Ombudsman finds local authority at fault after it left man in unsuitable care for ‘prolonged period’

A council left an older man, whose health was deteriorating, in a care setting it knew to be unsuitable for almost two months, an ombudsman investigation has found.

The Local Government and Social Care Ombudsman concluded that Warwickshire council had maintained the man’s placement “for a prolonged period with the knowledge his care needs were not being met”.

The watchdog also found the local authority at fault for delays in organising an alternative placement for ‘Mr P’, and for failing to maintain appropriate contact with his wife, ‘Mrs D’.

It identified additional faults on behalf of the council because the care home in which Mr P was staying failed to notify Mrs D of a fall by her husband, and did not adequately assess whether he required treatment after another fall.

The ombudsman found that the care provider and council had also both neglected to provide Mrs D with a formal notification that Mr P’s placement had ended, after he was transferred to hospital and, subsequently, to another care setting.

Warwickshire council issued a written apology to Mrs D and agreed to pay her £500 to remedy the injustice caused to her. The investigation report noted that “harm and distress” caused to Mr P could not be remedied because he had died since Mrs D raised her complaints.

Social worker was ‘largely unresponsive’

Mrs D’s complaints related to a stay by her husband at Orchard Blythe, a care facility operated by Runwood Homes, which commenced in early July 2020. Before this, Mr P had already had two periods of respite care at Orchard Blythe in February and June 2020.

By mid-July, staff at Orchard Blythe had determined that the home could not adequately meet Mr P’s increasing needs and that a specialist service should be sought. Mr P’s social worker was notified immediately of this assessment, with the ombudsman commenting that there was “evidence this point was acknowledged by the Council and reemphasised to the Council by both Mrs D and management at Orchard Blythe at later dates”.

Over the following weeks, Mr P had a series of falls, some of which Mrs D said she was not told about. One such fall in late August caused an elbow injury requiring stitches, which Mrs D said was not picked up quickly enough by care staff. She also raised concerns about her husband’s appearance, that he was becoming distressed and that he had been left sitting in his own urine and faeces.

The council did not contact Orchard Blythe asking for details as to the change in Mr P’s needs until early August. It only began trying to identify alternative accommodation in the middle of that month, which it acknowledged represented a delay.

Over this period Mrs D repeatedly tried to chase up Mr P’s social worker regarding her concerns over the inadequacy of her husband’s care and the possibility of him being transferred. “In my view, the council [social worker] was largely unresponsive,” the ombudsman’s report said.

‘Council failed in discharging its responsibilities’

In summary, the watchdog found, Warwickshire council was “fully aware” that Orchard Blythe could not meet Mr P’s complex needs and therefore was at fault for not finding him an alternative placement.

“The council has a responsibility to ensure that the care and treatment Mr P received was appropriate to his needs and in accordance with the CQC Fundamental Standards,” the report said. “The evidence suggests the council failed in discharging its responsibility in this respect.”

Orchard Blythe admitted to the ombudsman that there was an occasion when Mrs D had not been notified of a fall by her husband – though the investigation found that, in general, staff at the home had monitored Mr P and taken steps to mitigate risk.

The ombudsman accepted that Orchard Blythe staff checked Mr P for signs of injury but found they had not been thorough enough in assessing his elbow injury in August 2020, resulting in a delay of hours before paramedics were called.

The watchdog’s inquiry revealed no evidence of failings relating to Mr P’s personal care and sanitary needs on the part of Orchard Blythe staff.

‘We have undertaken the agreed actions’

Responding to the ombudsman report, a spokesperson for Warwickshire council said it fully accepted the findings of the ombudsman and has “undertaken the agreed actions as a result of their investigation”.

Besides the apology and payment to Mrs D, the ombudsman had considered recommending that Warwickshire put in place service improvements in light of Mr P’s case.

It concluded that the local authority had already identified in its communications areas where it could do better, but said these must be evidenced within two months of the investigation concluding.