The Ombudsman's final decision:
Summary: We found no fault by the Council and Bornel Care with regards to the care they provided to Mr C, a young man with complex needs.
- The complainant, who I will call Mrs D, is complaining about the care and treatment provided to her son, Mr C, by Torbay Council and Bornel Care.
- Mrs D complains that Bornel Care failed to provide Mr C with appropriate diabetes care. She says this resulted in him being admitted to hospital on five separate occasions between July and October 2021.
- Mrs D says the cottage in which Mr C was living was in poor repair and that he was left with a broken toilet which could have been dangerous for him. Mrs D also says Mr C was often left alone without activities to stimulate him.
- Mrs D says these failings have caused her significant distress. She says this has been made worse as Bornel Care and Torbay Council have refused to share information with her about her Mr C’s care.
- Mrs D would like greater transparency on the part of Torbay Council and Bornel Care and would like to be involved in decisions about her Mr C’s care. She would also like to ensure that Mr C’s complex care needs are being met.
The Ombudsmen’s role and powers
- The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
- If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- In making my final decision, I considered information provided by Mrs D and discussed the complaint with her. I also considered relevant information and documentation from Torbay Council, Devon County Council and Bornel Care, including the care records. In addition, I took account of relevant guidance and legislation.
- I invited comments from all parties on my draft decision statement and considered the responses I received before making a final decision.
What I found
Relevant guidance and legislation
Type 1 Diabetes
- Type 1 diabetes is a genetic condition whereby the body is incapable of producing insulin (a hormone that converts blood sugar into energy). This results in raised blood sugar levels.
- If the body has insufficient insulin, it will start to use fat for energy. This leads to the production of ketones (a chemical produced by the liver when it breaks down fat). When ketones build up in the blood, they can become acidic and lead to a life-threatening condition called diabetic ketoacidosis (DKA).
- A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. 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)
- Mr C is young man with learning disabilities. In early 2021, Mr C was living in West Banbury Cottages (the care home). This facility is run by Bornel Care and specialises in care for people with learning disabilities. The placement was joint funded by Torbay Council and the NHS.
- Mr C also has Type 1 diabetes. He was under the care of the diabetes team Royal Devon and Exeter Hospital and had a specialist diabetes care plan. This requires Mr C to have regular blood sugar and ketone level tests. Mr C also has insulin injections to maintain his blood sugar levels within the normal range.
- On 2 July, monitoring tests revealed Mr C’s blood sugar level was high, with traces of ketones. Care home staff arranged an ambulance for Mr C as a precaution and accompanied him to hospital. The hospital carried out further tests and discharged Mr C back to the care home later that night.
- Mr C subsequently returned a positive COVID-19 test. He self-isolated in his cottage and recovered well.
- On 16 July, monitoring tests again revealed raised blood sugar levels and traces of ketones. The care home staff called an ambulance and the paramedics decided Mr C should go to hospital as a precaution. Care home staff accompanied Mr C. The hospital clinical team treated Mr C with intravenous fluids and insulin and discharged him later that night.
- In the early morning of 7 August, Mr C was found by care home staff to be vomiting and distressed. Monitoring tests showed Mr C had raised blood sugar and ketone levels. Care home staff called NHS 111 for advice and spoke to a paramedic, who arranged for an ambulance. Mr C was admitted that day.
- Mr C was discharged to the care home on 9 August with diagnoses including DKA and a urinary tract infection.
- In the meantime, Mrs D contacted Torbay Council’s Emergency Duty Service (EDS) to report concerns about Mr C’s welfare. She reported Mr C had been admitted to hospital three times in a relatively short period and that this suggested the care home was not managing his diabetes properly. The EDS made a safeguarding referral to Devon County Council, which is the agency with responsibility for safeguarding in the area.
- Mrs D continued to raise concerns about Mr C’s care with various agencies, including the police and the Care Quality Commission (CQC), and on social media. On 18 August, Bornel Care issued Mr C with notice due to its deteriorating relationship with Mrs D.
- Devon County Council held a safeguarding meeting on 24 August. The meeting concluded there was no evidence of neglect on the part of Bornel Care and that it had provided care in accordance with Mr C’s diabetes care plan. However, Torbay Council agreed to review Mr C’s placement as the notice period was due to expire on 15 September.
- On 11 September, Mr C again attended hospital due to raised blood sugar and ketone levels. However, he was not admitted.
- Devon County Council initiated further safeguarding enquires due to concerns that Mrs D’s behaviour had put Mr C’s placement and wellbeing at risk. A safeguarding meeting on 1 October concluded that the care provided to Mr C by Bornel Care had been appropriate.
- On 4 October, tests again revealed that Mr C had high blood sugar levels with traces of ketones and was vomiting. Care home staff called an ambulance and spoke to Mr C’s diabetes specialist nurse. A member of staff accompanied Mr C to hospital.
- The treating clinical team were concerned Mr C may have a gastric condition that was causing him to vomit. This in turn was causing instability in his blood sugar levels.
- On 19 October, Bornel Care confirmed Mr C would not be able to return to the care home. A Torbay Council social worker noted this was due to ongoing concerns about Mrs D’s behaviour.
- Mr C is now medically fit for discharge. However, at the time of writing this draft decision statement, he remains in hospital while Torbay Council seeks an alternative placement for him.
- Mrs D complained that Bornel Care’s failure to properly manage Mr C’s diabetes led to him being admitted to hospital five times between July and October 2021.
- Throughout the period Mrs D is complaining about, Mr C was under the care of the diabetes team at Royal Devon and Exeter Hospital. He had an allocated diabetes specialist nurse and a detailed diabetes care plan.
- The care plan provided direction for care home staff as to what action they should take in the event that Mr C became unwell. This included guidance for staff if tests revealed Mr C had raised blood sugar levels or traces of ketones.
- The care plan set out that, if readings showed Mr C had blood sugar levels greater than 14 millimoles per litre (mmol/l) for two consecutive readings or “if he seems at all unwell”, staff should check for traces of ketones. The plan recorded that, if Mr C had ketone levels of more than 1.5mmol/l, staff should “[s]eek medical advice who will advise on additional insulin and possible admission to hospital for stabilisation.” Further guidance for staff noted that “if [Mr C] is unable to tolerate fluids and is vomiting, abdominal pain, seems drowsy or short of breath seek further advice immediately. He may require hospitalisation.”
- The care home records for 2 July show Mr C was vomiting and that staff sought advice from the diabetes specialist nurse and his GP. Later that afternoon, Mr C’s blood sugar levels measured at 20.4mmol/l, with ketone levels of 1.8mmol/l. These readings, along with the fact that Mr C had been vomiting, led care home staff to arrange for him to be taken to hospital as a precaution.
- The care records show Mr C had a similar presentation in the early morning of 16 July. Care home staff noted that Mr C had vomited several times. Subsequent readings showed that Mr C again had high blood sugar levels (26.3mmol/l) and traces of ketones (3.3mmol/l). It is unclear from the care home records whether staff sought advice from Mr C’s diabetes specialist nurse on this occasion. However, staff did discuss Mr C’s presentation with the attending paramedics, who advised that he should go to hospital.
- In the early morning of 7 August, care home staff again noted Mr C was vomiting and in distress. When Mr C returned high blood sugar readings (32.3mmol/l) and ketone levels (4.1mmol/l), staff called the NHS 111 service for advice. The 111 service arranged for an ambulance to take Mr C to hospital where he was admitted.
- As Mr C had experienced three hospital attendances in a short period of time, his care was discussed at the safeguarding meeting on 24 August. Mrs D and Mr C’s father attended. Others present included representatives from Torbay Council, Devon County Council, Bornel Care and a diabetes specialist nurse. The notes of the meeting record that one of the care home staff who accompanied Mr C to hospital on 16 July had been praised by the clinical team for the care he provided and his knowledge of Mr C’s diabetes. The meeting concluded that “there is no evidence of negligence or neglect of care relating to [Mr C] or the treatment of his diabetes.”
- The circumstances leading up to Mr C’s hospital attendance on 11 September followed a similar pattern. Mr C was vomiting and had raised blood sugar (26mmol/l) and ketone levels (2.7mmol/l). Staff sought advice from the NHS 111 service. The 111 service advised staff to call an ambulance immediately due to Mr C’s high ketone levels. Mr C returned to the care home later that day.
- Mr C’s care was discussed again at another safeguarding meeting on 1 October. The meeting heard that Devon County Council’s disability lead had carried out an unannounced visit to the care home and “has been very happy with the care and support they are providing, with no concerns.” All present agreed Mr C appeared happy in the placement and that his care needs were being met.
- On the evening of 4 October, Mr C began to vomit. Monitoring tests revealed raised blood sugar (25.9mmol/l) and ketone levels (3.1mmol/l). Care home staff contacted the diabetes team for advice. The diabetes team advised the care home to call for an emergency ambulance. Mr C was subsequently admitted to hospital.
- The case records show that Mr C’s diabetes was unstable throughout the period Mrs D is complaining about. However, I have seen no evidence to suggest this was the result of poor care by Bornel Care. The standard of care provided to Mr C was discussed at two safeguarding meetings and neither health nor social care professionals raised any concerns about the care he was receiving.
- The Council’s records contain a note of a telephone conversation between a social worker and a diabetes and endocrinology consultant shortly after Mr C admission on 4 October. This note records that the consultant told the social worker care home staff “had been doing an ‘excellent job’ and that [Mr C’s] diabetes had been well controlled.”
- In summary, the evidence I have seen shows Bornel Care staff sought medical advice and treatment on each occasion when Mr C became unwell. This was appropriate and in keeping with the emergency protocols set out in his diabetes care plan. I found no fault by Bornel Care regarding the diabetes care it provided to Mr C between July and October 2021.
- Mrs D complained that the cottage in which Mr C was living was in poor repair. She said he was left with a broken toilet cistern lid which could have been dangerous for him.
- In its response to my enquiries, Bornel Care acknowledged Mr C had broken a toilet cistern lid on the day of one of Mrs D’s visits, shortly before she arrived. Bornel Care said Mr C had broken the toilet cistern lid, or sometimes the toilet itself, at each of the cottages in which he lived at the care home. Bornel Care said these were replaced by its full-time maintenance team by the following day at the latest. In total, Bornel Care said it had replaced four cistern lids and two toilets for Mr C.
- I note that the CQC’s last full inspection visit in August 2019 awarded the care home a ‘good’ rating overall. The inspection found the care home to be safe and identified no concerns about the facilities.
- The case records show Mr C’s care has been subject to specific scrutiny as part of the safeguarding enquiries carried out by Devon County Council. This included the unannounced visit by the Devon County Council disability lead in September 2021 that identified no concerns about the placement.
- Bornel Care has acknowledged that Mr C sometimes broke his toilet or toilet cistern lid. However, I have found no evidence to suggest wider concerns about the state of repair of the care home or the safety of its residents. I found no fault by Bornel Care on this point.
Activities and stimulation
- Mrs D complained that care home staff often left Mr C alone and without activities to stimulate him.
- In addition to Mr C’s diabetes care plan, he also had a general care plan setting out his wider needs. This confirmed that Mr C required 1:1 support at all times. The care plan also emphasised the importance of sensory stimulation to Mr C and provided detailed guidance for staff on how to meet this area of need.
- The care home maintained detailed records concerning all aspects of Mr C’s care over each 24-hour period. I have reviewed the records relating to the period between June and October 2021. The care records provide ample evidence of staff spending time with Mr C and encouraging him to engage in activities. These activities included spending time in the care home’s sensory garden, watching television, listening to music, playing with toys, and helping staff with jobs (such as cooking and putting out the rubbish).
- The care records show there were times when Mr C declined to participate in an activity. However, I found no evidence to suggest he was left alone or that staff failed to engage with him. I am satisfied the evidence shows Bornel Care staff provided Mr C with appropriate care in this regard and were responsive to his needs and changes in his presentation. I found no fault by Bornel Care in this matter.
- Mrs D complained that Torbay Council and Bornel Care failed to share information with her about Mr C’s care and wellbeing.
- The care home’s records show staff contacted Mrs D after, or during, each hospital admission and attendance to provide her with updates on Mr C’s condition. In addition, the case records contain copies of email correspondence between Torbay Council and Mrs D regarding Mr C’s ongoing care following his hospital admission in October 2021.
- The safeguarding records provided to me by Devon County Council suggest there may have been some confusion following the meeting of 24 August. At this meeting, it was agreed Mr C’s diabetes specialist nurse would review his recent test results and provide feedback to Mrs D. The records of the subsequent meeting on 1 October suggest this had still not happened by that date. I appreciate this would have been frustrating for Mrs D. However, neither Torbay Council nor Bornel Care were responsible for this delay.
- I also note Mrs D encountered difficulty communicating with the clinical team during Mr C’s hospital admission in October 2021. This appears to have been because Mr C’s father, rather than Mrs D, was recorded as his next of kin in his clinical records. This situation was exacerbated as Mrs D’s health and the COVID-19 restrictions in place at that time made it difficult for her to visit Mr C. Again, neither Torbay Council nor Bornel Care were responsible for this.
- In summary, the evidence shows both Torbay Council and Bornel Care shared information with Mrs D about Mr C’s wellbeing and his ongoing care needs. I found no fault on this point.
- I found no fault by the Council or Bornel Care with regards to the care they provided to Mr C. I have now completed my investigation on this basis.
Investigator's decision on behalf of the Ombudsman