Summary: Mr D complained how the Council’s care home dealt with his mother when she was a resident. He also complained the complaints handling was poor, and he was not warned about his unreasonable behaviour until receiving a response to his complaint. We find fault with how the care home dealt with Mr D’s mother’s mobility needs. The Council was at fault with how it dealt with Mr D’s complaint, and there was a failure to consider whether to pursue a more informal route before applying a restrictive action for Mr D’s unreasonable behaviour. The Council has agreed to our recommendations to address the injustice caused by fault.

The complaint

1. Mr D complained how the Council’s care home dealt with his mother (Mrs E) when she was a resident. He says the care home failed to adhere to Mrs E’s mobility needs and it failed to properly deal with incidents that took place. He also says the care home failed to be open and transparent about why Mrs E’s care changed from 1:1 to 2:1. Finally he says the Council’s complaints handling was poor, and it told him his behaviour was disrespectful in the complaint response without any previous warnings.
2. Mr D says the matter has had a detrimental impact on himself and Mrs E.

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The Ombudsman’s role and powers

3. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
7. 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

8. I considered information from Mr D. I made written enquiries of the Council and considered information it sent in response.
9. Mr D and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant legislation

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
11. Regulation 9 says care and treatment must be appropriate and meet service users’ needs.
12. Regulation 17 says care providers should maintain an accurate, complete, and contemporaneous records in respect of each service user.

The Council’s unreasonable contact and customer behaviour guidance note

13. The Council has a guidance note for unreasonable contact and customer behaviour. The Council’s care home adopts this guidance. Unreasonable customer behaviour occurs where:

• The contact may be amicable but place very heavy demands on staff time or may be emotionally charged and distressing for all involved.
• There is an escalation of behaviour which is unacceptable, for example abusive, or threatening language or behaviour.

14. The Council will consider whether further action is necessary before deciding a customer’s behaviour is unreasonable. This could include offering the customer a meeting to explain why their behaviour is unreasonable or sharing this guidance with the customer and warning them restrictive action may need to be applied if their behaviour continues.

What happened

15. This chronology provides an overview of key events in this case and does not detail everything that happened.
16. Mrs E became a resident at a care home owned and run by the Council in December 2023. She transferred from another care home following a hip replacement.
17. Mr D visited Mrs E and spoke to a member of staff a few days later. He said Mrs E had extensive therapy input when she was at the previous care home. He said she could walk up to 10 metres with a wheeled zimmer frame with the assistance of one person. A second person pushed a wheelchair behind her for safety. The member of staff said they would need someone to show staff involved in Mrs E’s care how to complete the walking exercises.
18. An occupational therapist (OT) visited from the previous care home and showed staff how to complete the walking exercises. The care home updated Mrs E’s care plan and noted her mobility varied from day to day. It noted Mrs E’s goal of practicing walking twice a day with the support of staff.
19. Mr D spoke to a member of staff at the care home in late December. He said he was concerned Mrs E had not had any walking exercises for several days. The care home said it would complete an occupational therapy referral for Mrs E. It spoke to Mrs E and said it would try its best to reach her mobility goals.
20. The care home sent a referral to an OT in early January 2024. It also spoke to Mr D. It said Mrs E needed two staff to complete her tasks. It said it was happy to complete her tasks but two staff completing the exercises was time consuming and affecting the care needs of other residents. It also said Mrs E was complaining about painful knees after walking. It agreed to ask Mrs E’s GP to arrange X-rays of her knees. Mr D said he would arrange for a private physiotherapist to assess Mrs E after he had received the X-ray results. The care home said it would continue to encourage Mrs E with the exercises until it received the X-rays and the physiotherapist’s outcome.
21. The GP prescribed Mrs E pain management for her knees. An OT assessed Mrs E in mid-January. They recommended that Mrs E’s recliner chair could be brought in from home to support her standing up before walking practice.
22. An incident (Incident A) took place between Mrs E and a member of staff in late February. Mrs E said the member of staff moved a table too close to her, refused to move it when she asked and then lost his patience. The manager went to speak to Mrs E after the incident. She said she had spoken to the member of staff. She also said she had asked other members of staff to come in pairs while the care home monitored the situation. The care home’s notes indicate Mrs E was happy with this decision.
23. Mr D emailed the care home and said his understanding was it had asked staff to visit Mrs E in pairs because of Incident A. He said Mrs E felt humiliated and upset with this decision. Mrs E also spoke to a member of the staff directly and said she was upset. The care home told Mrs E it is normal practice for two members of staff to be present when using equipment for safety reasons. It said one person would deal with all her other care.
24. The care home had a meeting with Mr D to discuss Mrs E’s welfare, her progress with walking and Incident A. Mr D asked for the member of staff involved in Incident A to visit Mrs E to resolve the situation. The care home agreed in the meeting to walk Mrs E three times a day. Mr D said also said he was unhappy about staff visiting Mrs E in pairs. He disputed it was to do with manual handling. A manager reassured Mr D the care home had assessed Mrs E as needing two carers to help her with transfers.
25. The care home’s notes state the member of staff involved in Incident A visited Mrs E. Both parties expressed regret with what happened, and they were happy it was now resolved.
26. Mr D sent several emails to the care home and said it had failed to follow through with the agreement to walk Mrs E’s three times a day. The manager responded and apologised a staff member had agreed to walk Mrs E three times a day. She said staff would walk Mrs E when they could in consideration with other residents and staffing levels. She said the care home provided residential care and not reablement. She said Mrs E would benefit from care in a reablement unit. Reablement is a form of intermediate care which focuses on helping someone to learn or re-learn necessary skills for daily living.
27. Mr D sent a formal complaint to the Council. He said care home staff failed to walk Mrs E. He also said the care home had taken inappropriate action when there was an internal issue with a member of staff.
28. The care home updated Mrs E’s risk assessments on her mobility and safety needs. It noted Mrs E could be supported to transfer safely with one member of staff, who was confident and experienced, but a second member of staff could be present if necessary. One member of staff would carry out Mrs E’s personal care.
29. Mr D continued to raise concerns about staff visiting Mrs E in pairs. A member of staff spoke to Mr D and explained when incidents happen the ratio of staff can change to protect residents and staff. She said the care home had updated Mrs E’s moving and handling assessments, but some staff preferred to go in pairs due to their height and confidence.
30. Mr D was visiting Mrs E when he reported a further issue (Incident B) to the manager. He said a member of staff refused to have eye contact with Mrs E, and when Mrs E started talking they told her to stop shouting. The manager said she would speak to the member of staff. The care home told Mrs E it would start going to her room in pairs again because of the allegations and to protect her and its staff.
31. Mr D had an altercation (Incident C) with a member of staff. He said the member of staff was ignoring him, gave him an unpleasant look and then shouted at him. The care home’s notes of this incident state it was unwitnessed. Both Mr D and the member of staff discussed the incident with the manager. The manager told the member of staff not to engage in an argument.
32. Mr D contacted the Council and said he wanted to add how the care home handled Incidents B and C to his complaint. He said Mrs E’s welfare was suffering.
33. The Council responded to Mr D’s complaint in early May. It said it had spoken to the member of staff who was involved in Incident B and a witness. They had a different version of events to Mrs E. Therefore, it did not uphold the complaint, but it had reminded staff about the need to be respectful when interacting with residents. It upheld the complaint about the behaviour of the member of staff in Incident C. It said it would review the matter during a supervision session with the member of staff, but it could not share details of internal disciplinary matters with him. Finally, it said it did not tolerate bullying or harassment towards its staff. It said his behaviour at recent meetings had not been respectful. It said if he did not moderate his behaviour, it would have the consider the terms of his visits. It also said meetings where individuals he complained about were present was not an appropriate way to manage his complaints. It said it would not have any further meetings with him about such matters.
34. Mr D emailed the Council and said it had not addressed Incident A or its failure to walk Mrs E in its response. The Council responded and said he did not raise Incident A in the initial complaint. It asked Mr D to specify what the issue was. Mr D responded and said he mentioned Incident A in his complaint form.
35. Mrs E is no longer a resident at the care home.

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Analysis

Failure to adhere to Mrs E’s mobility needs

36. The care home initially agreed to try and walk Mrs E twice a day. I have checked the care home’s records. They do not consistently show staff attempted, or completed, the exercises every day. There were some occasions when staff tried to complete the exercises and Mrs E was in pain or she was too tired. However, there are also large gaps in the records, and it is not indicated whether a walk was offered or not. This was not in line with Mrs E’s care plan and not in line with Regulations 9 and 17 of the CQC guidance.
37. The care home later agreed to walk Mrs E three times a day and then subsequently apologised for this and said it was not possible. It said it would try and walk Mrs E as often as it could. I have looked at the care home’s records after this and they are still inconsistent with whether staff offered Mrs E everyday as stipulated in the care plan.
38. The care home’s failure to follow the care plan and its inconsistent record keeping provides Mrs E with significant uncertainty about her mobility needs and whether they may have improved. There is also an injustice to Mr D. He was caused frustration and uncertainty about Mrs E’s mobility. He has also explained he had to take time out of his day to walk Mrs E to ensure she was meeting some of her mobility needs. This put him to some inconvenience, and it could have been avoided if the care home had not been at fault.

The care home’s handling of the incidents

39. The care home spoke to Mrs E about Incident A and had a meeting with Mr D. The member of staff involved in the incident went to speak to Mrs E and both parties agreed it was resolved. This was an inappropriate way to handle the incident when no one else saw what happened. I do not find fault.
40. The care home asked the member of staff involved in Incident B for their version of events. It also asked a witness to the incident to provide their account of what happened. Both parties accounts differed from what Mrs E had said. The Council addressed this in the complaint response and said it could not uphold the complaint, but it would remind staff to be mindful when interacting with residents. This was an appropriate response. I do not find fault.
41. The Council acknowledged the member of staff’s behaviour was wrong during Incident C, and it would raise it with them in a supervision session. I consider that was an appropriate way to address it with the member of staff. It is under no obligation share its internal disciplinary process with Mr D. However, the Council failed to apologise to Mr D for the upset caused to him. It should now do so.

Mrs E’s care changing from 1:1 to 2:1

42. Mr D says the care home failed to tell him or Mrs E it changed Mrs E’s care to being in pairs because of Incident A. He says the management told him it was because of manual handling.
43. The records show the care home told Mrs E it would change her care from 1:1 to 2:1 while it monitored the situation after Incident A. The care home’s notes also suggest manual handling was an additional reason for this change, as some staff were uncomfortable transferring Mrs E on their own.
44. The care home initially told Mr D staff were visiting Mrs E in pairs because of manual handling. However, it later clarified this and also explained to Mr D when incidents happen it can change the staff ratio to protect the residents and staff. I do not consider this was unreasonable. It appears the decision to change the ratio of staff was twofold, and the care home cleared up any confusion with Mr D. I do not find fault.

Complaints handling

45. Mr D raised the issue of the care home failing to walk Mrs E in his complaint. He also raised this issue again when he received the Council’s response to his complaint. The Council failed to address this issue at all. This is fault.
46. Mr D says the Council failed to address Incident A. Mr D did not explicitly refer to Incident A in his complaint. However, he did mention it in his follow up correspondence. I cannot see the Council addressed this matter. This is fault.
47. As mentioned in paragraph 41 of this statement, the Council upheld Mr D’s complaint about the member of staff involved in Incident C, but did not acknowledge his injustice or offer a personal remedy. This is fault.
48. The Council’s faults caused Mr D frustration, and he was put to time and trouble repeating himself.

Warning about Mr D’s behaviour in the complaint response

49. Mr D says he was unaware staff were unhappy with his behaviour until he received the Council’s complaints response. In response to my enquiries, the Council said Mr D’s approach could be described as confrontational and staff reported feeling uncomfortable and intimidated after their interactions with him. Therefore, it decided to warn Mr D in the complaint response.
50. I have not seen any evidence the care home/Council considered applying the guidance referred to in paragraph 14 of this statement before deciding Mr D’s behaviour was unreasonable and applying a restrictive action (declining meetings to discuss his complaint). This is fault. This caused Mr D frustration, and he lost the opportunity to address his alleged unreasonable behaviour before it applied the restrictive action.

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Agreed action

51. 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. In this case the Council owns and runs the care home. Therefore, I have made recommendations to the Council.
52. By 17 February 2025 the Council has agreed to:

• Apologise to Mr D and Mrs E for the injustice caused by fault in this statement.
• Pay Mrs E £250 to reflect her uncertainty.
• Pay Mr D £300 for his frustration, time and trouble, inconvenience and uncertainty.

53. By 17 March 2025 the Council has agreed to:

• Issue written reminders to staff in its care home to ensure they are aware they must maintain accurate and complete records for all service users.
• Issue written reminders to staff in its care home to ensure they must adhere to a service user’s care plan.
• Issue written reminders to staff who deal with complaints to ensure they respond to all issues a customer has raised.

54. The Council should provide us with evidence it has complied with the above actions.

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Final decision

55. There was fault by the Council, which caused Mr D and Mrs E an injustice. The Council has agreed to my recommendations and so I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman