Summary: Ms A complained that the Council failed to safeguard her late mother Mrs X in a care home where admissions had been suspended. The evidence shows the Council-commissioned care provider did not take all necessary measures to ensure Mrs X’s safety and she fell and was injured several times as a result. The injustice to the late Mrs X cannot now be remedied but the Council offers a payment to Ms A in acknowledgement of the distress suffered.

The complaint

1. Ms A (as I shall call her) complains the Council returned her mother to the same care home several times despite her individual risk and despite the home being closed to admissions. As a result, Mrs X was placed back in a place of danger where insufficient steps were taken to prevent further falls.

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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. 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)
4. 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)
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 evidence provided by Ms A and the Council as well as relevant law, policy and guidance. I discussed the complaint with an officer of the Council.
7. Ms A and the Council had an opportunity to comment on my draft decision. I consider their comments before I reached a final decision.

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What I found

Relevant law and guidance

8. 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)
9. 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.
10. Regulation 12 says care and treatment must be provided in a safe way.
11. Regulation 13 says service users must be protected from abuse and improper treatment. It says, “Care or treatment for service users must not be provided in a way that significantly disregards the needs of the service user for care or treatment.”

What happened

12. Mrs X moved into Longview care home in April 2023. Her placement was arranged by the Council. From July 2023 Mrs X became a full cost payer. The Council as the commissioning body remained responsible for her care.
13. In November 2023 admissions to the care home were suspended in view of concerns about the home’s ability to meet the needs of residents. The Council says the safeguarding concerns included “inadequate management oversight, unrecorded falls with injuries, lack of risk assessments, substandard medication practices, significant weight loss with insufficient evidence of corrective actions, lack of investigations into accidents and incidents, inadequate care planning, and staffing issues”.

Safeguarding concerns about Mrs X

14. The first safeguarding alert in respect of Mrs X was raised in August 2023 following an unwitnessed fall. The fall resulted in a head injury and assessment in hospital. The care home said it had taken steps to reduce the risk of further falls and the Council agreed that correct protocols had been followed by the home. Ms A expressed concern that the safeguarding enquiry was to be closed in October, and said the family was not satisfied with the care at the home.
15. In December 2023 Mrs X fell again and was admitted to hospital again for assessment. The records show consideration was given to another safeguarding alert but it was decided to merge consideration of this incident into the ongoing organisational safeguarding investigation.
16. In January 2024 Mrs X had two further falls. Notes of the first incident were recorded by paramedics as “The crew were called to the PT on the 19/01/24 for an injury fall. On the crew's arrival; the PT was lying face down & the PT’s nose was running a lot with a surplus of mucus whilst on the floor. Nobody had cleaned/wiped this for her. The PT was lying in a urine-soaked night dress, with no blankets or pillows on her for comfort. The PT was in this condition for at least 7hrs, which shocked the crew.” Mrs X suffered a fractured lumbar vertebra and a bleed to the brain. She was discharged but fell again three days later.
17. At the start of February Mrs X fell again in the home. Paramedics were called and recommended a urine sample as they suspected a urinary infection. Ms A says she doubts this happened as when she saw Mrs X 3 days later she remained unwashed and unkempt.
18. Ms A spoke to a social worker and expressed her concern again about Mrs X’s condition. She said they wanted to move her to another home.
19. At the end of February Mrs X fell again and after a long wait of 36 hours was taken to hospital. The Council’s records show Ms A emailed Mrs X’s social worker with a list of her worries about her mother’s deterioration and said she was very concerned that Mrs X would be discharged back to Longview, as she said the home was not able to keep Mrs X safe.
20. The social worker spoke to Ms A the next day and agreed the care home was no longer safe for Mrs X.
21. The safeguarding investigation showed that Mrs X was at very high risk of falls. There was contradictory evidence provided by the home – for example, the “-Risk assessment states, ‘no’ to incontinence, but the care plan states that (Mrs X) is incontinent and wears pads”; “Risk assessment states ‘no’ to underlying physical conditions but (Mrs X) has a diagnosis of osteoarthritis”.
22. The safeguarding allegations were substantiated. The report noted “Most importantly, the care home did not seem to be aware that (Mrs X) had fractures to her spine, despite them receiving the hospital discharge summary stating she had fractures to her back. Also, no reference is made to either the back fractures or the brain haemorrhage and how this was to be considered when (Mrs X) is mobilizing or receiving personal care”. A range of measures was agreed for the care home.

The complaint

23. Ms A complained to the Council in March 2024 after receiving a copy of the safeguarding report. She said the Council had failed to notify family of the organisational safeguarding in place and the fact that admissions were suspended. She said the Council shared responsibility with the care home and she asked that the Council reimburse care home fees from November 2023 onwards.
24. Ms A said the safeguarding report had been very distressing to read. She said the Council’s decision to keep discharging Mrs X back to the care home even while it was under organisational safeguarding investigations may have contributed to the number of falls.
25. The Council’s service manager responded in July, apologising for the delay. She said it was not normal practice for the Council to tell families of suspension of admission to a care home and she did not uphold that complaint. She agreed that more could have been done to prepare Ms A for the content of the safeguarding report, and so she upheld that aspect of the complaint.
26. In respect of the request to waive charges, the manager said, “Regrettably, the request for waiving charges for (Mrs X)'s care services cannot be accommodated. During this period ECC continued to contract care for (Mrs X) from Longview which was chargeable.”
27. The Council agreed to waive the charges from the date in February when Mrs X admitted to hospital as it was agreed she would not return to Longview then.
28. Ms A complained to the Ombudsman. She said as well as the preventable falls, there were multiple examples of failings by the care home detailed in the safeguarding report.
29. The Council says, “The decision to return (Mrs X) to the home following each hospital admission was informed by multiple factors and measures implemented by the Council to ensure her needs could be safely met. The Council established safeguarding management plans in response to individual inquiries, which were meticulously documented and reviewed during organizational safeguarding meetings involving the provider, Adult Social Care (ASC), partners, and other relevant stakeholders.”
30. The Council says it felt confident that with all the measures it had put in place, Mrs X’s needs could be met safely after each hospital admission. Ms A says on the contrary, Mrs X “experienced neglect and abuse, that the Council would have been aware of at the time, if their involvement and meetings had been so regular and robust”.
31. The Council says it will not reimburse care fees for this period. It says “the Council cannot waive charges despite safeguarding concerns as (Mrs X) continued to receive care at the home”.
32. The Council has offered £100 to recognise the distress caused by its delay in responding to the complaint.
33. Sadly Mrs X has now died.

Analysis

34. From August 2023 onwards Mrs X suffered multiple falls at the home which resulted in paramedic attendance and/or hospital admission. On one of those occasions she was left on the floor for seven hours without her dignity being considered. The home was already under an organisational safeguarding enquiry yet on each occasion the Council deemed it safe for Mrs X to return.
35. The safeguarding enquiry uncovered multiple failings in Mrs X’s care beyond the number of falls and the resulting injuries. The Council says that the decision to return her to the home each time was informed by the measures put in place which the Council was confident would keep Mrs X safe. That was simply not the case, however: the care home was demonstrably not a safe place for Mrs X.
36. There was a missed opportunity on the part of the Council to move Mrs X from the home and possibly prevent the additional falls. That was a potential breach of the regulations to provide safe care and protect her from abuse.

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Action

37. In my original draft statement I recommended that the Council should reimburse the fees paid by Mrs X from November 2023 to her admission to hospital in February 2024. There was already an organisational safeguarding enquiry underway which uncovered many areas of poor care and yet Mrs X was returned to the home time and again. However, that injustice was suffered personally by Mrs X and as such it cannot be remedied now.
38. However, within one month of my final decision the Council will apologise formally to Ms A for the failure of its commissioned care provider to keep Mrs X safe and for its own role in discharging her back to the home when it was known to be unsafe.
39. Within one month of my final decision the Council will also make a payment of £500 to Ms A to recognise the distress caused to her by the continued failure of the commissioned care provider to keep Mrs X safe.
40. The Council has already offered £100 to Ms A as apology for the delay in responding to her complaint and that will also be paid.
41. The Council should provide us with evidence it has complied with the above actions.

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Decision

42. I have completed this investigation as I find fault causing injustice, which the completion of the recommendations at paragraphs 38 – 40 will remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman