Summary: Mrs X complains about the Council’s handling of her concerns about the quality of care her late mother received in a care home. Mrs X has no confidence in the Council’s safeguarding enquiries into the care home’s actions or that it has implemented any meaningful improvements to the care home’s practices. I have found no fault in the way the Council carried out the safeguarding investigation. However, for the issues proven we recommend several service improvements. We find the care home acting on behalf of the Council was at fault for failing to follow its policy regarding privacy and dignity and keeping an inventory of personal items. We also find fault with the way the Council handled Mrs X’s complaint. The Council has agreed to make service improvements and a payment to Mrs X for the injustice caused.

The complaint

1. Mrs X complains about the Council’s handling of her concerns about the quality of care her late mother (Mrs C) received in a care home. Mrs X says she has no confidence in the Council’s safeguarding enquiries into the care home’s actions or that it has implemented any meaningful improvements to the care home’s practices. Mrs X is also very unhappy with how long the Council has taken to respond to her complaints and the quality of its responses.
2. Mrs X says the Council actions have caused her and her family additional distress at an already difficult time of bereavement.

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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)

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 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)
5. 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

6. We spoke to Mrs X and considered the information she provided. We made enquiries of the Council and considered its response.
7. Mrs X and the Council now had the opportunity to comment on my draft decision. I considered all comments before reaching a final decision.

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What I found

Legislation, policies and procedures

Safeguarding

8. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
9. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help and protect the adult.
10. The Care and Support Statutory Guidance sets out what a safeguarding enquiry should look like. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively.

Council’s complaint procedure

11. Councils should have clear procedures to deal with social care complaints. Regulations and guidance say they should investigate and resolve complaints quickly and efficiently. A single stage procedure should be enough. The council should include in its complaint response:

• how it considered the complaint;
• the conclusions reached about the complaint, including any required remedy;
• whether it is satisfied all necessary action has been or will be taken by the organisations involved; and
• details of the complainant’s right to complain to the Local Government and Social Care Ombudsman.

What happened

12. Below is a chronology of key events. It is not meant to show everything that happened.
13. The late Mrs C was a resident at Oaklands Care Home (the care home) from 27 May 2021 to 11 September 2021. Mrs C was admitted from hospital and the placement was funded under the provisions of section 117 of the Mental Health Act. Mrs C had a diagnosis of dementia.
14. On 30 May, the care home informed Mrs X’s sister (Mrs Y) that Mrs C had fallen out of bed and injured her head. The care home had called 111 and was waiting for a call back. Mrs C was admitted to hospital the following day. Mrs C was discharged back to the care home with a very small bleed on her brain.
15. Mrs Y spoke to the care home about using bed rails. The care home explained that when a resident was able to lift their legs, they would not use bed rails for safety reasons. There was a risk Mrs C could climb over the rails and fall from a greater height or get trapped.
16. On 11 June, a meeting took place by telephone between Mrs X, the care home and the Council about Mrs C’s care. They asked about Mrs C’s glasses and were told Mrs C did not have them when she returned from hospital. A week later the Council spoke to Mrs X. Mrs X said Mrs C’s glasses and items of clothing had been misplaced by the care home. The next day the care home confirmed it had located the glasses.
17. On 4 July, Mrs C had another fall at 7.30p.m. The care home called for an ambulance but said it was not urgent. Mrs C was admitted to hospital the following morning at 6:30 a.m. The care home contacted Mrs Y at 8:00a.m. Mrs C was discharged from hospital with a chest infection.
18. The next day Mrs X contacted the Council and expressed several concerns about Mrs C’s care and her recent fall and hospital admission. Mrs X said the care home failed to contact them at the time of the fall and did not know which hospital Mrs C had been admitted to. Mrs X said Mrs C had fallen twice in five weeks. The Council responded and suggested a review meeting with the care home. The Council contacted the care home to arrange this.
19. On 12 July, a meeting took place between the Council, the care home, Mrs X and Mrs Y. Mrs X and Mrs Y asked about bed rails to prevent further falls at night. The care home said bed rails were not appropriate for Mrs C because she was mobile and there was a risk of her arms and legs being trapped. Mrs X and Mrs Y were satisfied with the care home’s response. The care home confirmed that Mrs C was on a low profiling bed at night and a sensor mat was in place. It said staff completed hourly safety checks and this had increased to every half hour at night following her fall.
20. On 2 September, Mrs X and Mrs Y visited Mrs C. This was a prearranged garden visit.
21. On 9 September the care home called Mrs X and said Mrs C had rolled out of bed overnight and had a small bruise on her nose.
22. On 11 September Mrs C had a fall while in the communal lounge. The care home called for an ambulance and informed Mrs X. Mrs C was admitted to hospital wearing a short nightie and dressing gown.
23. On 13 September, the Council received a safeguarding referral from the ambulance service. The referral stated Mrs C had two black eyes, skin tears and lacerations which had not been treated properly. The referral queried why the care home had not sought medical attention after the previous fall, as Mrs C had hit her head and was taking prescribed blood thinning medication. The Council implemented a section 42 safeguarding inquiry. The Council sent a copy of the referral to the care home requesting a response to the issues raised.
24. On 15 September, the Council requested further information from the hospital. On the same day the Council received a safeguarding referral from the hospital reporting the same concerns raised by the ambulance service.
25. Sadly, Mrs C passed away on 18 September.
26. On 22 September, Mrs X complained to the Council about the care Mrs C received at the care home.
27. On 23 September, Mrs X went to collect Mrs C’s personal items from the care home. Mrs X said a number of items did not belong to Mrs C and some items were missing, including a pink dressing gown.
28. On 11 November, the Council held a safeguarding meeting. The meeting was attended by the provider, the care home, community matron, the Council’s contracts team and Mrs X and Mrs Y. The Council explained the purpose of the meeting was to discuss the referral received from the ambulance service.
29. The safeguarding investigation identified the following faults:

• clear inconsistencies in documentation and conversations around bruising on Mrs C’s face;
• poor record keeping following the fall on 9 September. An accident form had been completed but did not explain the care home’s reasoning for not calling 111 or emergency services. This was not in line with the care home’s policy;
• provider failure or act of neglect by the nurse on 9 September; and
• the care home failed to take a statement from the nurse in a timely manner which meant the nurse left her post before the care home completed its investigations.

30. It was agreed the care home would wait a month for the nurse to contact them and then decide whether it needed to instigate disciplinary procedures. With regards to Mrs C’s skin integrity the Council said it could not prove care was inappropriate as the community matron had been well engaged with regards to monitoring and dressing Mrs C’s wounds.
31. The Council sent Mrs X a copy of the minutes from the meeting. Mrs X responded with a number of queries.
32. The provider located the nurse, and a statement of events was received on 29 November. The nurse said she had examined Mrs C following the fall and found no medical reasons for calling111 or the emergency services for advice.
33. On 24 December the Council responded to Mrs X’s complaint and queries following the safeguarding meeting. Mrs X said the response had not been formatted as she would expect. The Council re-issued its response on 11 January 2022. A further response was issued in May 2022.

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Analysis

34. Mrs X says she has no confidence in the Council’s safeguarding enquiries into the care home’s actions or that it has implemented any meaningful improvements to the care home’s practices.
35. The safeguarding investigation considered the referral from the ambulance service and hospital following the care home’s actions after Mrs C’s falls on 5 July and 9 September and issues surrounding her skin care and integrity. Paragraphs 29 and 30 above detail the outcome of the safeguarding investigation.
36. The Ombudsman does not reinvestigate matters that have been subject to scrutiny as was the case with the safeguarding investigation. Having considered the documentary evidence, I am satisfied the Council carried out a full and detailed safeguarding investigation into the concerns raised by the ambulance and hospital services. The Council made safeguarding enquiries of the care home, sought input from the National Health Service, its contracts team and considered the views of Mrs X and Mrs Y.
37. As explained in paragraph 10, it is for the Council to determine the appropriateness of the outcome of the enquiry. I have not found fault with the way the Council completed its safeguarding enquiry. In response to our enquiries the Council confirmed the Care Quality Commission had received a copy of the safeguarding minutes. Furthermore, the Council’s contracts team had attended the meeting and the Council said relevant information would be used to inform future visits.
38. I will however consider in the next section whether the Council has properly remedied the injustice caused by the faults identified.
39. I have reviewed the care home’s response to Mrs X’s complaint and find it accepted the following additional faults:

• Mrs C was admitted to hospital in a night gown that did not belong to her;
• poor administrative error in processing Mrs C’s personal allowance;
• verbal miscommunication and delay in responding to emails; and
• failing to notify the family which hospital Mrs C was taken to.

40. Following Mrs X’s complaint and the outcome of the safeguarding investigation, the care home said the following actions had been taken:

• reiterated to nurses and nursing assistants the falls protocol;
• nurses to be aware of residents that are prescribed blood thinners;
• the appropriate actions to take in the event of injury and this is to be highlighted in care plans and risk assessments;
• revisited its housekeeping measures to ensure clothing remained labelled after laundering;
• reviewed the role of the key worker to include checking residents clothing and property; and
• resident belongings to be recorded on admission and prior to them being put away in bedrooms.

41. I have reviewed the Council’s complaint response dated 11 January 2022 which said it had discussed the following issues with the provider:

• failure to take a statement from the nurse in a timely manner;
• review of the care home’s protocols for personal items; and
• review and implement changes to ensure residents are dressed in their own clothes and that personalisation and dignity are upheld.

42. Mrs X also raised several complaints about the decisions and actions of the community matron and certain health practices. The Council appropriately referred Mrs X to the correct agencies.
43. Mrs X complained about the Council’s handling of her concerns about the quality of care Mrs C received in the care home. Having reviewed the responses to Mrs X’s complaint, I will consider whether the Council has properly remedied the injustice caused by the faults identified.

Garden visit

44. Mrs X says, Mrs C was dressed inappropriately at a pre-arranged garden visit. Mrs X said it was a chilly day and Mrs C was dressed in a top with a deep neckline, cardigan with a broken zip and a thin blanket over her knees (not tucked in). Mrs C was not wearing a scarf or socks.
45. The Council said the care home had responded to Mrs X and said Mrs C was appropriately dressed for the visit. The Council said it had nothing further to add. As I was not present and there is no independent witness it is difficult to say now whether Mrs C was inappropriately dressed and whether this was poor practice.

Dignity

46. The care home’s policy on privacy and dignity states that older people’s self-respect can be undermined by neglect of their appearance and clothing. Preferences should be respected as well as choice in how support is provided, for example, when choosing what to wear, having clean ironed clothes that fit and have not been damaged or mixed up with someone else. Mrs C’s support plan stated that she should be appropriately clothed at all times.
47. Mrs C was in the lounge when she fell and was admitted to hospital on 11 September wearing a nightie that was too short and a dressing gown that did not belong to her. The care home said this occurred because Mrs C was being admitted to hospital in an emergency. Nevertheless, placing Mrs C in somebody else’s gown was fault. Furthermore, Mrs C was already in the lounge wearing a nightie that would have undermined her dignity. It is my view the care home failed to adhere to its own policy and Mrs C’s support plan. They should have dressed Mrs C more appropriately for her personal dignity. That is fault which could have caused Mrs C discomfort and impacted her dignity.

Bed rails

48. Mrs X says the care home had previously refused to implement bed rails for safety reasons but in September it told the hospital that it would implement bed bumpers on Mrs C’s return. Mrs X says the Council and the care home consistently confused ‘bed rails’ with ‘bed bumpers. Mrs X said Mrs C’s bed in the hospital had bed bumpers.
49. The care home responded to Mrs X and said the hospital had advised bed rails were in situ for Mrs C on the ward. The care home explained that it would complete an assessment on Mrs C’s return and disputes saying that bed rails had been put in place. As I was not present it is difficult to establish what was discussed during the telephone conversation. In any event, in accordance with its policy the care home would have had to assess Mrs C’s condition and complete a risk assessment before making such a decision. I find no fault here.

Inventory

50. Mrs X complained the care home failed to complete an inventory of Mrs C’s possessions and clothing on admission and that it included items not belonging to Mrs C to Mrs X and Mrs Y following Mrs C’s death.
51. The Council confirmed that an inventory of Mrs C’s personal items was provided on transfer from hospital in May 2021. However, the care home failed to check items against this and did not complete its own inventory. This is fault.
52. The care home said it received three bracelets on admission but then said it only had two. It said that it had returned one bracelet to the family following an outdoor visit, as it was causing irritation to Mrs C’s skin. There are no records that show the bracelet was returned. Mrs X said a photo frame was also missing from Mrs C’s belongings.
53. An inventory of Mrs C’s personal items was provided on transfer from hospital in May 2021. However, the care home failed to check items against this and did not complete its own inventory. Failure to complete an inventory is fault and means the care home is now unable to identify what happened to the missing items. It seems likely if an inventory had been completed on admission, the care home would have been able to identify the point at which the bracelet was returned and when the photo frame went missing. This has caused Mrs X uncertainty about what happened to Mrs C’s personal belongings. The care home was also at fault for including items that did not belong to Mrs C.

Communication

54. The care home’s procedure on falls states that residents next of kin should be informed about the accident, either immediately if any injuries had occurred or the next day if overnight.
55. The care home failed to contact the family in a timely manner when Mrs C had a fall in July. In fact, it informed Mrs Y almost 13 hours after the fall. This is fault. The care home then failed to tell Mrs X or Mrs Y which hospital Mrs C was taken to. This is further fault. I do not doubt the distress this caused the family.
56. The care home also failed to inform Mrs X and Mrs Y that Mrs C was unconscious after her fall on 11 September. This is fault and further evidence of poor communication. The Council has acknowledged there was a lack of communication between the care home and the family.

Council’s complaint response

57. Mrs X complained to the Council in September 2021, but the Council did not issue a response until January 2022. I have reviewed the Council’s final response dated 22 May 2022. The Council apologised for the delay in responding to Mrs X’s complaint. It also acknowledged the response issued in December was not formatted correctly. Mrs X spent a considerable amount of time chasing the Council for a response to her complaint. This added to Mrs X’s distress and frustration, at a time when she was grieving the loss of her mother.

Injustice

58. Mrs C has now sadly passed away and therefore it is not possible for the Ombudsman to remedy any injustice caused to her. We can remedy the distress and uncertainty caused to Mrs X including the time and trouble taken pursuing her complaint.

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Agreed action

59. 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 home, the following actions are against the Council.
60. I acknowledge the Council had already identified several service improvements. I have requested evidence of the action taken in respect of these.
61. Within one month of my final decision the Council will:

• apologise to Mrs X for the faults identified in this statement;
• pay Mrs X £500 for her time and trouble in making her complaint and the uncertainty and distress caused by the faults;
• provide evidence the provider has reviewed its policies for housekeeping and inventories for when people move into the care home;
• provide evidence that staff at the care home have been reminded of its privacy and dignity policy;
• provide evidence the provider has discussed with nurses and nursing assistants the falls protocol;
• provide evidence that nurses are aware of the residents that are prescribed blood thinners and the appropriate actions to take in the event of injury; and
• provide evidence that relevant staff at the care home have been reminded of the importance of obtaining statements from all witnesses in a timely manner.

62. Within two months of my final decision the Council should ensure the care home has reviewed it falls policy and accident reporting procedure and consider whether it should include specific guidance about what action to take if a resident who is taking blood thinning medication falls.

63. Within three months of my final decision the Council should through contract monitoring ensure the care home is:

• correctly applying its fall prevention policy and procedure;
• accurately completely incident reports and body maps;
• maintaining robust records that clearly document decisions about seeking medical attention following a fall;
• communicating with family members where there are significant changes in a residents needs or circumstances; and
• adhering to its privacy and dignity policy and residents are dressed in their own clothes and that personalisation and dignity are upheld;

64. The Council should provide us with evidence it has complied with the above actions.

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Final decision

65. I have found fault causing an injustice to Mrs X. I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman