Summary: Mrs X complained that the care provider failed to safeguard her elderly mother Mrs A against abuse by a carer and also failed to take appropriate action afterwards. The evidence shows the care provider was at fault; the actions of the carer caused Mrs A significant distress and the care provider did not respond properly. The care provider will now take action to recognise Mrs A’s distress and review its processes for responding to allegations.

The complaint

1. Mrs X complains on behalf of her mother Mrs A who is resident in the care home Mount Ephraim House. Mrs A says a carer wiped her roughly and inappropriately during personal care to the extent that she felt violated. Mrs A no longer tolerates having her room door open in fear of seeing that carer. Mrs X says the care provider failed not only to safeguard her mother but did not respond properly after the incident with any concern for Mrs A’s wellbeing.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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 evidence provided by the care provider, the local authority and Mrs X as well as relevant law, policy and guidance.
7. The care provider and Mrs X 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

Relevant law and guidance

8. 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.
9. Regulation 10 says service users must be treated with dignity and respect.
10. Regulation 13 says care must not be provided in a way that is degrading for the service user.
11. Regulation 16 says appropriate action must be taken without delay to respond to any failures identified by a complaint or the investigation of a complaint.
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).

What happened

13. Mrs A is a resident in the Mount Ephraim care home. She needs support with her personal care needs. Her care plan says she is able to wash her body independently but requires help with washing her back, legs and feet. She is largely able to manage her own continence needs. Her care plan stipulates that there should be “discreet and appropriate communication during continence support”.
14. Mrs X says when she visited her mother on 21 July 2024 she could see Mrs A was upset. On prompting, Mrs A explained that during personal care on 16 July a carer who was in the bathroom with her after her shower had wiped her intimate areas with a flannel without warning and so roughly that Mrs A had exclaimed to her aloud about her actions. The carer said she was just making Mrs A clean. Mrs A said she had told another carer what had happened the next day, who then told the manager. Mrs A said the manager did not come to see her about it until 18 July. The manager said she had sent the carer to work upstairs (with dementia residents). Mrs A said the more she thought about it the more violated she felt.
15. Mrs X says she was horrified to learn what had happened. She emailed the care provider asking for an official investigation. She said she had notified the police of what had happened and asked why the care provider had tried to sweep the matter under the carpet by moving the carer upstairs to care for more vulnerable adults. She complained that the care provider had not notified her personally of what had happened.
16. The divisional director responded to Mrs X and said the matter was being referred to the local safeguarding team. The carer was suspended during the investigation.
17. The police interviewed Mrs A on 23 July and notified Mrs X the following week that they would not take the matter further. They said it was one person’s word against another.
18. Mrs X emailed the divisional director with this news. She asked again why the care home manager had not told her what had happened. She said she had spoken to other senior carers who had expressed their concerns about the carer involved. She asked why the trainee who had been present was left on her own with Mrs A during her shower. She said she understood the carer’s version of events was that Mrs A was not clean after her shower – Mrs X asked why if that was the case had the carer not explained to Mrs A what was happening and cleaned her the correct way? She said although the carer had now been suspended Mrs A still had nightmares about her returning to the home. The divisional director replied that the investigation would be in two parts – the initial actions when Mrs A raised her concerns, and the allegation itself. She undertook to respond within 25 working days.
19. The local safeguarding team interviewed Mrs A by telephone on 2 August. Mrs A told them the trainee had supported her on her own with a shower and then the carer came into the bathroom while Mrs A was drying. Mrs A said “(The carer) came into the bathroom and was running a tap. (Mrs A) asked for support to pull up her pants. “I heard water running and next (the carer) has run a towel from my backside to the front. I asked her what she was doing and she said she was making sure I was clean. I was very upset. I felt as if I had been assaulted and asked her to leave”. Mrs A said although she knew the incident had been reported to the manager, the manager did not ask her what had happened but saw her two days later and said there was no need to worry as the carer had been moved upstairs.
20. Mrs X complained to the divisional director about the length of time it was taking to complete the investigation. The safeguarding team also contacted the divisional director on 17 September asking for an update as the investigation was taking too long. The director said there were a lot of staff to be interviewed. The following week the director updated the safeguarding team that “Carer is going through disciplinary as she did not follow the appropriate procedure; giving intimate personal care without the consent of the client who was deemed to have capacity”. She also said she recognised the culture of the home needed to change and said there would be ongoing refresher training for staff members and she would start offering staff drop-in sessions to see what needed improving to make the work environment better.
21. The outcome of the internal investigation was that the carer’s actions fell short of the standards expected and she would be required to complete refresher training on her return to work.
22. The council’s safeguarding investigation was closed with no further action on receipt of the care provider’s internal investigation.
23. Mrs X complained to the Ombudsman. She said there had been a profound effect on Mrs A who no longer wanted even to have her door open in case the carer passed by – and as Mrs A is generally confined to her room, this had significantly reduced her social interaction. She says Ms A continues to have nightmares about the carer accessing her room.
24. The care provider has not provided any additional comments on the complaint or its actions, other than the requested documents of its investigation.

Analysis

25. The care provider did not treat Mrs A with dignity and respect. That is fault, and a potential breach of regulation 10.
26. The care provider’s actions were degrading for Mrs A. That is fault, and also a potential breach of regulation 13.
27. The care provider failed to notify Mrs X of the incident. She was left to find out directly from Mrs A and was understandably shocked and upset that it had been kept from her.
28. The care provider took too long to respond to the complaint. The local safeguarding investigation could have been concluded much sooner had the care provider acted with greater urgency.
29. Those are all examples of fault by the care provider. In addition however there was a significant and fundamental lack of care and empathy for Mrs A in the aftermath of the incident. The manager made no approach to Mrs A until two days after the incident and said she had been too busy. Her reassurance to Mrs A was to tell her not to worry, that the carer had been moved upstairs. That was not an appropriate response to the situation and did not begin to meet Mrs A’s needs following what had been a traumatic episode for her.
30. It is not the role of the Ombudsman to comment on personnel matters so the care provider’s response following the upheld safeguarding enquiry is a matter for it. However, we can suggest a remedy for the injustice suffered by Mrs A.

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Action

31. Within one month of my final decision, the care provider will review the way it responds to residents and relatives after allegations are made to ensure it offers proper support and counselling: it will provide us with details of its intended processes in this respect.
32. Within one month of my final decision the care provider will apologise formally to Mrs X and Mrs A for its failures in this case.
33. Within one month of my final decision the care provider will offer £500 to Mrs X for the distress caused to her.
34. Within one month of my final decision the care provider will offer £1000 to Mrs A in recognition of the distress caused by its failure to safeguard her, to treat her with dignity and to offer her support. It should also now consider, in consultation with Mrs A and Mrs X, how best to support her going forwards.
35. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

36. I have completed this investigation on the basis that I find fault causing injustice

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman