Date of decision:
30 April 2025
Summary
The complaint focused on the Council’s failure properly to assess a vulnerable adult before placing her in residential care, excluding her daughter (with Power of Attorney) from key decisions, and on its delayed response to safeguarding concerns, causing distress and uncertainty.
What happened
Mrs Y, diagnosed with Alzheimer’s, lived at home with her husband and received care and support at home. A care provider was involved, but in May 2023, her daughter, Mrs X, contacted the Council for respite care in a home because Mrs Y’s presentation had changed, becoming more aggressive, which Mr Y was struggling to cope with.
A duty social worker met with Mrs X in May 2023 and agreed to look for a respite placement, Mrs X said she would look for care homes too but felt Mrs Y required a permanent placement. Later the same month, another social work visit took place, at which point Mrs X the daughter confirmed she believed Mrs Y needed a permanent care home placement not just respite.
In early June, Mrs X told the social worker about a placement she had found for her mother. An assessment was completed by a representative for the care provider and on that basis they told the Council it could provide a room for Mrs X. Mrs Y moved into the setting, a residential home in June 2023, but the placement failed within hours, and she was admitted to hospital.
The Council’s social worker explained the challenge of finding a suitable placement as Mrs Y (now) needed EMI nursing. Mrs X’s father listed the areas he would like considered. The Council looked for placements in those areas. Due to difficulty identifying a placement the Council suggested a placement slightly further away. The family declined that suggestion.
A preferred nursing home was found by the family but charged an £80 top up per week, which the family was not willing to afford.
The Council refused to fund the top up charge as it had identified two homes in the family’s preferred areas. One of those homes was Springfield Grange. Mrs X visited the care home on 7 July and raised some concerns about the suitability of the placement. Mrs X also explained the things that needed to be in place for Mrs Y to go there for respite. Mrs Y moved into Springfield Grange on 12 July.
The Council then continued the placement at Springfield Grange despite concerns expressed about basic care for Mrs Y conveyed by Mrs X on 18 July, after she had visited.
Mrs X raised repeated concerns about her mother’s care and safeguarding at Springfield Grange, including issues with hydration, nutrition, medication, and staffing.
Despite being initially reported just 6 days after first arriving at Springfield Grange, the Council delayed investigating safeguarding concerns and did not hold a formal meeting until the end of September. During this meeting, the Council decided they could not substantiate the claims relating to abuse to Mrs Y (involving another resident) and that meals taken and amounts drunk had been noted. It said it would carry forward issues relating to weight. Springfield Grange also accepted in this meeting it could have provided better care.
By early October further concerns were raised with regard to dehydration and constipation of Mrs Y.
Mrs Y was hospitalised in October 2023; hospital staff raised safeguarding concerns about weight loss. Mrs Y died before the safeguarding enquiry concluded.
What was found
The Ombudsman found the Council at fault for:
- failing to properly assess Mrs Y and failing to consult the medical and care professionals already involved in Mrs Y’s care at the time
- failing to involve Mrs X in placement decisions despite her Power of Attorney, and delaying responding to safeguarding concerns.
- Ignoring further concerns raised by Mrs X from October 2023.
The Council accepted these failings and agreed to improve processes, including better engagement with families and clearer safeguarding procedures.
The Council as commissioner was responsible for care failures at Springfield Grange, which had since closed.
As Mrs Y had passed away at the time of the Ombudsman’s report, the injustice Mrs Y experienced could not be remedied. However, Mrs X suffered distress and uncertainty; Mrs Y was at risk of neglect.
The Council agreed to apologise to Mrs X and pay her £500 as remedy.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The needs assessment and any decision about safeguarding must be timely, rational, and procedurally fair, involving the individual and where suitable their carer or any other person they might want involved, or anyone objectively interested in their welfare if they lack capacity.
Mrs X commented other professionals involved in the care of Mrs Y were not consulted.
We are interested to note that the needs assessment phase in Wakefield was being done through a Model Assessment ‘Conversation’. The Council’s conversation model guidance provides guidance for social care assessments. It says the conversation record should include:
- basic information about the person and information about why the conversation is taking place;
- a record of the conversation as it happened;
- a record of additional issues such as risks, self-neglect or other safeguarding concerns;
- discussions held with others such as carers, family members and other professionals;
- the agreed actions and who is completing them, along with timescales;
- the professional judgement of the person completing the assessment.
We would have to emphasise that this template is completely inadequate to align with the Care Act, because it leaves out all reference to the requirements in the Care Act Guidance regarding advance information, and whether advocacy applies as a right under s67. It makes no reference to any concept of eligibility, significant impact to wellbeing, or to inability to achieve across the domains. We think it was a screening assessment only.
The Ombudsman did not hold the assessment to have been in breach of the Care Act for failing to deliver the analysis required of a needs assessment by the Act and case law, but simply said that the investigator could not tell for sure whether anyone would have demurred from the suggestion that the first care home was in fact suitable.
The investigator merely recommended the Council remind officers completing assessments for residential and nursing care to ensure input is obtained from any carer agencies and medical professionals already involved in the service user’s care. That is an obvious part of the public law duty of enquiry, and the duty to take all relevant considerations into account and the report would have been better for the investigator having said so, we think.
The Ombudsman’s investigator said it was fault to make arrangements for Springfield Grange without consulting Mrs X or seeking her consent. Nevertheless, the report does not go so far as to say that Mrs Y had been ‘forced’ into the home because of the suggestion of widening the area a little, beyond the area the family had insisted upon or paying a top-up (even though the one mentioned was unaffordable).
We think that this very much misses the point that the Council is the decision-maker about suitability subject always to taking account of the wellbeing duty owed to carers as well as to clients for care and support: distance away from people’s visitors is part of suitability and suitability is a pre-condition for a lawful budget.
The Ombudsman’s investigator referred to the safeguarding delay and the failure to involve Mrs X in the second series of probing as conduct that would have done little to satisfy Mrs X that she was being taken seriously.
We also think that the learning points identified by the Council provide some context for just how poor the knowledge and skills base of the staff working with the woman were , even if they related to the care home. These things should have been part of the commissioned obligation, as they are all related to fundamental standards of care. They included:
- understanding the legal requirement to involve and engage with those with lasting Power of Attorney;
- the role of the lasting Power of Attorney in relation to decision-making;
- checking and supporting robust recruitment documentation for care staff;
- checking and supporting overseas staff to ensure they have had the appropriate English exams and training before employment;
- checking and supporting care homes to ensure all staff have appropriate training, development and supervision to ensure safe delivery of care to residents;
- robust quality assurance and contract monitoring checks, working closely with CQC and other partners to ensure residents are safe and well.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Wakefield City Council (24 008 316) report.
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