Summary: Care provided to Mr X at a residential care home, on behalf of the Council, was below an acceptable standard. A safeguarding investigation completed by the Council into complaints raised about the care was insufficient.

The complaint

1. Mrs X complains about the quality of care provided to her husband during a respite stay at Cedar House Residential Care Home, between November 2022 and December 2022. The placement was arranged and funded by the Council.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I have:

• considered the complaint and discussed it with Mrs X;
• considered the correspondence between Mrs X and the Council, including the Council’s response to the complaint;
• made enquiries of the Council and considered the responses;
• considered relevant legislation;
• offered Mrs X and the Council an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

5. 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 Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. These include:

• Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
• Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

6. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect; and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

7. If the section 42 threshold is met, then the council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

Key facts

8. Mr X is in his seventies. He has physical health problems and a progressive illness resulting in gradual vision loss which can cause him to experience hallucinations.
9. Mr X went into the care home on 4 November 2022 for emergency respite care due to Mrs X’s own ill-health.
10. I have had sight of an admission form completed by care staff on 4 November 2022. The document lists Mr X medical conditions, including diabetes. It also records his wish to be cared for in bed. He was reported to be able to communicate effectively and had no issues with cognition, that he could make his own decisions to accept/refuse care, and that care staff should document any refusal of care. A risk assessment was also completed the same day and reviewed again on 22 November 2022.
11. Under ‘skin condition’ the admission form records Mr X to have no open pressure areas, but he had several superficial skin abrasions to toes and legs, and that the district nurse should be contacted with any concerns.
12. Under ‘specialist equipment’ it records air-flow mattress as ‘needed’ as was a bedside table.
13. Mrs X says Mr X was not provided with an air-flow mattress. The Council says an air-flow mattress was in situ and this was noted on the pre-admission form. Whilst the form does record such a mattress was required, it does not confirm one was provided. The care home says an air flow mattress was provided, and the district nurse could verify this.
14. Mrs X says that during his stay Mr X sustained injuries to his thighs and toes, and that she was not informed about this. Mrs X provided this office with photographs of bruising to Mr X’s skin and the poor condition of his toe. She says a dressing that had been applied to his toe was dirty. She says there are some discrepancies in the care homes records of visits from a district nurse. She believes some visits were not recorded by care staff.
15. The daily care records show care staff noted Mr X’s right foot was ‘sore’ on 12 November 2022 and that the district nurse was contacted the following day. Care staff photographed the sore and added it to Mr X’s care record. The district nurse attended the same day and concluded no dressing to Mr X’s foot was required. The district nurse recorded she would refer Mr X to a podiatrist.
16. The Council says Mr X did not receive a visit from a podiatrist because the referral was not completed until the day Mr X returned home on 2 December 2022.
17. The records show further entries in Mr X’s daily care record on 14, 21 and 23 November 2022. These document a grazed knee, sore groin, and further concern about Mr X’s right foot. On each occasion the records show care staff contacted the district nurse and Mr X’s GP.
18. Mrs X says the care home did not install cot sides on Mr X’s bed and consequently he fell out of bed. The Council says cot sides are not usually provided unless specifically requested and agreed by district nurses. The admissions form records cot sides refused by district nurse. It is unclear when, and on what basis, a district nurse would have come to this conclusion, as Mr X was not seen by a district nurse on the day of admission.
19. The records show Mr X fell from his bed on 28 November 2022 and was hoisted back into bed. Care staff completed an accident form. Mrs X believes Mr X had another unrecorded fall from his bed.
20. In response to my enquiries, the care provider said the social worker’s assessment of Mr X did not state cot sides were required. I have seen no record from the district nurse confirming this.
21. The care home says it placed a second soft mattress against the wall to prevent Mr X knocking/scratching his legs against the wall. The care home says Mrs X was made aware of this.
22. Mrs X says at some point the care home placed Mr X’s mattress on the floor and he was then unable to reach his drink from his bedside table and his urine bottle. The care home refutes this and says the mattress placed on the floor was to prevent Mr X injuring himself should he fall from his bed. It says Mr X did not sleep on this mattress.
23. Mrs X says the care home registered Mr X with a new GP practice without informing her, and that this caused difficulty when Mr X left the care home and returned home. She says Mr X returned home without his medication and she was put to a great deal of trouble obtaining replacement medication.
24. The care home says it gave Mr X’s medication to the ambulance staff that transported Mr X home.
25. Mrs X also says the care home charged her £18 for a taxi for its carers to pick up Mr X’s medication from a pharmacy.
26. Mr X made a complaint about the care he was receiving at the care home on 25 November 2022. The care home referred this to the Council’s safeguarding team the same day. The Council allocated a social worker to investigate the complaint, following which a further five safeguarding allegations were recorded by the social worker.
27. The Council investigated the allegations under its safeguarding procedures. It says because of the number of safeguarding referrals it recorded each one separately, some of which were substantiated, partially substantiated and some were unsubstantiated. Because of this the Council concluded the overall outcome was partially substantiated.
28. The allegation substantiated and partially substantiated related to:
1. Conflicting information provided in respect of a referral to podiatry for the management of Mr X’s toe and the dressing of the toe by care home staff.
2. As part of its investigation, the Council made enquiries of the care home and district nursing team. The Council noticed some discrepancy around the dates Mr X was said to have been referred to podiatry. The district nursing team confirmed the attending nurse had informed staff the referral would be done on 13 November 2022, but it was not completed until 2 December 2022.

• The Council concluded the care home should have monitored the wound and had a wound care plan in place.
• The grazes were caused because of Mr X’s bed being placed next to a wall. Mr X has not had cot sides in situ because it had not been authorised by the district nurse. The Council concluded the care home should have sought a better solution.
3. Falls from bed due to no cot sides in place.
• The Council concluded Mr X had fallen from his bed and care staff had completed an accident form. It found Mrs X had not been informed and on that basis, only the complaint was partially substantiated.

29. I have seen no evidence which shows the Council enquired why cot sides had not been approved by the district nurse, or indeed if the care home had requested such an assessment. It also appears the Council failed to enquire as to why cot sides were not considered after the fall. I have also seen no evidence the Council confirmed every visit made by the district nursing team.
1. The care home charged Mrs X £18 for a taxi to collect medication from a pharmacy to be delivered to the care home.

• The Council found this action to be inappropriate.
2. The care home registered Mr X with a new GP practice without informing Mrs X.
• The Council concluded Mr X’s GP should not have been changed. His stay was respite only. The change in GP caused additional stress for the family on Mr X’s return home.

e) Mr X was not sent home with his medication.

• The Council reiterated the care home’s response, that care staff had given the medication to the ambulance staff. However, it partially upheld this point because the change in Mr X’s GP caused the family unnecessary difficulty replacing the medication.

30. The Council appears not to have sought records from the ambulance service to confirm if ambulance staff had received Mr X’s medication from the care home. It accepted the care home’s version of events without question.

f) Management of Mr X’s weight during his stay at the care home

• The Council concluded the care home had failed to record Mr X’s weight at the outset of his stay and consequently the Council was unable to determine if Mr X had lost weight during his stay.

31. The Council concluded the following allegations to be unsubstantiated:

• A file sent home with Mr X contained no information.
• Care staff ignored Mr X’s buzzer calls for toilet assistance.

32. In response to my enquiries, the Council said at the time of Mr X’s stay the care home was “…not following the SKKIN bundle recommendations appropriately which should be paper based… management is no longer employed in the company due to many areas of concern at the time of this complaint. [staff member] advised they have made several improvements with change of staff, electronic records and documentation to avoid similar issues raised from [Mrs X’s] complaint.
33. The care home says “…lessons have been learned have been shared with all staff which include:

• The need for timely interventions
• The names of external visiting professionals and follow up plans to be recorded to ensure that agreed actions completed.
• Care home staff will not change the registered GP practice when residents are placed in the care home for respite care.

34. The Council provided Mrs X with a final complaint response on 23 January 2023. I have had sight of the letter. There is no reference to the safeguarding investigation nor its conclusions. The Council’s response to some points does not reflect the outcome of the safeguarding investigation. For example, in response to the complaint about the care home charging a taxi fee to collect Mr X’s medication from the pharmacy, the Council said, “The care home have indicated that this was in fact to collect his prescribed medications as the home could not deliver these on this occasion due to their own staff shortages”. In response to the change in Mr X’s GP, the Council said, “The care home have advised they do this on a new resident entering the home as the home is aligned to a particular GP service… The home advise they not intend for this to cause any upset and will review this internally going forward”.
35. Mrs X is dissatisfied with the Council’s response.

Analysis

36. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them.
37. People are entitled to safe, effective and high-quality care. In Mr X’s case, the care provided fell short of the required standards and failed to reach the Care Quality Commission’s fundamental standards particularly in terms of person-centred care.
38. The failings by the care home resulted in avoidable injury, discomfort, and distress to Mr X.
39. I find the Council’s safeguarding investigation into the complaints about the care to be lacking. The Council relied heavily on the care home’s own internal probe into the concerns and failed to cross check some information. For example, the Council failed to establish if, when, and on what basis the district nursing team decided cot sides were not appropriate for Mr X’s bed. The Council also failed to establish if Mr X had the use of an air mattress. In response to my enquires, the Council referred to the care home’s admission assessment as evidence such a mattress was provided. The assessment only refers to the need for an air mattress, there are no records to show one was actually provided.
40. Any safeguarding investigation into a complaint about poor care in a residential setting should consider the possible wider implications for other residents. It is imperative that councils cross reference information/evidence provided by care providers to avoid any possible systemic failings in care provision being missed.
41. The Council’s final written complaint response to Mrs X was also lacking. Its findings on some points did not reflect the findings of the safeguarding investigation. The Council appears to explain and defend the care home’s position rather than setting out the failings highlighted in the safeguarding investigation. This added to Mr and Mrs X’s frustration and sense of injustice.

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Agreed action

42. The Council will, within four weeks of the final decision:

• apologise for the poor care provided by the care home, and the insufficient safeguarding investigation undertaken by the Council;
• pay Mr X £500 in acknowledgement of his discomfort and distress caused by the poor care;
• pay Mrs X £250 to acknowledgment her time and trouble pursuing the complaint. The Council should also reimburse Mrs X for the £18 she paid the care home for a taxi to collect medication;
• consider training and guidance for staff on completing safeguarding investigations;
• show how it has ensured the recommendations it made to the care home following the safeguarding investigation have been implemented.

43. The Council should provide this office with evidence it has complied with the above actions.

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Final decision

44. The care provided to Mr X at a residential care home on behalf of the Council was below an acceptable standard.
45. The Council’s safeguarding investigation into the complaints raised about the care was insufficient.
46. The above recommendations are a suitable way to remedy the injustice caused.
47. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman