Council apologises after man was placed in unsuitable care home without consulting his wife

The council also failed to consult the man’s wife, who had lasting power of attorney for his health and welfare, in the move and did not arrange a proper handover for his transfer, meaning the home was not expecting him.

An investigation by the Local Government and Social Care Ombudsman found a string of faults, and made a series of recommendations to ensure similar mistakes are not made in future.

The man, identified in the report as Mr X, has since died.

The council has apologised for its failings and says it has made improvements.

The ombudsman report said Mr X was discharged from hospital to a nursing home, Care Home A, after a stroke in August 2021, to allow his needs to be assessed before going home.

The hospital ‘fact finding’ assessment found he was able to move around with assistance.

When he was assessed at the nursing home by a social worker, they said his condition had deteriorated and recommended a permanent nursing home placement. Mrs X agreed.

The social worker contacted several homes but they did not have availability. Care Home B said it had vacancies, and the social worker shared Mr X’s fact finding assessment from the hospital – but not the needs assessment carried out at Care Home A.

Care Home B says it tried to contact Care Home A to discuss Mr X’s care needs, but no one called back.

In late September 2021 Mrs X was informed that her husband would be transferred to Care Home B the day after a hospital appointment, but when she contacted the home it was not aware of Mr X’s impending arrival.

Mr X was taken straight to Care Home B from hospital. Staff agreed to accept him but said they felt they could not send him back.

Later that day he was found on the floor in his room. He was assessed as being unable to weight bear, at high risk of pressure sores, and staff checked on him every two hours. An alarm mat was in place next to his bed but Mr X would try to avoid it.

After two weeks Care Home B advised it was unable to meet Mr X’s needs long term and the social worker arranged a review meeting for mid October.

The night before the planned review, Mr X suffered a fall and was admitted to hospital with a broken hip.

He was discharged to a nursing home later that month, where he lived until his death in the spring of 2022.

The ombudsman found “no documented evidence” explaining why the council decided Mr X no longer needed nursing care and instead arranged a care home placement.

The report says the council failed to discuss Care Home B as an option with Mrs X, meaning she did not have chance to visit and give her view on whether it could meet her husband’s needs.

The report says: “This has caused Mrs X distress and uncertainty over whether the inappropriate move to Care Home B could have been averted had she been consulted during the decision making.”

The report is also critical of the council’s failure to arrange a proper handover between the two care homes and provide Care Home B with the most recent assessment of Mr X’s needs.

“Had a proper handover been completed it is likely Care Home B would not have accepted Mr X,” the report says.

The ombudsman ordered the council to apologise and make a symbolic payment of £200 to Mrs X, as well as making improvements in arranging handovers and involving representatives in decisions about placements.

A council spokesperson said: “Shropshire Council regrets that this situation has occurred and has acknowledged that improvements could have been made in the service received by this individual.

“The council have established a discharge planning process to prevent a recurrence of the issues which happened in this instance and will comply with the recommendation for further service improvements from the ombudsman.

“The council successfully supports many hundreds of people every year to move from hospital to care homes with good outcomes for individuals and their families and sincerely regrets that this did not happen on this occasion.”

The ombudsman report added that Care Home B was not at fault in how it assessed and cared for Mr X.