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Telford & Wrekin Council (19 021 140)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 17 May 2021

The Ombudsman's final decision:

Summary: Mrs X complained the Care Provider commissioned by the Council, St Georges Park Care Home, unnecessarily prevented her from visiting her mother Mrs Y. Mrs X also complained the Care Provider did not properly care for Mrs Y and falsely accused her of abusing her mother. Mrs X says the Care Provider’s actions caused her distress. There was fault when the Council failed to respond to Mrs X’s complaint within the required timescales. This caused Mrs X inconvenience. The Council has made an offer of £250 to address its handling of Mrs X’s complaint and has agreed to my recommendation to address the service failure. This is a satisfactory remedy to address the injustice Mrs X suffered. There was no fault in the Care Provider’s actions.

The complaint

  1. Mrs X complained the Care Provider stopped her from visiting her mother, Mrs Y, without giving her a proper reason for doing so.
  2. She also said the Care Provider wrongfully accused her of abusing Mrs Y and she further complained that the Care Provider was neglectful in its treatment of her mother.
  3. She said the Care Provider’s actions caused her distress and meant that she lost out on spending time with Mrs Y before she died.

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The Ombudsman’s role and powers

  1. 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. If we are satisfied with a council’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)
  3. 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, section 25(7), as amended)
  4. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

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How I considered this complaint

  1. I contacted Mrs X and discussed the complaint with her.
  2. I made enquiries of the Council and considered the information it provided. This included the Council’s complaint chronology and correspondence shared between Mrs X and the Council.
  3. I will write to Mrs X and the Council with the draft decision. I considered the comments I received from both before I wrote the final decision.

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What I found

Statutory Guidance

  1. Part 3 of the Local Government Act 1974 covers complaints where councils provide services themselves or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. The Act says we can treat the actions of the Care Provider as if they were the actions of the council in those cases.
  2. In this case, the Council commissioned the Care Provider to care for Mrs Y.
  3. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets 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.
  4. Regulation 13 states Care Providers must take a zero tolerance approach to abuse and should have robust procedures and process in place to prevent service users from being abused by staff or other people they come into contact with, including visitors.

Adult social care complaints

  1. There is only one stage to the Council’s complaints process. When a complaint is received a Council officer will contact the complainant and explain how the case will be investigated. The officer should also agree a timescale with the complainant which can be from 25 to a maximum of 65 working days.

What happened

  1. Mrs Y was elderly and suffered from dementia. The Council arranged for her to stay at the Care Provider’s nursing home on 29 September 2019.
  2. In October 2019, Mrs X made five calls to the Police regarding safeguarding concerns she had about the care Mrs Y and other residents were receiving at the home. She said:
    • She saw a carer lift a resident up by the seat of their trousers
    • There was a sore on Mrs Y’s bottom she believed was caused by carers helping her up in a similar way
    • A third party told Mrs X that Mrs Y had been left to sit in urine soaked clothes
    • Mrs Y was distressed a male carer had attended to her personal needs
  3. Mrs X also referred her concerns to the CQC.
  4. The Police visited the nursing home and investigated the allegations.
    They interviewed Mrs Y, the management, the carers and reviewed care records. The Police concluded there was no evidence of wrongdoing on the Care Provider’s part.
  5. The Council also began an investigation into the allegations, which included reviewing the Police’s findings, visiting to the home and interviewing staff and Mrs X. The Council did not find anything to substantiate Mrs X’s claims.
  6. On 28 November 2019, the Care Provider met with Mrs X to discuss her behaviour when visiting the nursing home. The Care Provider had received reports Mrs X was telling residents and visitors that carers were abusing Mrs Y and other residents. The Care Provider also said Mrs Y was taking pictures of residents, making social media posts and dispersing letters to the relatives of residents at the home making serious allegations of abuse, which one of the resident’s relatives found very upsetting. Mrs X disputes this.
  7. After discussing the matter, Mrs X said she would not stop making the allegations. The Care Provider told Mrs X she was no longer welcome to visit Mrs Y at the nursing home because her behaviour was distressing residents.
  8. The Council arranged for a care agency to support Mrs Y in visiting Mrs X outside of the home and the Care Provider offered to set up skype calls between Mrs X and Mrs Y. In December 2019, the Care Provider also offered for Mrs X to visit Mrs Y in the reception area of the home, but Mrs X declined this because she did not want to engage with the management. The Council later asked Mrs X to consider speaking with the home manager to resume visits but Mrs X declined this because she felt the relationship had broken down.
  9. On 2 January 2020, Mrs Y died.
  10. Mrs X complained to the Council on 3 April 2020 about her mother’s treatment and the contact restrictions implemented by the Care Provider. She said the Care Provider was wrong to stop her visits because the complaints she made were valid. She said the Care Provider had neglected Mrs Y’s personal hygiene and misplaced her underwear. She also said she was a staff member accused her of abusing Mrs Y.
  11. The Council investigated and wrote to Mrs X at Stage 1 of its complaints procedure on 4 November 2020. The Council said Mrs Y had upset other residents by spreading rumours of abuse taking place at the home and taking pictures and videos of the residents without permission. The Council listed the ways it had tried to help Mrs X maintain access with Mrs Y. The Council said the Care Provider arranged an assessment of Mrs Y and it concluded that the ongoing conflict between Mrs X and the Care Provider could be having a detrimental effect to Mrs Y’s mental health.
  12. The Council referred to a meeting it had with the Care Provider in late 2019 after Mrs X carried out an intimate physical examination on Mrs Y. The Care Provider voiced concerns that Mrs Y lacked the capacity to consent to this examination and felt this may have distressed her or put her at risk of physical harmed. It was agreed at the meeting that only trained professionals should attend to Mrs Y’s intimate needs and the Council explained this to Mrs X. The Council acknowledged Mrs X’s unhappiness about this but noted Mrs X had agreed with the arrangements.
    The Council said it did not intend to accuse her of intentionally causing her mother harm.
  13. Regarding Mrs X’s allegations that a carer at the home abused another resident, the Council said the Police investigated and confirmed there was no evidence of abuse taking place at the home. The Council said it contacted Mrs X on 28 October 2019 to tell her this and she accepted this. The Council also interviewed staff after Mrs X reported a staff member had behaved inappropriately with a resident at the nursing home and it had not found any evidence to support her allegations. The Council spoke with the Care Provider manager and staff at the home and decided it would not carry out further investigation regarding the lost underwear because it was an isolated incident and it was satisfied there were no other safeguarding concerns.
  14. Mrs X was unhappy with the Council’s response and sent the Council several letters in November 2020 reiterating her complaint points. She also raised further complaints regarding Mrs Y’s care on 3 December 2020. She said Mrs Y was suffering from a chest infection when she died, and the Care Provider failed to notice. She said the Care Provider offered Mrs Y food she could not eat due to her diabetes. Mrs X concluded the letters requesting that the Care Provider dismiss the staff she had complained about.
  15. The Council investigated Mrs X’s new complaints and responded on 2 February 2021. The Council said its review of Mrs Y’s care records did not show any evidence of Mrs Y suffering a chest infection and this was not raised at the time. The Council reviewed Mrs Y’s diet plan and notes taken by the nurse monitoring her diet and said the food Mrs Y received was varied and appropriate to her dietary requirements. The Council did not uphold Mrs X’s complaint.
  16. Mrs X brought her complaint to the Ombudsman.
  17. In response to our enquiries, the Council acknowledged it delayed responding to Mrs X’s complaint and could have been clearer in its communication with Mrs X. The Council has further elaborated that the pressures of the COVID-19 pandemic on its resources and staff made a significant contribution towards the delay. In recognition of the inconvenience caused, the Council has made an offer of £250 to Mrs X.

Findings

  1. Mrs X remains unhappy the Care Provider restricted her from visiting the care home. The Care Provider had a duty to ensure Mrs Y’s safety as well as the wellbeing of the other residents staying at the home. After Mrs X made her allegations, the Police and Council investigated and did not find evidence supporting her claims. The Care Provider discussed the allegations Mrs X was making and advised her of the impact it was having on the other residents. Mrs X advised she was not prepared to stop raising the allegations. The Care Provider told Mrs X she was not allowed to visit the home because it was causing distress to the other residents. The Care Provider and Council facilitated contact between Mrs Y and Mrs X and attempted to rebuild the relationship between Mrs X and the home manager in order to resume visits but the evidence indicates Mrs X was not open to this. I am satisfied the Council acted appropriately. The Care Provider was entitled to decide restrictions on Mrs X’s contact were necessary having considered alternatives and taken steps to minimise the impact of the restrictions.
  2. Part of Mrs X’s complaint regards her belief that the Care Provider wrongly accused her of abusing Mrs Y. As stated above, once the Care Provider became aware that Mrs X had observed Mrs Y in a state of undress, it had a responsibility to investigate this and make sure Mrs Y was safe. It properly considered the circumstances of the situation and took appropriate, consequential action. The evidence shows the Council put measures in place to ensure the incident did not happen again and explained this to Mrs X. I do not find the Council or Care Provider at fault.
  3. The Council’s statutory complaints process requires it to respond to a complaint within a maximum of 65 working days. The Council took 215 working days to respond to Mrs X’s complaint. In the interests of fairness, I note that the Council was impacted by the COVID-19 pandemic however, this is still a significant delay and is fault. Mrs X was likely put to inconvenience and stress because of this fault. The Council has made an offer of £250 to address the injustice Mrs X experienced. This is an appropriate action for the Council to take that remedies this injustice. However, the Council should also address its failure to keep to its timescales.

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Agreed Actions

  1. Within three months of the date of my final decision, the Council has agreed to provide evidence showing it has reminded staff to ensure it keeps to required timescales.

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Final decision

  1. There was fault when the Council significantly delayed responding to Mrs X’s complaint. The Council has made a satisfactory financial award to address the injustice caused by the fault however I have made a recommendation to address the service failure. There was no fault on the Care Provider’s part. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman

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