Decision Date: 02 Jan 2025
Summary
A complaint against Enfield Borough Council of inadequate care provision in a Council-arranged placement was upheld. The Council was also found to be at fault for its flawed and inadequate safeguarding investigation. This resulted in injustice to Mr F, the care recipient, and his daughter, who visited him while he was placed in the care home.
What happened
Mr F entered Stamford Care Home, a registered nursing home run by BUPA Care Homes (ANS) Ltd in 2022 following a short stay in hospital, where he lived for two months before he died. The Council arranged for his care with the understanding that Mr F had enough financial resources to be obliged to pay in full for his own care, but lacked the capacity to manage his financial affairs. So, it paid for Mr F’s placement with the intent of invoicing Mr F subsequently, once someone had authority to deal with his finances. If Mr F died before anyone gained such authority, the invoice would pass to his estate.
Mr F had dementia, could not speak or swallow, and had to be fed via a PEG feeding tube. He had a history of pneumonia caused by food or liquid accidentally entering his lungs. Following a visit from a Speech and Language Therapist (SALT), it was recommended that the care home put a ‘regular oral regime’ in place for Mr F.
Despite this, on a second visit three weeks later, SALT recorded a significant decline in his oral health, including a ‘very foul smell’ and thick chunks of dry secretions in and around his mouth.
They noted the area where the PEG tube entered Mr F’s body was “yellow and crusty with a build-up of debris”, suggesting the care home staff had not cleaned it for some time.
His daughter, Miss E, took photos of Mr F’s mouth and feeding tube. SALT made a safeguarding referral following their second visit, but Mr F died before the Council received it.
On receipt, the Council carried out an initial assessment, which included speaking to Miss E.
The safeguarding officer noted that:
- Miss E said nurses on site had only attended to Mr F’s PEG feeding tube and not to his oral hygiene;
- No-one had told her to buy a toothbrush or toothpaste for Mr F until the day before the SALT’s second visit when Mr F had been in the care home for several weeks.
However, the officer did not record Miss E’s concern about the care of Mr F’s feeding tube, despite later notes stating that Miss E had expressed concern ‘mainly with PEG care and oral care.’
Nearly four months after the initial safeguarding referral the Council received care logs and commentary from the care home.
It said these showed care workers struggled to deliver mouth care to Mr F as he would push them away and sometimes refuse to open his mouth. It said staff, after talking with Miss E, had not wanted to distress Mr F, and so had sometimes stopped trying to give him mouth care.
However, it had not recorded those conversations in its records. It said that it had received advice from the SALT after their first visit and drew up a new mouth care plan for Mr F around 10 days later. It said every day after that, staff recorded giving him mouth care.
At the same time, Miss E was repeatedly telephoning the Council for an update, but received no reply or response to messages she left. The Council did not record any other action on file until seven months later, when the case was assigned to a new social worker, who made some further enquiries of the care home regarding Mr F’s oral care.
The Care Provider simply reiterated its earlier statement, which did not address why it failed to procure the SALT-recommended oral care kit for Mr F, or why no further advice on managing Mr F’s condition was sought before SALT’s second visit. The Council’s investigation proceeded no further and was closed just over 12 months after SALT’s referral.
Separate from the safeguarding referral, Miss E made a complaint to the care provider about Mr F’s care, raising concerns about Mr F’s oral hygiene and care, and his feeding pump.
The complaint also noted that the hospital which discharged Mr F to its care had provided a detailed procedure for maintaining oral hygiene. However, in response, the care provider merely offered some of the information it later gave to the Council in the safeguarding investigation. It also noted that:
- it had not incorporated guidance from the hospital into Mr F’s mouth care plan but that it should have;
- its mouth care plan (both the original and that revised following the first SALT visit) was not specific or detailed enough;
- staff had asked the SALT to visit again after their first visit, but it had no documentation of this;
- the care home had a care plan requiring it to clean Mr F’s PEG tube daily, but had a partial record of doing this. On other occasions the notes referred to the tube as ‘crusty’, and that staff reported Mr F was sometimes resistant to cleaning that area.
The care provider’s response concluded by stating what lessons had been learnt from dealing with Mr F, and how Miss E could escalate the response, if she so desired.
In March 2024, the Council invoiced Mrs F for Mr F’s care. Miss E complained that Mrs F should not have to pay, setting out her concerns about Mr F’s care and providing copies of her complaint to the provider and its response. She also stated that she had received no further update about the Council’s own investigation.
Finally, in May 2024 the Council responded to Miss E’s complaint. While acknowledging a ‘prolonged delay’ arising from the transfer of Mr F’s safeguarding investigation between social workers, it did not respond to Miss E’s allegation that they had repeatedly ignored her calls.
They also claimed that Mrs F had been correctly invoiced for Mr F’s care. The Council said its safeguarding investigation had found Mr F died from causes unrelated to the poor care he received. It said the Care Provider had undertaken some “organisational learning” as a result.
What was found
The Investigator noted several faults with the care received by Mr F and with the Council’s safeguarding investigation.
The Investigator found that it was ‘unacceptable’ that the care provider allowed Mr F’s mouth care to decline to such a point where his SALT felt obliged to make a safeguarding referral.
As the care provider recognised, there was not a sufficiently detailed mouth care plan in place, and no account was taken of information provided on Mr F’s hospital discharge. In addition, its staff failed to obtain urgent advice on Mr F’s mouth care. Nor was the condition of Mr F’s feeding tube acceptable.
The challenges presented by Mr F resisting oral hygiene treatments were deemed not so severe or unusual that the care provider should not have tried to overcome them, yet there was no evidence that they made any effort to do so.
These faults with the provider’s care ultimately rested with the Council.
These faults meant there was both a significant loss of service for Mr F and resulted in him being at risk of harm. But the inspector also found that Miss E suffered an injustice as a consequence of these failures, due to her distress at seeing her father suffer due to poor care.
The Investigator also had concerns about the safeguarding investigation. First, it was conducted too slowly: once the case went to the local social work team to investigate, that social worker held the case for several months. There was little evidence of any activity in that time, and no evidence of any factor justifying such a delay. There was then a three-month period before the Council assigned the case to the second social worker. After that, there was no further delay, but the matter was nearly 12 months old at that point.
The inspector also had concerns about the Council’s approach to communicating with Miss E. The Council involved Miss E in the investigation at the beginning, but did not record whether or how it would do this, or what Miss E indicated were her preferences in this area. It also did not challenge Miss E’s account that it failed to respond to her repeated requests for an update on the safeguarding investigation.
Finally, the Investigator was concerned about the limited scope of the safeguarding investigation. The Council made no enquiries into the issue of Mr F’s feeding tube, despite Miss E raising it with them.
They also failed adequately to investigate and compare a similar case of inadequate care being received at the same facility. This omission meant it could not know if there may have been a wider pattern of poor care.
Finally, the investigation was concluded prematurely, it apparently being enough that the Care Provider had learnt appropriate lessons from this complaint. These consisted mainly of a commitment to remind staff of the importance of record keeping and to improve the details in care plans, and some targeting of these messages. The Investigator felt that while these commitments were to be welcomed, they did not go far enough. It was not clear why the Care Provider did not answer the Council when it asked about why it had not sought more help for Mr F before the second SALT visit. Nor did it answer the question about why it had not bought items needed for Mr F’s mouth care. Overall, the Council’s report did not suggest it had reflected on why Mr F’s oral care was so poor and if the Care Provider had done enough to prevent similar issues arising. It relied on general, high-level assurances and failed to consider how staff coped with residents’ resistance to care.
The Council accepted these findings and agreed to undertake the following remedial actions. Within twenty working days, it would:
- make a written apology to Miss E, taking account of section 3.2 of the LGSCO published guidance on remedies;
- make a symbolic payment of £500 to recognise the distress she experienced from seeing the poor care her father experienced and from the faults in its safeguarding investigation.
Within three months, it would:
- Provide the Ombudsman with an update on its review of safeguarding procedures and the time required to complete safeguarding investigations.
- Describe its current arrangements for communicating with relatives when carrying out a safeguarding investigation. This would consider what advice it gives its social workers on keeping in touch with relatives during investigations and on telling them the outcome of investigations.
- Ask its contracting team to review any placements currently open for users of services at the care home, to check in particular if any of those residents need mouth care or PEG tube feeding as part of their care plans.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
It is noteworthy that in this case, an investigation was launched even though it took Miss E more than twelve months to make the Ombudsman aware of her concerns. The investigator concluded that there were special circumstances justifying the investigation, including the considerable delay in the Council concluding their own safeguarding investigation.
Furthermore, the importance of documenting inadequate care arrangements, such as Miss E photographing her father’s insanitary conditions and feeding tube, is clear here.
The feature of the man’s mental capacity with regard to his oral care, and the complete lack of grasp on the part of the staff that that is exactly what the Mental Capacity Act is FOR – providing care in a person’s best interests, even if it is without their consent, suggests serious management failings within the home. Abiding by the wishes of a capacitated person is honouring them; abiding by the wishes of a person lacking in capacity can be a form of abandonment.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s [London Borough of Enfield (24 004 238)] report.
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