Doncaster Clinical Commissioning Group (19 007 581a)

Category : Health > Mental health services

Decision : Upheld

Decision date : 25 Sep 2020

The Ombudsman's final decision:

Summary: Mr X and Mr Y complained about the care their late wife and mother, Mrs F, received at Northfield Care home (the Care home) during April 2018. This was jointly arranged and funded by the Council and the Clinical Commissioning Group as Section 117 aftercare. The Council and the Clinical Commissioning Group were at fault. The care provided by the Care home to Mrs F was inadequate and it was slow to respond to Mrs F’s pressure sores. The Council was also at fault for delays in carrying out the safeguarding investigation. The Council and the Clinical Commissioning Group agreed to apologise and pay Mr X and Mr Y a total of £500 between them to acknowledge the distress and uncertainty caused by the faults.

The complaint

  1. Mr X and Mr Y complained on behalf of their late wife and mother, Mrs F. They complained about the poor standard of section 117 aftercare provided to Mrs F at Northfield care home (the Care home) during April 2018. The Council and the Clinical Commissioning Group (CCG) jointly funded and arranged the section 117 aftercare. Mr X and Mr Y said
    • the Care home failed to care for and respond to Mrs F’s pressure sores and skin condition which led to her admission to hospital, and
    • the Council significantly delayed its safeguarding investigation into the matter.
  2. Mr X and Mr Y said the failings caused Mrs F distress and has caused them both ongoing distress, uncertainty and time and trouble.

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The Ombudsmen’s role and powers

  1. 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).
  2. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
  3. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
  4. 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)
  5. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

  1. I spoke to Mr Y about the complaint.
  2. I considered the Council’s safeguarding investigation into the matter.
  3. I considered the Council’s response to my enquiry letter.
  4. I considered the CCG’s response to my enquiry letter.
  5. The Council, the CCG, Mr X and Mr Y had the opportunity to comment on my draft decision. I considered comments before I made a final decision.

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What I found

Section 117 aftercare

  1. A person previously detained under the Mental Health Act 1983, is entitled to aftercare under section 117 of the Mental Health Act 1983 (s117 aftercare). This means the Council and the CCG have a joint legal duty to provide or arrange free aftercare to meet her relevant health and social care needs. The purpose of this is to reduce the risk of her mental condition worsening and the need for another hospital admission. Aftercare services should meet a person’s immediate health and social care needs and aim to support them to build skills to cope with life outside hospital. People are entitled to s117 aftercare until the CCG and council agree that they no longer need it.
  2. The Council and the CCG have a joint Section 117 Policy in place. The purpose of the policy is to lay out a clear framework on, and commitment to, the provision of aftercare services to people who are entitled to s117 aftercare. The policy applies to all patients entitled to aftercare services within the Council’s and the CCG’s area.

Standard of care

  1. The Care Quality Commission (‘CQC’) is the independent registration body and regulator of health and adult social care services in England. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall.

Safeguarding vulnerable adults

  1. Section 42 of The Care Act 2014 says a council must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect, and if so, by whom.
  2. Councils play the lead role in co-ordinating work to safeguard adults. Anyone who has concerns for the welfare of a vulnerable adult should raise an alert. The Council’s policy sets out the responsibilities of the people involved and the timescales for action.
  3. The purpose of the safeguarding process is to:
    • Find out the facts about what happened; and
    • protect the vulnerable adult from the risk of further harm.
  4. The Council’s safeguarding policy and procedures set out how the Council will respond to allegations and concerns about abuse.
  5. When someone raises a concern with the Council, it should undertake an initial enquiry to decide how to respond. If the Council does not resolve the concern through initial enquiries it will need to investigate to decide on the most proportionate response. The managing officer should agree appropriate timescales at each stage.
  6. If it decides to investigate the Council appoints a Safeguarding Investigating officer to find out what happened and to collate information from all the relevant parties. From this they prepare a safeguarding investigation report for discussion at a case conference. This is a multi-agency meeting, with all interested parties, to consider the findings of the investigation. The case conference will decide on the findings and whether abuse or neglect has occurred, assess risk, what future actions are needed and how these should be monitored.
  7. It is not for the Ombudsmen to reinvestigate the safeguarding referral but to consider whether the Council conducted a suitable investigation in line with its safeguarding procedures.

The Council’s safeguarding investigation policy and procedure

  1. The Council’s policy says all safeguarding referrals are triaged in its Safeguarding HUB and any urgent ones are processed immediately. All other safeguarding referrals are triaged within 1-5 days to identify the level of risk, what actions are required and to determine who is suitable to respond to the concern.
  2. The Council’s policy says following the referral it will carry out a planning meeting, section 42 enquiry and then an outcomes meeting if required.

Pressure area care

  1. Pressure sores (also called pressure ulcers or bed sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. People with mobility difficulties and who are over 70 are more at risk. Pressure sores are graded in severity from 1 to 4 with 4 being the most serious.

What happened

Background

  1. Mrs F had dementia and lacked capacity to communicate and make her own decisions. At the start of 2018 Mrs F was an inpatient at hospital where she was detained under the Mental Health Act. Mrs F remained at the hospital until her health was stable enough for discharge. Following a best interest meeting Mrs F was discharged to the Care home in April 2018. The placement was jointly approved by the Council and the CCG initially as section 117 aftercare. Mrs F became a permanent resident at the Care home two weeks later.
  2. Records show that staff at the Care home noted a deterioration in Mrs F’s ability to walk in mid-April, just two weeks after she arrived. The Care home called the doctor who attended to take a blood sample from Mrs F, however, was unable to so requested Mrs F attend the surgery a few days later. Records show Mrs F became agitated on the day of the and staff at the Care home felt it was unsafe for her to use a wheelchair. Staff told the doctor they would monitor Mrs F.
  3. Later that day Care home staff informed the home manager that Mrs F four small pressure sores on her sacrum, two on the left and two on the right, however the skin was not broken. Two days later staff told the Care home nurse that the pressure sores had deteriorated and were now at grade three. The doctor told staff to call an ambulance for Mrs F which they did, and she was admitted to hospital. The Care home referred the matter to the Council as a safeguarding alert.
  4. Mrs F died a few days later at the end of April 2018.

The safeguarding investigation

  1. The Council received the safeguarding referral and progressed the matter to an initial enquiry at the end of April. That enquiry was to look at Mrs F’s care plans, risk assessments together with any other evidence or actions the Care Home had taken since the safeguarding referral.
  2. The Council made the decision to make further enquiries in July 2018 following a meeting with Mr X. Mr X raised concerns with the Council that in his view, Mrs F received poor care at the Care Home. However, it was no until October 2018 that the Council carried out a planning meet for its next steps. The planning meet decided the investigation needed to establish whether Mrs F was neglected during her stay at the Care home during April 2018. The records show the action was marked for completion ‘asap’.
  3. The Council completed its further enquiry in March 2019 and carried out an outcome meeting which Mr X and Mr Y attended. The Council shared its conclusions of the safeguarding investigation. It found the Care home had poor pressure care procedures. There was no evidence of a risk assessment or care plan in relation to her pressure sores and no evidence of a plan for monitoring them. It found undated documents identifying the pressure sores however no evaluation or ongoing treatment plan. The investigation found there were significant gaps in Mrs F’s wound management which allowed a minor pressure sore to progress to a more serious one.
  4. The investigation found Mrs F was given poor care in general during her stay. Mrs F had no eating and drinking plan and the Care home did not have a clinical oversight of Mrs F’s declining fluid and food intake. The investigation found the Care home practiced very poor record keeping. Mrs F’s records including her care plan and risk assessment were either incomplete or not signed and dated.
  5. The Council’s investigation concluded that the Care home was slow to respond to concerns about Mrs F’s pressure sores. It found clear evidence that the care provided to Mrs F’s skin care and fluid intake was inadequate due to the lack of formal monitoring and follow up. The Council concluded that on balance, Mrs F was neglected by the Care home. The Council said the Care home had accepted the outcome of the safeguarding investigation and were putting measures in place to avoid something similar happening again.

Mr X and Mr Y’s complaint

  1. Mr Y wrote to the Council and complained in June 2019. He complained both the Council and the Care home had failed to safeguard and care for Mrs F. He said Mrs F died because of the high level of neglect Mrs F suffered at the Care home. He said the Council should address the issue to ensure nobody else is subject to a similar ordeal.
  2. The Council responded to Mr X and Mr Y in June 2019. The Council said it had carried out a full and detailed safeguarding investigation following the referral from the Care home. The Council said the investigation found the Care home was slow to respond to Mrs F’s condition and pressure sores however felt that inaction was not a direct cause of her death. The Council acknowledged the delay in completing the safeguarding investigation and said it would take action to ensure it deals with future referrals in a timelier manner.
  3. Mr X and Mr Y remained unhappy and complained to the Ombudsmen.

My findings

  1. The Ombudsmen’s investigation found that Mrs F’s placement was provided as section 117 aftercare. The CCG was not involved in the Council’s investigation of Mr X’s and Mr Y’s complaint but had a joint responsibility for the placement as outlined in the Mental Health Act 1983. Therefore, the Ombudsmen have considered both the Council and the CCG as named authorities in this investigation.
  2. The Council carried out a detailed safeguarding investigation and I have already outlined its findings in paragraphs 29-33 The purpose of the safeguarding investigation was to look at safeguarding issues. However, the investigation picked up several areas where the Care home failed in its general care of Mrs F. It concluded that the Care home was slow to respond to Mrs F’s pressure sores and found Mrs F suffered poor care in general. That was fault and I find on balance that the poor care contributed to a decline in Mrs F’s health which led to her admission to hospital. It caused Mr X and Mr Y distress and left them with the knowledge that the care she received in the weeks before her death was not good enough.
  3. The Care home has outlined the serve improvements it has put in place to prevent similar incidents occurring in the future and to minimise pressure damage to its residents. It has implemented robust pressure sore assessments and care plans and ensures relevant equipment is in place before residents are admitted. All areas of pressure concern are now immediately photographed and reported to the duty nurse or the district nurse. I am satisfied the Care home has put in adequate improvements in how it cares for pressure sores following the conclusion of the safeguarding investigation in March 2019.
  4. The safeguarding investigation itself was detailed, robust and considered the relevant records and information from the Care home. However, the investigation took too long and the conclusion of it was significantly delayed. The records show there were no measurable timescales and most actions had simply ‘ASAP’ rather than a measurable timescale for completion. This contributed to the delay and caused the enquiry to drift. That was fault and caused Mr X and Mr Y distress and uncertainty. The Council now has new procedures in place, so the allocated officer keeps the safeguarding enquiry from the start to maintain consistency.

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Agreed actions

  1. The Council and the CCG had a joint responsibility for Mrs F’s placement as it was provided under the terms of section 117 of the Mental Health Act 1983. Therefore, they remain responsible for aftercare provided to Mrs F. So, although I found fault with the actions/service of the Care home I made recommendations to both the Council and CCG.
  2. The Council and the CCG agreed to jointly, within one month of the final decision:
    • apologise to and pay Mr X and Mr Y £150 each for the distress caused to them by the poor level of care Mrs F received at the Care home which they jointly commissioned for section 117 aftercare during April 2018
  3. The Council agreed, within one month of the final decision to:
    • pay Mr X and Mr Y £100 each to acknowledge the distress and uncertainty caused by the significant delays in carrying out and concluding its safeguarding investigation.
    • remind its staff who carry out safeguarding investigations that actions should be SMART (specific, measurable, achievable, realistic and timely) with measurable timescales to help ensure similar delays do not occur in the future.

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Final decision

  1. I have completed my investigation. I found fault and the Council and the Clinical Commissioning Group agreed to my recommendations to remedy the injustice caused by the fault.

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Investigator's decision on behalf of the Ombudsman

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