Summary: Mrs Y complained the Council commissioned care home, Bamford Grange Care Home, failed to provide her late father, Mr X, with appropriate care and support. Mrs Y also complained the Council failed to properly investigate her concerns under its safeguarding procedures. The Council properly investigated Mrs Y’s safeguarding concerns. It accepted the care home delivered inadequate care to Mr X and was at fault. The Council has offered to waive Mr X’s care fees and make a payment to recognise her distress. It has also put in place service improvements to learn from Mrs Y’s complaint. This is a suitable remedy.

The complaint

1. Mrs Y complained the Council commissioned care home failed to provide her late father Mr X, with appropriate care and support. Mrs Y also complained the Council failed to properly investigate her concerns under its safeguarding procedures. She says her father did not receive the care he needed and she wants compensation.

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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. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
4. 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). In this case, the Council had commissioned residential care services from Bamford Grange Care Home.
5. 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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

7. I have not investigated events before April 2023. It was open to Mrs Y to complain to us sooner about events before that date and I have decided there was no good reason why she could not have complained to us sooner.

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How I considered this complaint

8. I have discussed the complaint with Mrs Y and considered the information she provided. I have also considered information provided by the Council.
9. Mrs Y and the Council have had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Safeguarding

10. 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)

CQC and fundamental standards

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 have an effective and accessible system for identifying, receiving, handling and responding to complaints (regulation 16).
• providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

What happened

12. In April 2023 Mr X moved from self-funded residential care at Bamford Grange Care Home (the Care Home) to receiving financial support from the Council. The Council carried out a care needs assessment in June 2023 and put a care and support plan in place.
13. During this time Mrs Y raised several concerns with the Care Home about the standard of care provided to Mr X. This included concerns about poor hygiene standards, missing clothing, and Mr X not using the toilet to urinate. The records show the care home responded to these concerns as they were raised.
14. By September 2023 Mr X’s health had deteriorated. Mrs Y asked for a Speech and Language Therapy (SALT) referral due to Mr X struggling to chew his food. The SALT service told Mrs Y and the care home there was an eight week wait for SALT assessments.
15. On 19 September 2023 Mr X’s GP placed him on an end-of-life pathway. In late September Mrs Y raised a safeguarding concern about Mr X’s care. The Council spoke with Mrs Y on the phone. She raised several concerns, including:
• Mr X choking on his food, suffering significant weight loss and being found unsupervised out of his room.
• Staff not ensuring Mr X’s sensor mat was in place.
• Not enough staff to supervise Mr X or who were familiar with his care needs.
• Care charts not up to date.
16. The Council carried out safeguarding enquiries. A social worker visited Mr X at his care home on 4 October 2023. It met with staff from the home, Mrs Y and Mr X. It reviewed Mr X’s care charts. Staff at the home agreed Mr X had lost weight and needed full support with meals. The social worker offered the home advice to help address Mrs Y’s concerns. They said they would speak to Mr X’s GP before deciding whether the Council needed to take more safeguarding action.
17. Mr X died on 5 October 2023. On 9 October the social worker spoke to Mr X’s GP. They said they had visited Mr X regularly at the home and did not feel there was any evidence of neglect. The Council finished its safeguarding enquiry in November 2023. It found a lack of evidence of neglect but identified several learning points for the care home. This included:
• Directing concerns from relatives to the person in charge.
• Regular checking of sensor equipment and improving the reporting process when staff identified a fault.
• Regular updating of care plans and risk assessments so they continue to reflect the resident’s needs.

The Council wrote to Mrs Y on 23 November with the outcome of the safeguarding enquiry.

18. Mrs Y continued to complain about the care Mr X received during his time at the Care Home. The Council met with Mrs Y in February 2024 and responded to her complaint in April 2024. The Council said the Care Home’s responses to Mrs Y’s concerns were not to the standard it would expect from a commissioned care provider. It added that Mrs Y had received an inconsistent service from its social workers. As a result, the Council said Mr X’s standard of care was not adequate.
19. The Council offered to waive Mr X’s care fees of £6819.42 and pay Mrs Y £500 for the distress caused. It said it would learn from Mrs Y’s complaint to improve its services and ensure the care home completed the learning from its safeguarding investigation.
20. Mrs Y remained unhappy and complained to the Ombudsman. In response to our enquires the Council provided evidence of the steps it had taken to act on the learning from the complaint. This included:
• Training sessions with its staff on the learning from complaints and best practice
• Confirmation from the care home of changes and training it had completed since the safeguarding investigation, including increased staff walk-arounds and checking of sensor equipment and improved staff supervision.
• Continuing regular monitoring of the care home.

My findings

21. Mrs Y raised concerns with Mr X’s care home about Mr X’s care throughout 2023. This culminated in a safeguarding referral in September 2023. The Council acted immediately on this concern and made safeguarding enquiries.
22. Our role is not to decide whether we agree or disagree with the Council’s decisions. Instead, we look at whether there was fault in how it made its decisions. If we decide there was no fault in how it did so, we cannot ask whether it should have reached a different outcome. There is no evidence of fault in way the Council carried out its safeguarding enquiries. It visited the home, spoke to Mrs Y, staff, and Mr X’s GP. It decided there was no evidence of neglect. This was a decision the Council was entitled to make. The Council is not at fault.
23. While the Council did not find evidence of neglect, in its complaint response it accepted there were some inadequacies in Mr X’s care. The Council commissioned Mr X’s care at Bamford Grange Care Home, therefore we treat actions taken by or on behalf of the Care Home as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the Care Home, we can make recommendations to the Council alone. Here we have found fault with the standard of care Mr X received from the Care Home. The Council is at fault. It has apologised to Mrs Y, offered her £500, and offered to waive Mr X’s care fees of £6819.42. It also put in place service improvements with its staff and the care home and provided evidence of these. I consider this to be a suitable remedy for the injustice caused as a result of this fault.

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Agreed action

24. Within one month of the final decision the Council should confirm it has waived Mr X’s care fees of £6819.42 and paid Mrs Y £500 to recognise the distress caused.
25. The Council should provide us with evidence it has complied with the above actions.

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Final decision

26. I have completed my investigation, finding fault causing injustice, which the Council has agreed to remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman