The Council failed to monitor whether the placement was meeting the woman's needs.

Local Government Ombudsman, Dr Jane Martin, has today issued a report criticising the way Bristol City Council dealt with the care of an elderly woman living in a residential care home. The Council failed to monitor whether the placement was meeting the woman’s needs. The Ombudsman says, “I find this particularly troubling in view of the number of serious safeguarding alerts the Council was receiving throughout the time she was a resident,” and added, “Had more robust action been taken by the Council, then the poor standard of care and treatment she received may have been detected far sooner.”

Mrs J, an elderly lady with dementia who requires 24 hour care, was resident in a care home in Bristol. The placement was partly funded by the Council (Mrs J also made a contribution to the cost). During 2008, the social care regulator, Care Quality Commission (CQC, then Commission for Social Care Inspection, CSCI) rated the care home as a zero, meaning that the service users experienced poor quality outcomes. The complainant’s son, Mr J, said that the standard of care his mother received during this period of time was poor and of great concern to the family. He was not informed of the zero rating by the Council.

Mr J eventually felt it was necessary to move his mother to alternative accommodation – identified by the family – following a particularly appalling incident at the care home. The cost of the placement at the new care home was more than the Council would usually fund, and Mr J felt he had no other choice than to make a ‘third party contribution’ to the cost. Mr J complained to the Council about the poor standard of care at the initial care home, the lack of support and advice he had received from the Council about moving his mother to another placement and the financial contribution he had made for the new placement.

The Council’s own investigation made a number of findings and reported that Mrs J had not had her personal care needs met for a number of months and that this had impacted negatively on her health and wellbeing. However the investigation concluded that the Council had taken appropriate action to safeguard Mrs J. The report recommended a number of improvements to procedures which included informing relevant individuals when care homes had been zero rated. The Council apologised for the shortcomings and provided Mr J with a copy of its action plan to improve services.

The Ombudsman considers that there was maladministration in the Council’s reviewing and safeguarding strategy and is concerned about the poor communication between the Council and the family. The Ombudsman also finds that the Council had not properly considered the circumstances around Mrs J’s move to an alternative placement, which had led to Mr J contributing to the cost.

Although the Council’s investigations did reveal faults, it appears that the responsibility for the poor standard of care had been attributed directly to the care home. As the commissioner of the service that Mrs J received, the Ombudsman concludes that the Council was responsible for the poor service received, which led to both Mr and Mrs J being caused significant distress.

The Council has informed the Ombudsman that it has implemented further procedural improvements to address the difficulties highlighted in this investigation and has agreed to review its action plans in light of this report. The Council has also agreed to the following actions:

• provide an apology for the faults identified in this report
• make a payment of £500 to Mr J in recognition of the distress he has suffered and his time and trouble in pursuing the complaint
• pay financial compensation to Mr J equivalent to any contributions that he made towards his mother’s care costs for the period February 2009 to October 2009 in recognition of the failings that led to the move to Orchard House, and
• make a further financial award to Mrs J of £6,000 in recognition of the Council’s failings in providing a suitable standard of care and in failing to protect her under its safeguarding procedures.

The names used in the report are not the real names, for legal reasons.

Report ref: 09 005 944

Article date: 17 June 2011