Summary: There is evidence of a poor standard of care by the Council’s commissioned care provider, and a safeguarding investigation upheld Mr A’s complaints about neglect which affected his brother Mr X. The Council has waived the fees for the period of care and offered a sum in recognition of the time and trouble Mr A went to in making the complaint. It agrees to offer a greater sum to recognise the distress caused by the poor standard of care, and evidence the action taken to ensure service improvements at its commissioned provider.

The complaint

1. Mr A (as I shall call him) complains about the poor standard of care given to his brother Mr X for the five months he was resident in Vauxhall Court. He complains about a delay in responding to his complaints, poor practice in terms of his brother’s skin integrity and infections which were common amongst the residents, poor communication, and inadequate response to medical issues.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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 our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered the information provided by Mr A and by the Council. I spoke to Mr A. Both Mr A and the Council had the opportunity to comment on a draft of this statement before I reached a final decision.

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What I found

Relevant law and guidance

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
8. Regulation 10 says that service users must be treated with dignity and respect.
9. Regulation 12 says care and treatment must be provided in a safe way, which includes preventing and controlling the spread of infection.
10. Regulation 13 says service users must be protected from abuse and improper treatment, including significantly disregarding the needs of the service user for care or treatment.
11. Regulation 15 says all premises and equipment used by the service user must be kept visibly clean.
12. Regulation 16 says “Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation”.
13. 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

14. Mr X, who has dementia, became resident at Vauxhall Court in May 2022 as an emergency placement after his wife died. The placement was arranged by the Council.
15. Within a few days of the placement starting Mr X managed to leave the home unnoticed and was found in the local town. A few weeks later he was involved in an altercation with another resident and although Mr B (his son) was told there were no injuries after this incident and an unwitnessed fall, he wrote to the care provider to say there were a number of grazes and marks on his father’s legs which he would expect to have been told about. He asked for a copy of the falls policy but says it was not sent to him.
16. Mr X’s care plan, which Mr B signed on 22 June, said that Mr X was able to carry out some personal care tasks himself, but it was important that staff ensured he was carrying out personal hygiene tasks properly. A regular infection risk assessment stated in both July and August that Mr X had no infections at the time.
17. In August 2022 Mr B raised concerns with the care provider and with the GP about his father’s care. He sent photos (dated 14 August) to the GP of the rash which his father was suffering from and said when he had mentioned it to the senior carer at the home, she said that “they all have it here”.
18. The care home records first mention the rash on 31 August. A carer telephoned the GP surgery and asked for some cream for the rash. The records show the GP visited a few days later and took samples as he suspected scabies (a highly contagious skin infestation of burrowing mites). The home’s records show the home instigated a scabies care plan on 13 September on advice from Public Health England. The home’s records say the rash was first noticed on 2 September.

The complaint

19. Mr B also wrote to the CQC in August with his concerns. He copied the letter to the Council. He said his father had lost over 30kg in weight since entering the home because he was not being encouraged to eat foods liked (which Mr B was providing); he said the standard of personal hygiene at the home was appalling – he said “If a resident simply refuses on being woken from bed, they fail to have the support for the rest of the day in washing and dressing” and he sent photos of the soles of Mr X’s feet which were black with dirt. He said the home ignored medical concerns. His father had suffered acute kidney injury which the home diagnosed as depression and wanted to ask for more antidepressants until Mr B insisted the GP was contacted, who attended and conducted the appropriate tests. He raised a number of other concerns, including other people’s clothes being worn and stored in his father’s room, a commode left in the room although Mr X was not incontinent, a lack of activities in the home which meant Mr X was being left in bed a lot of the time.
20. The Council began a safeguarding investigation.
21. Mr X moved to another care home in October.
22. Mr B wrote again to the Council in January 2023. He said he still had not had sight of the safeguarding report. He said he had been reporting Mr X’s rash for about a month to the care staff and action was only taken when ambulance staff (called to attend another unwitnessed fall by Mr X) asked to see the home’s scabies care plan (none existed). He said the home had failed to respond to complaints and had finally emailed him to say his access to visit Mr X would be limited and notice would be given if the complaints persisted. The manager then wrote to him on 22 September 2022 giving notice. Mr A says the manager rang him in June 2022 and said she would stop Mr B visiting his father if he continued to complain.
23. The Council replied. It said the first safeguarding concern was received on 16 September and it started its investigation then. It said its contracts team did not have legal authority to enforce action by the care provider but would monitor the concerns Mr B had raised. It said out of the 16 areas of concern investigated by the safeguarding team, 12 had been upheld (including the concerns about the failure to notice and treat scabies, failure to seek medical advice, lack of records of falls, allowing Mr X to abscond from the home), 4 were not upheld and one was deemed inconclusive. It said in relation to the scabies outbreak, “once it became evident that there was an issue within the home, steps were taken by the care provider to work with the health protection team to manage the outbreak”.
24. Mr B and his uncle Mr A complained again to the Council about unresolved matters. They said they understood the home had already been subject to an improvement plan at the time of Mr X’s admission but that had not prevented the problems they had experienced.
25. The Council responded in November 2023. It apologised for the delay. It acknowledged that the care was not of the standard expected and it apologised. It apologised for the delay in communicating the outcome of the safeguarding investigation. It waived the fee contribution of as an acknowledgement of the poor care and also offered £150 in recognition of the time and trouble in making the complaint. It said it was continuing to monitor the home.
26. Mr A and Mr B complained to the Ombudsman.
27. The Council says that an improvement plan had been put in place with the home in April 2022, covering internal audits, falls recording, staff training. staff dependency tool, care planning, cleaning schedules and bed rail risk assessments. It says, “Between March 2022 and September 2023 there were 18 visits to the service by the Commercial Team. The home continues to have visits on a quarterly basis to ensure that improvements have been sustained”.
28. The Council says it has no records of this safeguarding concern being raised about the home before September. However, it says the social work case recording shows a conversation between the family and the social worker in early August “where the family raised several concerns regarding the care home. At this point they were not referred as a safeguarding concern; however, the Social Worker did explore if they had been raised with the care home, which family confirmed they had. The Social Worker suggested that they could also raise their concerns with CQC.”
29. The Council also says, in relation to Mr X’s weight loss, that this was not upheld as a safeguarding concern. It says that as Mr X was classed as obese, his weight loss was not seen as a concern by the dietitian to whom he was referred by the home. The care provider said, “Instead, he advised us to seek supplements from the G.P and to add a high calorie intake in-house which we followed.” Mr A says, and has provided supporting evidence, that Mr X ‘s weight loss only stalled when he started to be brought down to the dining-room to eat with other residents. Mr A says the contradictions in the care provider’s records are in his view evidence of further neglect which the Council should have upheld as a safeguarding concern.

Analysis

30. The Council should accept responsibility for the actions of the care provider. It is not enough to say that there was no delay in dealing with the safeguarding concern. Those concerns were also raised with the social worker but no action taken as a consequence. There clearly was a poor standard of care at the home which led to an unacceptable situation where among other issues there was an outbreak of scabies with no care plan in place (and apparently an acceptance among the staff that ‘they all have it here”). That was fault on the part of the Council which caused injustice.
31. The safeguarding investigation upheld most of the concerns raised and the Council put in place an improvement plan which it says was being monitored every two – four weeks. But as there was already an improvement plan in place for the home when Mr X was admitted, including some of the areas which had been raised as safeguarding concerns, I am not confident of the effectiveness of the way the Council has monitored that process.
32. The faults on the part of the care provider are potential breaches of the regulations.
33. The Council has waived the assessed fee contribution and offered a symbolic payment of £150 to recognise the family’s time and trouble in making the complaint. In my view, given the poor standard of care received by Mr X, it should go further.

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Agreed action

34. Within one month of my final decision the Council will offer £500 to Mr X to reflect the avoidable distress to him of the poor care suffered;
35. It will also offer £250 each to Mr A and Mr B within one month of my final decision in recognition of the time and trouble in dealing with the complaint as well as their own distress at the injustice caused to their relative;
36. Within one month of my final decision the Council will provide me with a detailed account of the way the monitoring has been conducted since the conclusion of the safeguarding investigation and evidence how that is meeting the required outcomes of the investigation.
37. The Council should provide us with evidence it has complied with the above actions.

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Final decision

38. I have completed this investigation. There was fault on the part of the Council’s commissioned provider which caused injustice to Mr X and his family; that can be remedied by completion of the recommendations at paragraphs 34 - 36.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman