A local authority has been ordered to review its adult safeguarding procedures after the local government and social care ombudsman found it investigated a woman’s complaints about her mother’s care home treatment too slowly.
A social worker from Rochdale council asked the woman, Mrs X, to provide a statement of her concerns in October 2016, but the resulting safeguarding investigation was not concluded until a year later.
“While there are no statutory timescales for completing such enquiries, the expectation is for enquiries to be completed in a timely fashion,” the watchdog’s report said.
The council also failed to explain to the care home the gravity of its actions in preventing Mrs X from entering to see her mother, Mrs Y, who is in her nineties and has dementia. In doing so the care home effectively deprived Mrs Y of her liberty, the ombudsman said.
Covert medication plan
Mrs X first complained to Rochdale council about the home’s quality of care in July 2015. After a social worker discussed her reports with the home, it was agreed at a meeting that Mrs Y, who was refusing medication, would have it administered covertly.
A subsequent psychiatric assessment concluded Mrs Y needed residential dementia care, and two mental health professionals provided support to care staff about this – but stopped doing so because staff appeared not to be following their advice. One told the council that the covert medication plan was not being followed, depriving Mrs Y of pain medication.
“It was also reported that the care home was not providing Mrs Y with social stimulation, and consequently Mrs Y was agitated,” the ombudsman’s report said. “General concerns about the care home, which had previously been discussed with the council, were also reiterated.”
Mrs X and her sister met the care home manager in early October 2016 to discuss ongoing issues – and when this resulted in no improvement, a social worker agreed to investigate. An alert was raised on 7 November 2016, with records indicating problems over communication with Mrs X – including access to Mrs Y’s paperwork – and that the council intended to liaise with the Care Quality Commission (CQC) and others.
‘A year and a lot of chasing’
A November 2016 report by the care home in response to the council’s enquiries showed carers failing to complete bowel movement and medication charts for Mrs Y, and noted that warnings had been issued and training identified as a need.
Over the next few months, Rochdale council’s social worker coordinated specialist assessments of Mrs Y, securing both an NHS contribution towards her nursing care and, at the end of February 2017, a move to a new home.
But the case conference in response to the safeguarding investigation did not take place until July 2017. It substantiated allegations around medication management and omitting to act of injuries and falls, but did not do so on four others, including organisational abuse.
At the meeting, the council also disclosed that an annual inspection of the care home in spring 2016 had flagged potential problems, including around medication errors. This resulted in an action plan being produced – which the home did not act on.
“Mrs X says the council did not provide her with any feedback during the safeguarding investigation, nor did it inform her about what action it had taken in response to the findings,” the ombudsman’s report said. “Mrs X says in the end the council did investigate the claims she made, but it took a year and a lot of chasing from her.”
In a separate complaint, Mrs X also said the care home had blocked her from entering in December 2016, further alleging that she had been abusive and threatening. The council deemed this to be unjustified and discussed the ban with the care home manager, who lifted it.
The ombudsman concluded that Rochdale council was at fault on a number of counts.
First, it had failed to pursue its own concerns, identified in April 2016, by not chasing up the action plan agreed with the care home.
“It should have taken a proactive and firm approach in seeking a response from the care home. It failed to do this,” the ombudsman said.
“At that time, the council did not know the full extent of events complained about and if there was a possible risk to other vulnerable residents at the care home,” the ombudsman added. “This may have had grave consequences had other residents been at risk.”
The watchdog also said the council had been “slow to act” in response to Mrs X’s concerns, first by taking its time to open the investigation and then by dragging it out over most of a year.
“There was no good reason for the council’s enquiries to take eight months, before a case conference was held,” the ombudsman said. “The time taken to complete the enquiries caused injustice to Mrs X and her family by prolonging the uncertainty.”
Finally, the council was deemed to have been too soft in response to the visiting ban.
“Once it was made aware it acted,” the ombudsman said. “However, it failed to explain to the care home the gravity of its actions and the legal implications for depriving Mrs Y of her liberty.”
‘Ensure adequate care’
In response to the findings, the watchdog said Rochdale council should pay £600 to Mrs X. It also ordered the council to explain what action it would take to ensure safeguarding enquiries were completed in an effective and timely fashion, and to ensure adequate quality of care was being provided in Mrs X’s former home.
Steve Blezard, the council’s adult care director of operations, said: “We accept the findings from the ombudsman in full. We have implemented all the agreed actions, made changes to our systems and apologised to the family for any distress that was caused.”
He added: “As a responsible council we have robust safeguarding procedures in place and we work with partners and the Care Quality Commission to ensure our procedures are rigorously enforced. The safety, wellbeing and care needs of our residents will always be our main priority.”
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