Summary: Ms B complains about two incidents when her mother suffered maltreatment at a care home. We have found fault in the Home’s actions and the Home has agreed to apologise, pay a financial remedy and carry out a service improvement.

The complaint

1. Ms B complains on behalf of her mother, Mrs C, who lives at Westbury Court care home (the Home) in Westbury. She complains about an incident where a man was found in Mrs C’s bed and another incident where Mrs C was found to have multiple bruises on her body.

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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 an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused a significant injustice or that could cause injustice to others in future we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) 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)

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How I considered this complaint

4. I have spoken to Ms B. I have considered the information provided by her and the Home, the relevant law, policy and guidance and both sides’ comments on the draft decision.

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What I found

Law, guidance and policies

Care Quality Commission

5. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

Safeguarding duty

7. Section 42 of the Care Act 2014 says that, if a local authority has reasonable cause to suspect that an adult in its area:
• 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.
8. The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken.

The Home’s policies

9. The Home has policies and checklists which set out what staff should do when there has been an adverse incident.
10. This says staff should (among other things):
• Fill in an adverse event report.
• Take photos.
• Complete a body map.
• Inform the family.
11. If the incident relates to the behaviour by a resident, staff should:
• Fill in an ABC (antecedent, behaviour, consequence) form.
• Review the risk assessment and care plan.
• Review any safeguarding risk and report (‘peer on peer, sexual behaviours…’)

What happened

12. Mrs C is an older woman who has dementia. She does not have the mental capacity to make the relevant decisions.

Incident – July 2024

13. On 8 July 2024 Mrs C and a male resident (Mr D) were found in bed, naked. Mr D had dementia and also lacked the mental capacity to make the relevant decision.
14. The Home noted that, during the evening of 8 July 2024, Mr D had been unsettled and was seen entering other residents’ rooms. Mr D was a respite resident who had only been at the Home for a few days. From the time of admission, he had been increasingly confused and unsettled.
15. Mr D was seen watching tv in his room at 22:31. Staff completed hourly checks on all residents at 23:00 and found Mr D in Mrs C’s bedroom. The Home said no physical activity appeared to have taken place. When asked to leave the room, Mr D became aggressive. Staff then ‘forcefully’ led Mr D out of Mrs C’s room and escorted him back to his own room.
16. The records showed there was a further incident involving Mr D and another female resident later.
17. The Home completed an ‘adverse event report’ on 9 July 2024 and recommended actions to prevent a recurrence which included making a safeguarding referral, a medication request to the GP and a referral to the community mental health team.

Incident – September 2024

18. There was a second incident on 2 September 2024 when bruising was found on Mrs C.
19. The care records showed Mrs C was assisted with personal care by two care workers on 2 September 2024 at 06:29. She was assisted with a shower. A note was entered at 06:50 which said ‘[Mrs C] has been aggressive towards team members when assisted with personal care…’
20. At 09:52, a different care worker noted that Mrs C had bruises on both hands (left and right wrist).
21. On 3 September 2024 at 11:00 a care worker noted further bruises on Mrs C’s right arm, left elbow and left breast. Photos were taken on both days and the manager was made aware of the bruises.
22. The Home investigated the incident. The Home interviewed the two care workers who had assisted Mrs C with a shower at 06:29 on 2 September 2024 and interviewed Mrs C. Mrs C said she sustained the bruises during the night when she was being assisted by night staff with personal care. The care workers said Mrs C had grabbed the shower head and waved it around so that staff would not be able to shower her. They said that Mrs C already had a bruise on her left hand when they started to provide the care.
23. The Home noted that the care workers’ verbal statements did not match the daily records as the care workers had not recorded the bruise nor the incident with the shower head in their daily records.

Safeguarding meeting – 21 November

24. On 21 November 2024 the Council held a safeguarding strategy meeting about the incident in July 2024. Ms B attended the meeting. The Council said the allegation of neglect and acts of omission had been substantiated and it would close the enquiry. (I outline the details of the Council’s findings below).

Complaint – 30 November 2024

25. Mrs C’s family complained to the Home on 30 November 2024 and said:
• They had not heard anything further from the Home since the safeguarding meeting on 21 November.
• The Home had agreed, at the meeting, to meet with the family, to update them and to provide a risk assessment. The Home had not taken any of the actions it said it would take.
• The family was also still waiting to hear what the outcome of the investigation into the incident in September was.

Responses – December 2024 and January 2025

26. The Home provided three responses to the complaint which I have summarised. The Home said:
• It had re-opened the investigation into the incident in July 2024.
• In terms of the September incident, the Home said: ‘Following an investigation, we have concluded that the bruising was caused by poor manual handling of [Mrs C] whilst assisting her with personal care.’ ‘The bruising on the right hand is consistent with finger marks.’
• The Home admitted it failed to provide the family with written responses to the concerns although it said it provided the family with verbal information.
• The Home failed to provide the Council’s safeguarding team the police and the family with the requested information following the safeguarding meeting. The information had been sent since then.

The Council’s safeguarding enquiries

27. The Council noted the following in its safeguarding enquiries into the two incidents.

Incident – July 2024.

28. The Council’s safeguarding enquiry into the incident in July 2023 criticised the Home and said:
• The Home did not take the appropriate actions to safeguard Mrs C and Mr D following the incident witnessed by the care team earlier in the evening. Had actions been taken, the incident could have been avoided.
• The Home failed to properly monitor Mr D after the incident which meant he went on to physically assault another resident.
• The Home did not have appropriate training in place to understand or manage Mrs C’s sometimes disinhibited behaviour.
• The Home did not ensure clinical oversight of Mrs C the day after the incident.
• The Home did not approach Mrs C the following day to ask her of her recollections of the incident nor made any intervention to ensure her wellbeing.
• The Home had not provided evidence that regular checks were made on Mrs C and Mr D after the incident.

Incident – September 2024

29. The Council’s investigating officer spoke to the Home’s manager to discuss the enquiry and said:
• There was a lack of record keeping relating to the incident.
• When the initial bruising was found on 2 September, there was no proper record keeping, incident report or body map.
• After further bruising was found on 3 September, there was still no incident report or body map, although photos were taken.
• The Home’s internal investigation report was not thorough enough. When the staff members were interviewed, they were not asked questions such as why they did not record the bruise or exactly what happened when Mrs C waived the shower head around.
• The Home said Mrs C was known to sometimes resist personal care, so the officer questioned whether a risk assessment for personal care should have been put in place.

Further information

30. I asked the Home to send me all the risk assessments and care plans for Mrs C and Mr D before and after the two incidents happened. The Home has sent me a risk assessment for Mrs C dated 21 November 2024 relating to the incident in July and a revised care plan dated 4 December 2024 relating to the incident in September.

Actions taken

31. I will summarise the actions that the Home or the Council (following the safeguarding enquiries) have recommended should be taken to reduce the risk of a similar incident occurring. These included:
• Staff had been subjected to disciplinary action.
• Staff to be retrained in manual handing, safeguarding, complaint handling and sexual behaviours in dementia.
• Staff to review the escalation policy and actions required.

Analysis

32. Both the Home and the Council have, to a large extent, upheld the complaints made by Ms B and I rely on their findings. I will summarise the fault that has been found.
33. In terms of the incident in July, there was fault as the Home failed to fully risk assess Mr D even though he had started to exhibit the behaviour prior to the incident with Mrs C. The Home then failed to properly risk assess the situation after the incident had happened, and, in particular, failed to monitor Mr D constantly (for example, by placing an alert mat by his bedroom door) after the incident which then led to a second incident happening with another resident.
34. The Home also failed to properly investigate the incident involving Mrs C after it happened. The Home did not ensure that Mrs C was checked by a GP. The Home did not interview Mrs C. The Home knew that Mrs C sometimes displayed what it described as ‘disinhibited’ behaviour which would put her at greater risk of an incident such as this one happening, but the Home did not carry out a risk assessment of Mrs C until November 2024.
35. In terms of the incident in September, the Home has now said that, on the balance of probabilities, the bruising was sustained while Mrs C was being provided with personal care on 2 September. So there was fault in this respect as personal care should never result in bruising.
36. I also agree that the record keeping was poor and this was fault. Firstly, there was the fact that the records of 2 September 2024 at 06:29 (when personal care was provided) did not match the statements by the care workers.
37. Secondly, the Home did not follow its own procedures, on 2 or on 3 September 2024, on what actions to take and records to keep when there has been an adverse incident. The staff did not fill in incident reports and there were no body maps. Also, I would have expected staff to complete an ABC chart and a risk assessment to reduce the risk of a similar incident happening, but this did not take place.
38. I also uphold the complaint that there was poor communication between the Home and Ms B (or the other members of Mrs C’s family). The Home should have kept the family informed of the investigations, the outcomes of its investigations and the actions it was taking to protect Mrs C, but there was no real communication, certainly not in writing, until after the safeguarding meeting and the family’s complaint. This added to the concerns that the family had that Mrs C was not safe at the Home, particularly as the two incidents happened within a few months of each other.
39. I am also of the view that the Home’s investigations into the incidents on both occasions were not thorough enough. An investigation should establish the facts (what actually happened), whether the incident could have been avoided and then a risk assessment to reduce the risk of a similar incident happening again, but the documents I was sent did not properly address those aspects.

Remedy

40. Mrs C has suffered the main injustice resulting from the fault, but I do not underestimate the stress Ms B and the other family members have experienced worrying about Mrs C.
41. Ms B explained that the main reason for coming to the Ombudsman was that she had asked the Home for compensation (a refund of 6 months’ fees). The Home had referred her to the Ombudsman if she was seeking compensation.
42. I explained to Ms B that this was, unfortunately, wrong advice. I explained that the Ombudsman was not a court and did not pay compensation or punitive damages. The aim of the Ombudsman’s remedy is to put the complainant in the position they would have been, if the fault had not occurred. In cases such as this one, where that is not possible and there is no direct financial injustice, we would not provide a financial remedy except for a small symbolic sum of a few hundred pounds. I asked Ms B whether she still wanted the Ombudsman to investigate the complaint and she said she did.
43. The Ombudsman recommended that the Home paid a symbolic sum of £500 at the draft decision stage. After the draft decision, the Home offered to pay a month’s fees instead (the weekly fee is £1,444) so I have amended the remedy to reflect the Home's offer. The Home also offered the family a meeting between the Home’s management and the family to apologise and to ensure that they are satisfied with Mrs C’s care plan. I have added this to the agreed actions by the Home.
44. I have also considered whether to recommend any further service improvements to the Home. I note the actions the Home has already taken following Ms B’s complaint. I recommend the Home reminds staff of the importance of good record keeping.
45. Under our information sharing agreement, we will share this decision with the CQC. The CQC is best placed to consider whether any other service improvements are required.

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Action

46. The Home has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mrs C and Ms B in writing for the fault.
• Offer Mrs C’s family a meeting as set out above in paragraph 43.
• Repay one month’s fees to Mrs C.
• Remind staff of the importance of good record keeping.

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Decision

47. I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman