Summary: A safeguarding investigation by the Council found serious failings by the Care Provider before the complaint came to this office, however, it failed to provide a remedy for the late Mrs Y’s family.

The complaint

1. Mrs X complains a Care Provider, acting on behalf of the Council failed to provide a satisfactory level of care to her late grandmother, Mrs Y. She also says the Care Provider failed to keep adequate records.
2. Mrs X complains about the way the Care Provider dealt with her complaints about the above.

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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)
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)

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How I considered this complaint

5. I have:

• considered the complaint and discussed it with Mrs X;
• considered information the Council provided to this office;
• taken account of relevant legislation;
• offered Mrs X, the Council, and the Care Provider an opportunity to comment on a draft on this document, and considered the comments made.

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What I found

Relevant legislation

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
7. One of the fundamental standards under regulation 9 is about person-centred care. This says each person should receive person-centred care and treatment, based on their individual needs.
8. Regulation 17 is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.
9. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect; and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

10. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

Background

11. At the time of the events Mrs Y was a centenarian and lived in a residential care home owned and managed by Quantum Care. The placement was arranged and funded by the Council.
12. On 7 January 2023 Mrs Y had an unwitnessed fall in her bedroom. Carers responded and an ambulance was called. Mrs Y was admitted to hospital and found to have significant injuries.
13. Mrs X did not believe Mrs Y could have sustained such injuries from a fall alone. She says the care home gave inconsistent reports of the events and of the severity of Mrs Y’s injuries. She was initially told Mrs Y had a cut above her eyebrow, when in fact she sustained a fracture to her pelvis and collar bone, and a bleed on the brain.
14. During examination Mrs Y was found to have older injuries, including a fracture to her back, reported to be caused by previous falls and which had not been discovered until this fall, and which Mrs Y’s family were unaware of.
15. Mrs X also concerned about the care home’s staffing ratio, that on the night in question there was one agency care worker on duty to care for 15 residents.
16. Mrs Y’s death was reported to the coroner, who reviewed the cause of death twice at the request of Mrs Y’s family. The coroner concluded Mrs Y died of natural causes.
17. Mrs X complained directly to the Care Provider, who then commenced a formal investigation. Mrs X says when she went into the care home to discuss her complaint with the care home manager, the manager said, “I have got my view and I have to trust my staff”. Given the events, Mrs X considered the comment inappropriate and insensitive.
18. A safeguarding referral was made to the Council, and a section 42 enquiry commenced.
19. Mrs Y discharged from hospital to a different care home, where she sadly died in February 2023.
20. Mrs X believes the Care Provider did not take proper accountability for what happened and that the events were ‘brushed under the carpet’. She has no faith that the recommendations have been implemented. She would like assurances the action plan has been implemented and monitored.

Care Provider’s investigation

21. The Care Provider investigated the complaint and found fault. It accepted Mrs Y’s injuries were more extensive than first reported to the family, and that more photographs should have been taken to document the extent of the visible injuries. It also found there had been inadequate and inaccurate reporting by a care worker.
22. The company wrote to Mrs X setting out its findings, the lessons learnt, and the subsequent action/improvements it intended to implement. I noted the absence of improvements relating to accurate record keeping.
23. Mrs X did not receive a formal apology from the company for the identified failings.

The Council’s safeguarding investigation

24. The Council conducted a joint investigation with the police. I have had sight of the final safeguarding report and the police report. Both reports are comprehensive. The police found no evidence of a criminal offence.
25. The Safeguarding investigation found no evidence of physical abuse and this allegation was unsubstantiated.
26. Concerns of neglect and acts of omission and organisational abuse were both substantiated. The lead safeguarding officer reported that, “Throughout the enquiry and evidence gathered it is clear that there have been gaps and errors in recording which whilst this may not have changed the outcome for [Mrs Y], I am of the view that this could have made a substantial difference to her family… There has been substantial learning as a result of Quantum Care's enquiries into what has happened to [Mrs Y] to the extent of making a request to the company PCS that changes are made to their recording system.”
27. The investigation concluded that not all of Mrs X’s questions could be answered, particularly those relating to older injuries that Mrs Y was said to have sustained prior to the fall in question.
28. The Council held a case conference on 14 August 2023. Mrs X was present.
29. Mrs X met with the Council’s safeguarding team and the police on 19 June 2023.The minutes of the meeting are detailed and comprehensive. The safeguarding conclusions were discussed along with the improvements to be implemented by the Care Provider.

Analysis

30. 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.
31. I can see how distressing the events must have been for Mrs X and her family. Her concerns about Mrs Y’s care and wellbeing are understandable.
32. I am satisfied the Care Provider investigated the events to a satisfactory standard. I noted the absence of records relating to service improvements/ staff training in relation to record keeping.
33. I am satisfied the Council investigated the concerns under its role as lead safeguarding authority properly. It conducted a thorough and robust investigation. We could achieve no more than this even if we investigated further.
34. However, there was an omission in that the Council failed to ensure Mrs X was offered a remedy for the injustice caused to Mrs X. Mrs X has experienced significant distress at witnessing the events that happened to Mrs Y, and stress and distress at the investigatory process afterwards.
35. Given the conclusion of the safeguarding investigation, I would expect the Council to ensure the completion of the service improvements and closely monitor the ongoing service provision.

The Council’s response to the draft decision:

36. Following receipt of the draft decision statement, the Council provided extensive documentation showing the action taken from January 2023 onwards in response to the events. One of which involved a monitoring officer visiting the care home.
37. The monitoring officer identified a need to improve record keeping. Officers continue to work with the care home to monitor and improve consistency in this area and further visits are planned for the coming months. The Council’s reviewing officers also regularly review the care and wellbeing of other residents and to date, the Council has no ongoing concerns about this.
38. The Council confirmed the care home had also been subject to inspection by the Care Quality Commission.

The Care Provider’s comments

39. The Care Provider confirmed it formally apologised to Mrs X as part of stage 1 complaint response on 11 February 2023. It provided evidence to show Mrs X acknowledged receipt of the apology. The apology was reiterated again as part of its stage 3 response on 10 May 2023.
40. The Care Provider confirmed the Care Quality Commission visited the care home on 26 January 2023. It provided an extract from the inspector’s report, which said, “The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken… We found no evidence during this inspection that people were at risk of harm from this concern”.
41. The Care Provider set out in detail the action taken in response to the events involving Mrs Y and to address the failings identified. It acknowledged “…we did not go into significant detail with the complainant about the actions we took as a result of the complaint. In retrospect this may have provided the reassurance that we took the matter very seriously by outlining our immediate improvement plan”.

Analysis of the responses

42. Having considered the comments and supporting information from the Council and Care Provider, I am satisfied with the actions taken to date. The documentation shows a robust response and a detailed action plan to address the identified failings, share lessons learned and improve standards.
43. Mrs X can be reassured her complaint was taken seriously and that robust action followed. It is unfortunate it did not share more detailed information about this with Mrs X.
44. There are no further recommendations needed from this office in respect of service improvements and service monitoring.

Agreed action

45. The Council should, within four weeks of the final decision:

• make a payment of £300 to Mrs X to acknowledge her distress;
• make a further payment of £250 to acknowledge Mrs X’s time and trouble pursuing this complaint with the Council and this office;
• provide us with evidence it has complied with the above actions.

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Final decision

46. The Council’s safeguarding investigation found serious failings by the Care Provider before the complaint came to this office, however it failed to ensure a remedy for Mrs Y’s family.
47. The above recommendations are a suitable way to settle the complaint.
48. It is on this basis; the complaint will be closed.
49. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman