Summary: Mrs C complained her husband was able to leave the care home without staff noticing it. We have upheld the complaint.

The complaint

1. The complainant, whom I shall call Mrs C, complained about the way the care home acted on the day her husband went into the care home for respite care. She said the care home had booked him on the wrong day so there was no room available on arrival. She said he was then offered an unsuitable room as a temporary solution.
2. Mrs C is also unhappy her husband mentioned to leave the care home unnoticed, walking 2km to his home, which put him at serious risk. She said that when the care home found out, it failed to inform the family. Mrs C said this was very distressing when she found out.

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What I have and have not investigated

3. I have not investigated the complaint about what happened on the day of Mr C’s arrival at the care home. The care provider has investigated this and apologised already for any distress. As such, I found that further investigation into this would not be able to achieve anything else.

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The Ombudsman’s role and powers

4. 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)
5. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide we could not add to any previous investigation by the organization (Local Government Act 1974, section 24A(6), as amended)
6. If we are satisfied with an organisation’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)

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How I considered this complaint

7. I considered the information I received from Mrs C and the care provider. I shared a copy of my draft decision statement with both parties and considered any comments I received, before I made my final decision.

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What I found

8. Mrs C complained her husband left the care home unnoticed when he stayed there for a few days of respite care. She said that:
• Vulnerable residents should be prevented from leaving the care home unnoticed.
• The care home should have noticed, in the hour he was away, that her husband was missing.
• The care home failed to tell her daughter (Mr C’s emergency contact) as soon as they found out.
9. Mr C left the care home unnoticed and walked 2km back to his former home, where he was spotted and helped by a neighbour at 4.55pm. The neighbour called the care home to tell them they had found Mr C. The neighbour also told Mrs C by text, which she received when she arrived back in the UK that same day.
10. In response, the care home put Mr C on hourly observations to ensure that staff would know of his whereabouts at all times.
11. In response to my enquiries, the care provider has said that:
• It only had the home telephone number for Mrs C, not her mobile number. It tried to call Mrs C’s daughter but the number it had was incorrect. The contact details on the system show there is only a telephone number for Mr C.
• Staff were interviewed and various staff members observed Mr C in the quiet TV lounge between 3:45pm and 4:15pm. Mr C was able to walk back to his room without staff support and was not on regular checks due to his level of independence.
12. The care provider investigated the incident at the time and said that it was not possible to determine, for sure, how Mr C escaped. It said that:
• One way through which he may have escaped was when he was in the garden. The patio doors to the garden are locked with a key code and an engineer has established they are not faulty. Staff have also been told that residents should not be left alone in the garden. Alternatively, a staff member could have left the patio door open. As such, it has reminded staff of the importance to close doors behind them.
• Another option was through the front entrance. It said there is a 3 second delay when closing the front door to lock. As such, it has asked an engineer to see if this can be addressed. It has also added signs to remind anyone entering and leaving to check the doors are locked and secured and no resident is following them in/out.
13. Mrs C says that, even though her husband was not hurt in the event, it has been very distressing for her to find out her husband could have come to serious harm as he is disorientated and had to cross several very busy roads to go home.
14. The care provider told me it completely understands Mrs C’s concern following this incident, and it would like to offer its sincere apologies again that this happened.

Analysis

15. I found the care home was at fault for Mr C being able to leave the care home unnoticed.
16. The care home also failed to ensure that it had properly recorded the contact details for Mr C’s family. As such, it failed to contact his family following the incident.
17. The care home took appropriate actions in response to the incident.

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Agreed action

18. I recommended the care provider should, within four weeks of my decision:
• Apologise to Mrs C for the fault mentioned in paragraph 15 and 16.
• Share the lessons learned in response to this fault with relevant staff members and remind them of the importance of ensuring the contact details are correct and complete.
19. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

20. For reasons explained above, I decided to uphold the complaint.
21. Under our information sharing agreement, I have shared this decision with the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman