Bristol Council has been slammed for failing to protect an older person with dementia who was left in a zero-rated care home that the authority had identified as having serious safeguarding problems.
The local government ombudsman said earlier action by the council “may well have prevented an appalling incident” in December 2008, in which Mrs Johnson (not her real name) was found by her daughter-in-law in a distressed state, soiled, soaking wet with urine and bleeding over her sheets.
Ombudsman Jane Martin said the council failed to monitor her care regularly from her placement in 2005 until February 2009, despite imposing placement bans on Woodland Crescent (not its real name) twice during this time due to several safeguarding alerts and damning inspection reports.
It also failed to inform Mrs Johnson’s son about the home receiving a zero rating from the Commission for Social Care Inspection in 2008 or the safeguarding concerns at the home, despite him making repeated complaints to Woodland Crescent about the quality of her care during 2008.
Making a finding of maladministration with injustice, Martin said the council had failed in its duties as a commissioners and the lead safeguarding agency, adding: “It is reasonable to conclude that had more robust action been taken by the council, then the poor standard of care and treatment Mrs Johnson received may have been detected far sooner.”
Mrs Johnson was eventually moved in February 2009 to a more expensive home for which her son had to make top-up payments until October 2009, when she was deemed eligible for continuing healthcare funding.
Bristol Council has apologised and accepted Martin’s call to pay Mrs Johnson £6,000 and Mr Johnson £500 in compensation, as well as repay the payments he made for his mother’s care from February to October 2009.
Strategic director for health and social care Alison Comley said: “The lessons from this report are that while we did investigate and act to address concerns raised in 2008-9, our response was not adequate or robust enough. The action plan developed to deliver improvements has already been shared with the family and I shall personally ensure that we continue to monitor the issues raised in this report and update the ombudsman and family accordingly.”
She said the council had taken action to improve its system for reviewing people’s care and ensured there, where safeguarding issues were raised in a service, there were formal processes for informing service users and families.
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