made a safeguarding referral to the Council on 8 April about the assault on Mr Y.
27. The Council determined Mr Y remained at risk because Resident A was still living at the care home. To manage the risk, the care provider said staff supervised the lounge at all times, completed hourly checks at night, and Resident A has regular reviews with his social worker.
28. On 11 April, the care provider recorded staff were helping Mr Y to the bathroom when he complained of pain to his hip. The care provider called an ambulance, but again there was a long wait, so Mr Y went to hospital by taxi.
29. The hospital found Mr Y had sustained a broken hip and he was admitted to a ward after surgery. Sadly, Mr Y passed away in hospital. It is apparently unknown whether Mr Y’s hip injury was caused by the assault. This is being investigated by the Coroner’s office.
30. The police contacted Resident A’s social worker on 28 April. The Council subsequently found another care home for Resident A.
31. Mrs X complained to the Council and the care provider in June 2022. She said:
• Mr Y sustained serious injuries on 2 April 2022 which led to his death. She questioned why the care provider did not inform the family.
• The family received no information from the care provider about what happened on 2 April.
• The family asked the manager of the care home for the directors to contact them, or for their contact details, on 11 April and they have still not heard back.
• The manager of the care home lied to a family member on 7 April by saying that Mr Y was fine and did not have any upcoming medical appointments, despite being due a follow up in hospital about his shoulder injury.
• The family wanted to know who made the decision to take Mr Y back to the care home with Resident A still there.
• If the care provider had safeguarded Mr Y correctly his injuries could have been prevented.
32. The Council responded to the complaint on 23 June 2022. It said:
• The care provider apologised for the oversight (in not contacting relatives on the day of the incident or afterwards) and for any distress caused. The manager believed someone else had done this but accepts it was not correct procedure.
• The care provider said it contacted the Council on 4 April 2022, but the Council could not confirm this from its records. The Council’s records suggest it was contacted on 8 April 2022.
• It archived the message from the care home on 8 April because it had already received a safeguarding concern. It did not call the care home back and this was an error. The Council should have called to check how Mr Y was and whether the care provider had told relatives. The Council also failed to call the manager back on 11 April. The Council deeply apologised for this.
• The details around Resident A’s placement at the care home, and why he was allowed to remain there after Mr Y returned from hospital, are being considered as part of the Council’s safeguarding enquiry.
• The care provider put protection measures in place after the incident. Staff continued to monitor Mr Y and called for medical help at the earliest opportunity when he advised of discomfort.
• Care provider staff have been reminded to ensure relatives are told of significant events in future. And contact with relatives is to be logged.
• Its social care team will be reminded about the importance of returning calls from care providers at the earliest opportunity.
33. The care provider responded on 27 July 2022. It said the police and Council were still investigating the incident and cause of death, so it could not comment. The care provider accepted failures in communication and apologised it did not tell Mrs X about Mr Y’s injuries. The care provider said following Mrs X’s complaint it introduced a protocol where it logs contact with relatives in a residents daily file so that staff are aware. It said it will monitor this going forwards.
34. The Council wrote to Mrs X on 9 September 2022 with the result of its safeguarding enquiry. It found:
• The care provider sought suitable medical support for Mr Y after the incident occurred. Mr Y was mobilising normally after the incident and up to the point of complaining about hip pain.
• There were no reported incidents between Mr Y and Resident A, or between Resident A and any other residents before the incident.
• There was nothing in Resident A’s history to suggest he would pose a risk to others. Resident A met the care home manager prior to the placement. The care provider believed it could support Resident A.
• The care provider’s communication with Mrs X fell short of expectations and this was something to improve on.

My investigation

35. Mrs X told me Mancroft Healthcare Ltd runs a small care home with only one lounge area. She could not believe the care provider took Mr Y back to the care home from hospital with Resident A still there.
36. Mrs X said the police told her Resident A is a recovering drug addict. She thinks the Council and the care provider made the wrong decision placing him at the care home.
37. Mrs X said the manager of the care home was obstructive when she tried to complain, and it took the directors months to respond. She felt they tried to ignore things and hoped they would go away.

Analysis

38. I found the Council and the care provider did carry out the relevant assessments before placing Resident A in the care home. I cannot go into specifics about the assessments as this is confidential third-party information.
39. I have not seen evidence the care provider failed to supervise Mr Y, or that a lack of proper supervision led to his assault. The evidence seen suggests it was a random, unprovoked incident, which staff were there to witness but unfortunately could not prevent.
40. The care provider was at fault for failing to tell Mr Y’s family about the incident, or his injuries. This was acknowledged in the Council’s safeguarding enquiry and the care provider rightly apologised. I am satisfied the care provider put service improvements in place to ensure its staff tell families in future.
41. I have not seen evidence staff at the care provider failed to notice Mr Y’s hip injury, or should have noticed sooner. Mr Y was examined in hospital after the assault, and he did not report hip pain at the time. The evidence seen shows Mr Y was mobilising normally in the care home in the days after the assault. He did not report hip pain until several days later. Care home staff responded by taking Mr Y to hospital and I do not find fault with their actions. I cannot establish how or when Mr Y suffered his hip injury.
42. Mrs X was also concerned about the fact Mr Y returned to the care home straight after the assault, and Resident A was still there.
43. At that stage, the Council was still unaware of the assault. The Council did not receive a safeguarding referral until 8 April, several days afterwards. That was too long. The care provider said it contacted the Council on 4 April, but it could not provide evidence. I have seen evidence the care provider spoke Resident A’s social worker on 4 April, but there is no record of a safeguarding referral until 8 April. A safeguarding referral should be made as soon as practicably possible. If the care provider did make a referral earlier, it should have a record of this. That was fault.
44. The care provider said it put protection measures in place after the assault, which it explained to the Council as part of the safeguarding enquiry. I have seen from Mr Y’s care notes there were no further incidents or concerns after he returned to the care home. I did not see evidence of fault in the way the care provider managed the risk.
45. The care provider and the Council have already apologised to Mrs X for the failings identified through the safeguarding enquiry. The care provider put service improvements in place and the Council reminded its staff about their responsibilities. The Council should also remind the care provider about the importance of making safeguarding referrals promptly and keeping a record of them.

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Agreed action

46. 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 service of the care provider, I have made recommendations to the Council.
47. Within four weeks of my final decision, the Council will remind the care provider about the importance of raising safeguarding alerts immediately and keeping a record of safeguarding referrals.
48. The Council should provide us with evidence it has complied with the above actions.

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Final decision

49. I have completed my investigation. There was no fault in the way Mancroft Healthcare Ltd cared for Mr Y. However, it was at fault for failing to make a safeguarding referral promptly, and for failing to tell Mr Y’s family about the incident.

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Investigator's decision on behalf of the Ombudsman