Summary: Miss X complained about the care provided to her mother, Mrs Y, at the Council commissioned care home and about the care home’s decision to evict Mrs Y. She also complained about the way the Council dealt with safeguarding concerns. The care home was at fault for inaccurate care plans, for failing to supervise Mrs Y and another resident and for using a knife to open her locked door. The Council has agreed to apologise and make a payment to acknowledge the distress and frustration caused to Miss X. The care home also failed to provide Mrs Y with appropriate oral care. The Council has agreed to make a payment to acknowledge the discomfort this caused. There was no fault in the way the care home reached the decision to evict Mrs Y or in the way the Council responded to safeguarding concerns.

The complaint

1. Miss X complained the Council commissioned care home failed to respond appropriately to concerns she raised about her mother Mrs Y’s care and instead evicted her mother. Her concerns included the care home:
• left a knife, which was used to unlock Mrs Y’s door, in an unsafe place.
• failed to supervise residents appropriately so Mrs Y was left to clean up when another resident relieved herself.
• failed to follow the care plan regarding denture care and Mrs Y’s lactose intolerance and failed to properly consider Mrs Y’s hair care, skin care and cultural needs in the care plan.
• failed to respond appropriately and to seek medical advice regarding an incident where Mrs Y may have unintentionally hurt herself.
2. Miss X also complained the Council failed to investigate her safeguarding concerns appropriately and failed to do enough to try and prevent the eviction. Miss X says this meant Mrs Y’s care needs were not met and this has caused her significant distress and frustration.

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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 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)
4. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), 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, sections 24A(1)(A) and 25(7), as amended). As the Council commissioned the care home, we consider it was acting on the Council’s behalf.
6. We normally name care homes and other care 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). In this case I have not named the care home to preserve Mrs Y’s anonymity.
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. 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

9. I have considered information provided by Miss X and discussed the complaint with her on the telephone. I have considered information provided by the Council in response to my enquiries.
10. I gave Miss X and the Council the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.

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What I found

Relevant law and guidance

11. 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. The standards include:
• Providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• Providers must make sure that people who use their services have adequate nutrition and hydration to aid good health. People must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition (regulation 14).
• Providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).
12. 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)

Key events

13. Mrs Y moved into the care home in December 2022 following a hospital stay. Mrs Y has dementia and other health conditions. Mrs Y’s daughter, Miss X, has Lasting Power of Attorney for Mrs Y (a legal document which allows a person to choose someone else to make decisions for them when they become unable to do so themselves).
14. The care home wrote a care plan for Mrs Y. The care plan included that Mrs Y should have her denture cleaned daily, her hair combed daily, and cream applied to her body as a moisturiser. The care plan made no reference to Mrs Y being lactose intolerant. However, the records show the care provider’s diet notification form, completed in December 2022 and provided to its kitchen, noted Miss X was lactose intolerant.
15. In Spring 2023 the Council took over funding Mrs Y’s care. It requested the care plan from the care provider. Miss X raised concerns with the care home that the care plan contained different names in it and was full of inaccuracies. The care plan made no reference to Mrs Y wearing a lower denture or being lactose intolerant. Miss X met with the care provider to amend the care plan.
16. The daily care records noted Mrs Y was assisted with personal care, oral care and had cream applied in the mornings.
17. In July 2023 Miss X took Mrs Y to the dentist as she was complaining of sore gums. The dentist wrote to the care provider following this. The letter said that Mrs Y’s gum health was poor. The dentist had struggled to remove Mrs Y’s lower denture which was in a poor condition. They noted it looked like it had not been removed for several months. The dentist set out instructions for Mrs Y’s dental care including soaking both sets of dentures overnight and brushing Mrs Y’s remaining lower teeth. Miss X met with the care provider to update Mrs Y’s dental care plan.
18. In October 2023 Miss X noticed a knife being placed on the memory box outside Mrs Y’s room. She raised this with the care home. She found care staff were using it to open Mrs Y’s door when she locked it from the inside, but the care provider did not see the knife could cause harm. Miss X was concerned it posed a risk of injury to Mrs Y and to others in the home that lacked capacity. Miss X removed it but found it back in place the next time she visited. Care staff also advised Miss X of an incident where another resident opened their bowels in Mrs Y’s presence when they were left alone together at breakfast and Mrs Y used a tissue to clean this up. Miss X was unhappy she was not told of the incident at the time it occurred. She was also concerned as the other resident had previously shown aggressive behaviour and was left alone with Mrs Y. Following discussion with Miss X, the care home agreed to move Mrs Y to another unit.
19. Miss X complained to the care home about these incidents. She also raised these incidents with the Care Quality Commission (the statutory regulatory of care services). It raised a safeguarding concern with the Council, who carried out a safeguarding investigation.
20. The care home manager wrote to Miss X in response to her complaint. They apologised a knife was used to unlock Mrs Y’s door and said they had not passed the message to not do this to all staff as they had been off work. They said staff would now use a coin to unlock the door. They said Mrs Y had moved rooms at Miss X’s request but said if she wished Mrs Y to return to her previous room, they would remove the lock or replace it with a key lock.
21. They said when another resident opened their bowels, Mrs Y was not distressed but had tried to clear up the faeces. Staff had attended and supported both residents and had supported Mrs Y with hand washing. They acknowledged the incident was unpleasant but said none of the residents were distressed and staff acted immediately.
22. Miss X was unhappy with the care home’s response and in November 2023 a manager from the care provider met with her to discuss her concerns. At the meeting Miss X explained that Mrs Y’s relationship with the other resident had broken down previously and Mrs Y did not like to be in her company. She discussed the incidents and also reported that her mother’s bed linen was not being changed until she raised it with staff and that staff had not cleaned her bottom denture. The care home had since placed a note on the wall to remind staff of the actions required. Miss X said that while the spotlight was on the home she felt Mrs Y was cared for but had reservations about her continued care.
23. A Council officer visited the care home and spoke with Mrs Y. Mrs Y did not understand the concerns and was unable to hold complex conversations. She had no recollection of the incident with the other resident. The Council officer noted Mrs Y expressed she was happy and liked where she was staying.
24. The Council arranged a safeguarding case conference in December 2023 where the incidents were discussed. The notes recorded Miss X believed there had been a complete falsification of events by the home. Miss X expressed concern about not being told about things by the care home in a timely manner. The care home suggested Miss X be invited to review Mrs Y’s care plans on a monthly basis and to read through all risk assessments and request any changes. At the case conference Miss X also raised her concern about the lack of her mother’s denture care. The care home explained there was confusion over the fact Mrs Y had a lower plate and some of her own teeth. Staff had not realised she had a lower plate. The care provider had arranged for refresher training for care staff on oral hygiene.
25. In summary, the safeguarding investigation found Mrs Y had not come to any harm, but the care provider had failed in its duty to provide appropriate care. It found:
• after Miss X had raised her concern about the knife, the manager had not communicated with all staff about its removal which is why there was a repeat incident. It considered it would have been better for this information to have been passed to staff by internal memo or at appropriate handovers rather than the manager informing individual groups of staff.
• the care provider should have robustly risk assessed the other resident who was known to open their bowels or urinate anywhere at any time. Staff should have been more vigilant. Mrs Y was not harmed but the care home’s actions failed to meet expected standards. Mrs Y had now moved to another unit which mitigated the risk of further incidents. The case conference recommended training around robust risk assessment.
• the care provider had resolved the incident regarding Mrs Y’s care plan. The care provider had addressed the errors with the member of staff who had made the mistakes and had amended and updated the care plan.
26. In December 2023 Miss X emailed the care home as when she had visited Mrs Y a care worker had given Mrs Y her dentures but had not brushed her lower teeth and was unaware this was required. The care provider arranged a review meeting with Miss X. It apologised and said the nurse on duty had taken action to prevent this occurring again.
27. The Council decided to end the safeguarding in January 2024. It noted the care home was rectifying the mistakes and Miss X agreed there was some evident improvement in the care of her mother although it noted she was still not confident the care home could sufficiently support her mother. It noted Miss X could request a review of her mother’s care and placement if she felt that was required.
28. In early January 2024 a care worker reported to the nurse they had observed Mrs Y possibly causing herself an unintended injury. The nurse checked Mrs Y and found no signs of injury or discomfort. The nurse advised the care team to monitor Mrs Y for any signs of discomfort. Another nurse also checked Mrs Y and found no signs of discomfort or bleeding. The care home said staff tried to advise Miss X of the incident that morning however did not get through. The care home called Miss X early evening to advise her of what happened. Miss X wanted Mrs Y to be checked by a GP. She said the care worker said the GP would not be available as it was the weekend.
29. The care home called the out of hours GP who was satisfied with the care home’s actions. The notes record the GP decided they did not need to visit and said Mrs Y should be seen by the GP if she showed signs of discomfort, bleeding or pain. In the meantime, Miss X called 111 who advised Miss X to go to accident and emergency. Miss X visited Mrs Y and staff updated her following their contact with the GP. Miss X decided to take her to the hospital.
30. Miss X returned Mrs Y to the care home after midnight. She did not update the care home or provide a discharge summary.

31. Miss X reported what happened to the Council. She was concerned the care home had not contacted the GP or removed items from the room to prevent a recurrence. The Council’s notes record Miss X was thinking of reviewing the placement due to her ongoing concerns.
32. The Council obtained notes from the hospital which noted no signs of trauma or bleeding. The Council also asked the care home for its account of what happened, which it provided. Miss X was unhappy items remained in the room which Mrs Y may use to harm herself. The care home advised it had removed some items but as Mrs Y was mobile she could go in others’ rooms. It had advised staff to monitor her closely. The Council was satisfied the care home had taken appropriate action at the time and no safeguarding action was required. It noted it was unclear why Miss X had not spoken to staff on Mrs Y’s return from hospital and noted Mrs Y had come to no harm.
33. Following this, the care home advised the Council it had been contacted by the GP who wanted to know if Mrs Y had left the care home. The GP reported the hospital discharge summary said Mrs Y was brought in with safeguarding concerns with suspected fabrication of symptoms by the care home. It said Mrs Y would be going to the daughter’s that day and asked the GP to follow up the safeguarding concern. The care home advised the GP Mrs Y was still living there.
34. Later that month the care home met with the social worker. It considered the relationship with Miss X had broken down and she no longer trusted the care home. It said it had tried unsuccessfully to address her concerns but felt the relationship could not be mended.
35. In late February 2024 the care home gave notice to Mrs Y. The letter set out the care provider’s reasons and that Miss X had lost all trust and confidence in staff at the care home and it had lost trust and confidence in her. The Council spoke with Miss X who considered the letter was not factually correct. She said she had lost trust in the care home and as a long term plan would like Mrs Y to live with her. Miss X emailed the Council that she believed the eviction was a revenge eviction.
36. In April 2024 Mrs Y moved out of the care home.

Findings

Left knife in unsafe place

37. The care provider inappropriately used a knife to unlock Mrs Y’s door when she had locked it from the inside. When Mrs Y raised this as an issue, it agreed to stop doing it, yet it happened again. This is fault and caused Miss X frustration. The Council investigated this as a safeguarding concern and concluded the care home had failed in its duty to provide appropriate care. It was satisfied Mrs Y had come to no harm and highlighted the need to ensure information was passed to staff through internal memo or at handovers rather than to individual groups.
38. The Council properly investigated the concern through its safeguarding procedures and was satisfied the care home had taken action to prevent a recurrence of the fault.

Incident with Mrs Y and another resident

39. The care home failed to tell Miss X in a timely manner about the incident when Mrs Y cleaned up after another resident. The Council investigated this concern through its safeguarding procedures and found it partially substantiated. It found Mrs Y was not harmed but the care home’s actions did not meet expected standards. It said the care home should have robustly risk assessed the situation and staff should be more vigilant. The care home’s failure to properly risk assess the situation and mitigate the risk was fault. It also failed to tell Miss X about the incident in a timely manner. The Council properly investigated the concern and highlighted the failings in the care provider’s actions.
40. Although Mrs Y had no recollection of the incident and was not harmed, it caused Miss X distress and frustration.

Failed to follow the care plan regarding denture care, lactose intolerance and hair care, skin care and cultural needs

41. When Mrs Y moved into the care home it completed care plans. Mrs Y lacked capacity to explain her own care needs and there is no evidence it sought Miss X’s input as next of kin and Lasting Power of Attorney in completing these. This is fault and was not in line with the CQC fundamental standards of care which require providers to maintain accurate, complete and detailed records about each person using their service. This meant the care plans did not accurately represent Mrs Y’s needs.
42. The care plan referred to an upper denture but made no reference to Mrs Y having a lower denture. It was only following a period of gum pain and dental intervention that Miss X became aware the care home was not removing or cleaning Mrs Y’s lower denture. The failure to properly manage Mrs Y’s dental care was a failure to deliver person-centred care and was not in line with the CQC’s fundamental standards of care. This was fault which caused Mrs Y pain and discomfort and added to Miss X’s distress.
43. The original care plan made no reference to Mrs Y’s lactose intolerance. This was not in line with the CQC’s fundamental standards of care which set out that providers should ensure those using their service are provided with appropriate food and drink. This was fault. This meant Mrs Y may have been given inappropriate food. However, the care home has provided a notification form it completed on her admission which does state Mrs Y was lactose intolerant and which is provided to its kitchen. The care provider also updated Mrs Y’s care plan in Spring 2023 to include reference to Mrs Y’s lactose intolerance. Miss X says she saw Mrs Y being given inappropriate foods. Miss X has not provided me with specific dates, and it would be very difficult to prove exactly what was given to Mrs Y and when and I have seen no evidence Mrs Y suffered any ill effects. However, the inaccuracy of the care plan caused Miss X uncertainty over whether Mrs Y’s dietary needs were being met.
44. The care plan recorded that Mrs Y needed cream applying to her skin and the daily care records show this was applied. The records show the care home gave personal care and regularly combed and washed Mrs Y’s hair. I have seen no evidence that Miss X raised any concerns with the care home regarding the way it looked after her hair or regarding not meeting her cultural needs. If Miss X had such concerns, it was open to her to raise these at the time so the care home had the opportunity to address them.

Incident

45. The records show a nurse examined Mrs Y shortly after they were told of the incident by a care worker and was satisfied there was no evidence of harm. They continued to monitor Mrs Y. Another nurse later also examined Mrs Y and reached the same conclusion. The care home says it tried to contact Miss X to advise her of the incident but was unable to get through until later that day. When Miss X raised concerns that Mrs Y had not been seen by a GP, the care home contacted the out of hours GP. The GP was satisfied with the care home’s actions and decided not to visit. That was a decision made by a medical professional and I cannot consider their actions. Miss X decided to take Mrs Y to hospital. That was her choice, and the hospital also found no evidence of harm. There is no evidence of fault in the way the care home responded to this incident. Miss X raised a concern with the Council. It considered the evidence and was satisfied no further safeguarding action was required. There is no evidence of fault in the way it reached that decision.

Safeguarding investigation and Council’s action when given notice

46. The Council carried out at a safeguarding enquiry in response to Miss X’s concerns regarding the knife and the incident with another resident. It sought the care home’s and Miss X’s views and considered the records. It also spoke with Mrs Y. It held a case conference and the investigating officer set out their findings in the safeguarding report. It was satisfied the risk to Mrs Y was mitigated. There is no evidence of fault in the way the Council carried out the safeguarding investigation.
47. When Miss X contacted the Council with her further concern it considered Miss X and the care provider’s views and was satisfied with the care home’s actions. It decided no further action was necessary. There is no evidence of fault in the way it reached that decision.
48. The care home met with the Council in late January to set out its concerns that it and Miss X had lost trust in each other. The care home’s letter to Miss X set out its reasoning for giving Mrs Y notice. Miss X did not consider this was factually correct, but she told the Council she had lost trust in the care home.
49. The records show Miss X did not have faith in the care provider and the hospital records to the GP indicated Miss X questioned whether the care provider had fabricated what happened. Miss X did not update the care home following the hospital visit. The evidence shows the relationship between the care home and Miss X had deteriorated and it was on that basis the care home ended the contract. There is no evidence of fault in the way it reached that decision. Given both the care home’s and Miss X’s concerns, it is unlikely any intervention by the Council would have made any difference. The Council was not at fault.

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Agreed action

50. As the Council commissioned the care home, where we find fault with their actions we make recommendations to the Council.
51. Within one month of the final decision the Council has agreed to:
1. apologise to Miss X and pay her £250 to acknowledge the frustration and uncertainty caused by the care home’s faults. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended.
2. pay Mrs Y £300 to acknowledge the avoidable discomfort caused by the care home’s failure to provide appropriate oral care.
3. provide evidence that the care home, as recommended during the safeguarding investigation, has delivered staff training in robust risk assessment and oral hygiene care.
52. The Council should provide us with evidence it has complied with the above actions.

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Final decision

53. I have completed my investigation. The Council was at fault causing injustice which it has agreed to remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman