An elderly man’s health significantly deteriorated after Worcestershire County Council moved him from a nursing home to a less suitable care placement, a Local Government Ombudsman investigation found.

The man, who had dementia, diabetes, epilepsy and a history of stroke and heart problems, was living at a care home in the county, where he was settled. The man had limited mobility and needed help from carers to get around, was doubly incontinent and needed support with his medication, eating and drinking.

He had limited communication and, because of his dementia, often displayed challenging behaviour. The home provided the man with a quiet space to calm him when he became agitated.

However, when the area’s NHS Trust removed his funding, Worcestershire County Council sought an alternative, less expensive placement for him, despite its own assessment concluding that a move would be detrimental to his health and well-being.

The man’s family could not afford to pay the top-up to keep him at the home. Council officers failed to give the family correct information on ‘top ups’ and did not consider if the council should continue to fund his care there even though it could have done so.

The alternative accommodation that the council found was not suitable, and within 10 days of the move in early November 2011, the man’s condition had deteriorated.

Less than a month after his move, the man’s son complained to social workers that he had developed pressure sores, was being fed pureed food and had been found in bed fully clothed and covered in sweat with two pillows nearly covering his face. He also told social workers that his father may not have been having skincare checks and bed changes, and that notes were missing from his records. Additionally, his father was being returned to his room regularly because he was ‘shouting out’.

However, social workers never completed a safeguarding investigation. A month later – and less than two months after the father moved to the new care home – he was admitted to hospital for pneumonia and dehydration and died in hospital in January 2012.

The son complained to Worcestershire County Council about his father’s situation, but it failed to investigate under the statutory complaints process. Officers did undertake some investigations under the adult safeguarding process but that investigation was found to be inadequate. The second care provider did undertake some investigation work, but this too was found to be incomplete.

Dr Jane Martin, Local Government Ombudsman, said:

“Worcestershire County Council’s social workers ignored their own recommendations which stated that any move would have a detrimental effect on the man’s health and well-being and should have considered if any move should take place in these circumstances.

“While I cannot say that the new home and carers themselves caused the man’s condition to deteriorate, it is significant that the his condition did worsen once he was moved.

“The council should have done more to check that the placement at the second home was suitable, and officers should have done more to follow up the son’s concerns.

“I would like to remind councils that while they can contract out care for the elderly to private homes such as this, they cannot contract out the responsibility.

"In cases such as these, the actions of the care provider in carrying out these arrangements shall be treated as actions of or on behalf of the council.

"While you cannot put a price on the loss of a loved one, I have recommended a financial payment to the family in recognition of the stress and strain this situation must have placed them under."

A copy of the ombudsman’s report has been sent to the Care Quality Commission.

The council has agreed to review a number of procedures to make sure the situation does not happen again. It has agreed to conduct a review of the understanding among relevant officers of the Choice of Accommodation Directions 1992 and arrange for any training required, introduce a procedure to manage cases where residents of residential care become eligible for council funding of placements.

The council will also conduct a review to check all social care staff have basic awareness on how to identify a complaint, the social care complaint procedure and its interaction with adult safeguarding procedures; arrange any training required and review standard contract arrangements with care providers with regard to complaint handling

The council has also agreed to apologise and pay the complainant £1,500 in recognition of the distress caused to him and his mother and the time and trouble in pursuing the complaint.

Article date: 28 January 2014