The Ombudsman's final decision
Summary: Mr X complains the Council provided misleading information about Care Home A in its directory of registered care homes, which he used to search for a suitable placement for his mother in July 2019. He says they would not have placed her there if the Council had provided accurate information and she would have been protected from the medication errors she experienced at Care Home A. The Council was not at fault over this matter.
The complaint
The complainant, whom I shall refer to as Mr X, complains the Council provided misleading information about Care Home A in its directory of registered care homes, which he used to search for a suitable placement for his mother in July 2019. He says it advertised Care Home A as a safe service and did not alert him to the fact there was an ongoing investigation into incidents where some residents had suffered harm and died in 2017.
The Ombudsman’s role and powers
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) If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
How I considered this complaint
I have: considered the complaint and the documents provided by Mr X; considered the comments and documents the Council has provided; and invited comments on a draft of this statement from Mr X and the Council, for me to consider before making my final decision.
What I found
What happened In July 2019 Mr X’s mother, Mrs Y, was in hospital. She had been living in a care home which had given notice, having struggled to meet her needs because of challenging behaviour. Mrs Y was a self-funder as she had enough money to pay for her own care. The Council gave Mr X a copy of its Care Directory, which contained a list of care homes. The Care Directory contained advice on choosing a care home which included: “You should ask to look at the latest report on the care home by CQC (Care Quality Commission). This will contain comments by the inspectors and recommendations they have made to the owners. The report is a public document and you should tell adult services if you have any problems obtaining a copy.”
On 16 July Mr X told the Council he had contacted four care homes but they said they could not meet Mrs Y’s needs because of her challenging behaviour. The Council offered to contact Care Home B, as it had previously accepted people with challenging behaviour. Mr X accepted the Council’s offer. Care Home B agreed to assess Mrs Y on 17 July. However, the Council ended its involvement on the basis Mrs Y was self-funding and wanted to source care with her family.
Mr X arranged for his mother to move to Care Home A when she left hospital. He says he relied on the information in the Council’s Care Directory.
Between April 2018 and July 2019 CQC published four reports on Care Home A. This followed concerns raised by the Council in 2017 about the care of people it had placed there who died. The Council suspended all new nursing placements at Care Home A on 11 October 2017 and all new placements on 26 October.
CQC’s report published in April 2018 found Care Home A required improvement in all five areas: safe; effective; caring; responsive; and well-led.
A second CQC report published in April 2018 found Care Home A required improvement and was now inadequate in terms of being safe.
In August 2018, having satisfied itself Care Home A had made sustained improvements, the Council partially lifted the suspension on new placements. It agreed it could take one new resident a month, to enable a safe, managed increase in residents.
In November 2018 CQC published a further report which found Care Home A still required improvement but was now good in terms of being safe and well-led.
The Council decided to lift all restrictions on admissions.
In February 2019 CQC published a report which said Care Home A was providing a good service in all five areas: safe; effective; caring; responsive; and well-led.
In May 2019, following safeguarding concerns about the management of medicines at Care Home A, the Council reinstated increased monitoring.
On 9 July CQC published a report which found Care Home A required improvement overall and in terms of being safe, effective, responsive and well‑led. It found it was good in terms of being caring.
The Council visited Care Home A in August to discuss the action being taken in response to the latest CQC report to minimise the risk of medication errors.
The Council continued to meet the Care Provider, which runs Care Home A, to review new safeguarding and quality concerns and monitor overall performance.
Mrs Y went into hospital in August 2020. When she returned to Care Home A NHS Continuing Health Care funded her placement.
The Council made enquiries into safeguarding concerns which revealed a number of medication errors. These included: continuing to give Mrs Y medication which a GP had stopped on 28 July, which probably resulted in urinary retention and admission to hospital on 5 August; from 23 August to 24 September Mrs Y did not receive her repeat medications; there was no evidence to explain why this happened or that a GP was consulted before restarting the medication; and the failure to give Mrs Y her prescribed medication was likely to have had an adverse impact on her.
Mr X complained to the Council about it: promoting Care Home A as a safe environment in 2019, despite investigating safeguarding concerns; failing to safeguard the residents of Care Home A; failing to tell people about the safeguarding concerns at Care Home A; failing to protect Mrs Y from neglect and significant harm; failing to provide help in identifying a safe and appropriate care home for Mrs Y; and failing to act on the concerns raised by CQC in its 2019 report.
Mrs Y died on 1 April 2021.
When the Council replied to Mr X’s complaint, it said: it had to provide information about the services available in its area without bias. Its Care Directory complied with that duty by listing all the services registered with CQC in its area; there were no large-scale safeguarding enquiries during the time Mrs Y lived at Care Home A. Along with CQC, which had the power to register or de-register a service, it had worked with Care Home A to support it in meeting the expected standards. It could not predict the action of individual people working there; it would share information about large scale safeguarding enquiries with families, but not low-level enquiries There was no suspension on placements when Mrs Y moved to Care Home A. Information about Care Home A was readily available on CQC’s website; as Mrs Y funded her own care the Council had no responsibility to monitor her placement. No one raised any concerns about her care until October 2020; there was no evidence it had discussed the advantages and disadvantages of the Council contracting Mrs Y’s placement, for which there would have been a charge. It accepted it needed to make improvements to ensure it explained the options available to self-funding clients; and it had increased its monitoring following the publication of CQC‘s report in 2019. The Care Provider agreed to make improvements. The Council had dealt appropriately with safeguarding concerns on a case-by-case basis.
Eleven people working for the Care Provider and two of its care homes, including Care Home A, will stand trial in 2023 over the deaths of five residents in 2017 and 2018.
Is there evidence of fault by the Council which caused injustice?
Under the Care Act the Council has a duty to provide people with information. The Council is right to say it has to do this without bias. At the time Mr X was looking for a care home for his mother, there was no restriction on placements at Care Home A. It was registered with CQC but needed to make improvements. Information was available on CQC’s website about this. The Council’s Care Directory included advice on checking the latest inspection report. Mr X did not do this. But that was not because of any fault by the Council.
The Council accepts it was at fault over the failure to explain the options for funding Mrs Y’s care, either directly with Care Home A or via the Council. However, there is nothing to suggest Mr X would have chosen a different care home if the Council had done this.
The Council is not responsible for the poor care Mrs Y received in 2020.
Final decision
I have completed my investigation on the basis there is no evidence of fault by the Council causing injustice which requires a remedy.
Investigator's decision on behalf of the Ombudsman