Introduction
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1 From 1995 to 2001 Frank lived in what was referred to as a small staffed care home where he was both happy and settled. Frank has a need for a residential care setting as he is an adult with severe learning disabilities. He has no speech; cannot bathe, shave or dress himself; needs assistance to go to the toilet; and needs to wear incontinence pads at night, or for any lengthy periods spent outdoors. He needs one-to-one attention for about 95% of his waking time. In June 2001 he was moved to a similar home (hereafter referred to as ‘the Care Home’) in the same street. Mr and Mrs Taylor were not told about this move until after it had taken place. Their complaint to the Local Government Ombudsman and the Health Service Ombudsman concerned the level of care Frank was provided with from the date of this move.
2 Until July 2002 the Care Home was run and managed wholly by the Trust. The Council was responsible for providing day services for Frank, which involved regular attendance at a Day Centre where he had his lunch and undertook a number of different activities. The Trust then signed an agreement [3] (hereafter referred to as ‘the agreement’) with the Council whereby the responsibility for the Care Home – as well as a number of other small staffed care homes run by the Trust – passed to the Council.
3 In May 2002, some ten months after Frank had moved into the Care Home, an employee of the Trust (Ms A) carried out an investigation into the operation of the Trust’s small staffed care homes as part of an ongoing internal audit process [4]. Ms A’s report, which included in its remit the home that Frank lived in, contained many serious criticisms of the inadequacy of the fixtures and fittings, the decoration, staff training and supervision, and the absence of overall standards or quality assurance systems. The report concluded:
‘The concerns raised in this report call into question the prevention and protection of vulnerable adults from physical, psychological and emotional abuse.’
4 A copy of Ms A’s report was sent to the Trust’s Director of Learning Disabilities (the Director). He commented that there was much work to be done to ensure that the current residents had adequate lifestyles; he said that a full review was needed urgently. He suggested that the proposed new ‘Partnership’ organisation – which referred to the future sharing of responsibilities between the Trust and the Council – ought to make immediate plans to do this. The Director’s report was sent to the Council the following month (June 2002). However, the Council has advised that although the report was received it was never passed up to senior officers or members involved in taking the decision to enter into the agreement.
5 Having finally been agreed on both sides a few days earlier, on 1 July 2002 the agreement came into effect. Under the terms of the agreement the Council undertook to provide services to care home residents on behalf of the Trust, including accommodation, care and assessment and treatment of care home residents, as well as the day and community services provided for the residents. The Council has said that it assumed day-to-day managerial control only from 1 September 2002; although, in the Trust’s view, the Council took over both funding and managerial responsibility from July 2002.6 From about February 2002 Mr and Mrs Taylor had begun to have concerns about Frank’s clinical and social care. When he came home for visits they found that his behaviour had deteriorated badly: although he was usually a very gentle person he began to hit his mother in displays of unhappiness. Mr and Mrs Taylor attributed this to his new environment. Frank had got on well with the staff at the previous home, and although his parents had been told that he would be treated in the same way at the new home, they felt that the staff there had less time for him and he did not get the same level of care and attention that he had had previously.
7 In May 2002 Frank’s consultant psychiatrist diagnosed depression and prescribed paroxetine (a drug to treat depression which selectively inhibits the uptake of serotonin). Mr and Mrs Taylor say that a week or so later, when they went to collect Frank, staff said that they had advised the consultant psychiatrist that Frank was ‘high’. The paroxetine was stopped immediately and Mr and Mrs Taylor and Frank had ‘an awful weekend’ while Frank ‘underwent a traumatic withdrawal’. In August and September Mr and Mrs Taylor were concerned that Frank appeared to be over-sedated. His mood and behaviour did not improve and in September 2002, having already asked during a meeting with the manager of the Council’s ‘small homes’ that he be moved, they wrote a lengthy letter complaining that:
- Frank was moved from one home to another in June 2001 without their knowledge, and his needs for company and a limited social life were being ignored;
- they were subsidising Frank’s care by paying for clothing, soft furnishings, day care activities, lunches, recreation and snacks;
- they had to pay for paint to decorate Frank’s room when he first moved and he had to wait for months for a new floor covering;
- Mr Taylor had had to repair curtains in Frank’s room;
- Frank’s clothing was not looked after, and he sometimes wore other residents’ clothes;
- staff did not have any commitment to Frank’s care: by way of example, his dental health had been neglected;
- because Frank had no speech he was especially vulnerable, but staff who were providing cover overnight locked their own bedrooms. Mr and Mrs Taylor had therefore become very concerned for his safety;
- staff had talked about, or behaved towards, residents inappropriately and one member of staff had demonstrated to them how she had had to bang on a table to prevent Frank falling asleep when he was heavily sedated in order that he would stay awake and be able to sleep at night;
- on a recent occasion when they had collected Frank from the Care Home they had found him sitting in a chair near a door; he was cold and clammy to the touch, was unwashed, unshaven and had dirty teeth. Some time that morning he had clearly had an ‘accident’ and he and his clothes were covered in faeces and urine. Mrs Taylor could find no soap in the bathroom and had to go to Frank’s room to get soap and clean clothes. The member of staff on duty offered no explanation, apology or help.
8 Mr and Mrs Taylor added to their complaint in late September 2002, when they learned of an incident when the driver who usually took Frank to a day centre came to collect him from the Care Home but could not find a member of staff present and had to take him away without anyone knowing that he had gone.
[3] An agreement made under section 31 of the Health Act 1999 to delegate provider tasks in order to provide services to those in need of health and social care.
[4] South Buckinghamshire Homes Learning Disability Services Quality Audit (Draft Interim Report) May 2002.
