Summary: Mr X complained about the care his son, Mr Y, received at a Council commissioned residential home he lives in. There has been a failure to follow the care plan in place for Mr Y. The Council will apologise, make a payment to recognise the injustice caused and take action to prevent the fault recurring.

The complaint

1. Mr X complained about the care his son, Mr Y, received at the Council commissioned residential home he lives in. Mr X complained:

• The Care Home has failed to follow Mr Y’s care plan at night;
• The Council has failed to investigate his safeguarding concern properly; and
• The fire exit steps do not conform to safety standards.

2. Mr X says that he has been upset his son is not receiving the care required. He is concerned that this will be causing some confusion for his son.

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What I have and have not investigated

3. I have investigated Mr X’s complaints about the safeguarding investigation and the night care plan. I have not investigated Mr X’s complaint that the Care Home has failed to ensure the safety of the fire exit steps. Mr X has not suffered an injustice. Further the Council has already agreed to fix the steps.

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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, and must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• any fault has not caused injustice to the person who complained, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6))

6. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
7. We normally name care homes and other 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)
8. 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

9. I spoke to Mr X about his complaint and considered the Council’s response to my enquiries.
10. Mr X and the organisation 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

Law and guidance

11. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
12. 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. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safeguarding from abuse (Regulation 13): Service users must be protected from abuse and improper treatment, this includes neglect.

What happened

13. Mr Y is an adult who has a medical condition, learning difficulties and is non-verbal. He lives in a residential home and has done for some time. It is operated by a care provider called Achieve Together Limited. I have not provided the exact location as it could potentially lead to Mr Y being identified.
14. Mr X installed a camera in Mr Y’s bedroom in 2015. He reviewed the footage on a weekly basis to check on his son’s care.
15. Mr Y has a care plan. Mr Y needs assistance due to his learning difficulties. His health conditions mean he must keep well hydrated and drink regularly. Mr Y is continent during the day but began wetting the bed at night more regularly. The current care plan was issued in July 2021 following concerns about the bed wetting. It states that Mr Y should be checked every two hours once he has gone to bed until 8am. During checks staff should check if the toilet has been used. Staff should record the time, what Mr Y is doing and whether the toilet has been used. Further it states Mr Y should be reminded to go to the toilet at 3am. Mr Y has not been prescribed any incontinence aids and is able to go to the toilet independently.
16. In June 2021 Mr X raised concerns about Care Home staff not following the night care plan. The same month the Council enquired about making a referral to the continence clinic regarding Mr Y. He raised further concerns in August 2021 about the care plan not being followed.
17. The Council raised the concerns with the manager who agreed to address these concerns and increase supervision of staff working with the night time care plan.
18. The Council offered Mr X the option of moving Mr Y to a new home in January 2022. Mr X declined this offer.
19. In mid March 2022 whilst a member of staff was administering Mr Y’s drugs they dropped the cabinet keys whilst opening it. The cabinet is located near Mr Y’s chair where he was sat at the time.
20. In late March 2022 Mr X reported concerns that a member of staff from the Care Home had dropped the keys on Mr Y after reviewing the video. He asked the Care Home to check if Mr Y had sustained any injury to his legs or feet. Following the report a GP inspected Mr Y’s legs and feet and determined there were no visible injuries.
21. In late April 2022 the Council began a review of the incident. The Council recorded Mr X’s view of the accident. It spoke to the Care Home the following day and interviewed the member of staff. The Council raised the report as a safeguarding concern. It spoke with Mr X by phone and listened to his video clip.
22. In late April the Council also discussed Mr Y’s night plan. It agreed to review the night plan once it had heard back from the incontinence team with its advice.
23. In early May 2022 Mr X sent the Council a copy of the video clip for review. Following a review of the footage the Council said it could not determine the keys landed on Mr Y. Mr X complained about the conclusions as he felt it was clear his son had been hit because he expressed distress at the time.
24. The Council arranged for the Speech and Language Team to create a social story for Mr Y to explain the night care plan to him in mid May. This focused on why staff are waking him up and asking him to go to the toilet.
25. The Council had a telephone meeting with Mr X and his wife regarding the night care plan. Mr X raised concerns that staff were not communicating properly with Mr Y and reminding him to go to the toilet. As a result of this he felt Mr Y was wetting the bed.
26. In late May Mr X raised further concerns about the staff not checking Mr Y every 30 minutes when he is in his room and the staff failing to record a medical appointment. The Council suggested the possibility of moving Mr Y to a new residential home. Mr X declined this on the basis Mr Y is settled where he is and does not understand these issues.
27. In mid July 2022 Mr X reported concerns with staff adherence to the night care plan. The Council arranged a meeting with the Care Home and four night-staff. The Council explained that staff needed to follow the care plan in place.
28. The Council reviewed Mr Y’s night care plan following this. The Council agreed that Mr Y should be checked every 45 minutes when he is in his room and reminded to use the toilet at 2.30am rather than 3am. A new care plan was issued.
29. At the beginning of September Mr X reported further concerns about the care plan not being followed by staff and managers of the Care Home. The arranged meeting in September was cancelled when the public holiday was announced for that day. It held a rearranged meeting at the beginning of October due to annual leave.
30. In November 2022 the Council began fortnightly visits to the Care Home to review and work with the staff on following the night care plan. These are intended to run for two months.

Findings

Safeguarding investigation

31. I have reviewed the documents considered by the Council as part of its safeguarding review into the April 2022 allegations of injury to Mr Y. It is clear the Council took accounts from both the Care Home and Mr X and reviewed the video footage. It formed the decision from a review of this evidence.
32. There is no evidence the safeguarding investigation was biased. When reaching its decision, the Council took Mr X’s views into account. Although Mr X does not agree with the outcome, the Council were entitled to make this decision and there is no fault.

Care plan

33. The Council has accepted that Mr Y’s care plan has not been followed. It agreed that not all checks had been carried out as required. It is positive the Council has accepted there has been fault with the adherence to the care plan at night.
34. The Council has provided care notes and tag system records. This demonstrates that staff are checking on Mr Y each night. However, the checks regularly occur more than two hours apart as required under the care plan. Mr X first reported concerns in June 2021. Further he says Mr Y is regularly not asked to go to the toilet. The Council spoke to the Care Home about these concerns. Mr X continued to raise concerns about the care plan on a regular basis. The Council did not take further action beyond speaking to the manager until November 2022.
35. The Council is responsible for the care provider’s actions as it arranged Mr Y’s care. It has an obligation to ensure he receives the care detailed in the care plan. The Council should have taken action to ensure Mr Y’s needs were being met when it became aware of the concerns. The Council offered to transfer Mr Y to a new home and spoke to the manager between June 2021 and November 2022. The Council should have done more to ensure Mr Y received the correct care in his present home, such as the steps it is now taking. It is fault that the Council has not ensured the care plan is being followed.
36. Mr X says that his son is unaware of the issues with his care plan. However, Mr X has been affected. During the past year Mr X has repeatedly raised his concerns. He has been very worried about the care his son his receiving during this time.

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Agreed action

37. Within one month of this decision the Council should:
• Apologise to Mr X for the injustice caused by the fault identified above.
• Pay Mr X £200 to recognise the injustice caused.
• Complete its review of the care provider and share lessons learned with us and the care provider.
38. Within three months of this decision the Council should:
• Arrange for training for the Care Home on care plans and importance of sticking to them.
• Provide Mr X with a reporting system each month which contains information on the times staff checked on Mr Y during the night.
• Undertake regular monitoring of Care Homes’ records including the room log system to establish improvement.
39. The Council should provide us with evidence it has complied with the above actions.

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Final decision

40. I have completed my investigation. I have found fault leading to injustice. I have recommended action to remedy that injustice and prevent recurrence of the fault.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman