Safeguarding probe that failed to uncover harmful care ‘relied heavily on provider evidence’

A safeguarding investigation that failed to uncover the harmful care a woman received at a care home “relied heavily” on the provider’s own internal probe into the concerns.

The Lancashire council social worker carrying out the enquiry did not cross-check documentation submitted by the care home concerning “Mrs X’s” care, and reached an “inconclusive” judgment on the safeguarding concerns, found the Local Government and Social Care Ombudsman.

When the council reviewed the investigation it found the concerns substantiated and multiple failings by “Care Home B” in relation to Mrs X’s care during her four months there in 2019.

The ombudsman found that she suffered harm, and loss of dignity and respect, due to the care she received there.

However, despite the council review making recommendations for improvements at the home, the ombudsman found no evidence it followed it up.

The watchdog said both Mrs X and her husband, Mr X, who brought the complaint, were caused injustice by the council and the care home’s failings.

The council has agreed to all of the ombudsman’s recommendations, which include:

• Providing staff with training and guidance on completing safeguarding investigations.
• Paying Mrs X £1000 to acknowledge the poor care she received at Care Home B.
• Paying Mr X £250 to acknowledge the distress, time and trouble caused to him by raising concerns about his wife’s care.
• Reviewing with Care Home B staff knowledge and training in  assessment, care planning, managing risk, respecting dignity, managing challenging behaviour and record keeping, and what arrangements it has in place when things go wrong.
• Showing how it has ensured the recommendations it made to the care home following the safeguarding investigation have been implemented.

Inappropriate placement

Mrs X, who has dementia and other health problems, moved to Care Home B from another home (Care Home A), in June 2019, in a placement commissioned by the council.

However, shortly afterwards, the home told Mrs X’s social worker that it did not believe it was an appropriate placement, given her dementia diagnosis.

Its pre-assessment had wrongly concluded that she had standard nursing needs, and staff were unable to manage her needs, which included walking into other residents’ rooms, in such a placement.

It said it would support her until an appropriate placement could be found, which took four months, with Mrs X moving to “Care Home C” in October 2019.

Complaint to home

The following month, Mr X complained to Care Home B, saying:

• It did not properly assess Mrs X because they were not aware she was independently mobile.
• She was often left in bed for long periods of time with her clothes on and, on occasions, left wet in her urine.
• Staff did not complete personal care with Mrs X, affecting her personal hygeine.
• Mrs X had been getting urinary tract infections.
• Staff did not help Mrs X with her meals. His wife was not aware meals were for her and did not touch them, resulting in her losing weight.

Mrs X’s daughter had previously raised concerns about her mother’s appearance, personal hygiene and her being left in bed and missing meals.

Safeguarding investigation yields ‘inconclusive’ result

Following the complaint, the care home raised a safeguarding alert, triggering a council investigation that was based on a safeguarding visit, an internal probe by the home and supporting documentation.

However, it reached an “inconclusive” finding on Mr X’s concerns, leading him to complain to the council. In response, Lancashire launched a review of the investigation, which also considered her care plan from homes A and B, her pre-assessment for home B, its daily notes and falls risk assessments.

The council’s review found multiple failings by the home including:

• That it did not properly assess Mrs X’s needs, leading her to be inappropriately placed there and not receive the care she required.
• That it did not properly consider the risk of her falling nor take appropriate action to lower the risk. She had four falls while at Care Home B. However, staff did not refer her to the falls team or correctly complete falls assessments on each occasion.
• That it did not properly take account of Mrs X’s nutrition and hydration needs and the risks of not meeting these. While Care Home A’s plan said that staff were to assist her to eat and drink and monitor her intake, home B’s plan said she did not require assistance but just needed prompting.
• There was no personalised plan for managing Mrs X’s behaviour and no evidence that staff had considered different ways of responding to her behaviours. Notably, while she was up and dressed in the morning at homes A and C, this did not happen at home B.
• There was nothing in her plan on how to manage her personal care needs, despite Mrs X being doubly incontinent and requiring full assistance with her care. The council found Mrs X had suffered a moisture lesion – soreness and blistering where the skin has been exposed to wetness over a long period of time.

Following the review, the council found the safeguarding concerns “substantiated”, and made a number of recommendations to the home, in relation to meeting nutrition and hydration needs, mental capacity and working with residents who are resistive to care.

However, after only sharing the safeguarding investigation outcome verbally, rather than in written form, with Mr X, he complained to the ombudsman.

“In response to my enquiries, the council said the original outcome of the safeguarding investigation was inconclusive because the social worker relied heavily on information given in the provider led investigation,” the watchdog said. “It said the social worker did not thoroughly cross-check the documentation.”

‘Lessons have been learnt’

Louise Taylor, Lancashire County Council’s executive director of adult services and health and wellbeing, said: “We’re very sorry for any distress that has been caused to Mrs X and Mr X from this incident, which relates to the quality of care at a commissioned independent care home.

“We are assured that lessons have been learnt from this complaint and that correct training has been put in place. We are reviewing staff knowledge and training at the care home and ensuring they have taken the actions outlined in their safeguarding review.

“The Local Government and Social Care Ombudsman is happy the incident has now been resolved and that we have carried out the agreed actions set out in the report to ensure incidents like this don’t happen in the future.

“The ombudsman has now ended its involvement with this case.”