Summary: The care provider failed to provide proper care and treatment to the late Mrs X and did not protect her from abuse. It also failed to carry out a proper investigation of Ms A’s complaints. The care provider should now offer Ms A a sum as detailed below. It has confirmed its improvements to care quality.

The complaint

1. Ms A (as I shall call the complainant) complains about the care and treatment of her late aunt Mrs X in the care home. In particular she complains that the care provider handled her aunt roughly, did not give pain relief when required, failed to keep her (and her room) adequately clean, and spoke to Mrs X mockingly. She says the care provider failed to keep proper records. She also says the first responses she received about her complaint were inadequate and untrue.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C). If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
3. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

4. I considered the information provided by Ms A and by the care provider. We spoke to Ms A. Both the care provider and Ms A had the opportunity to comment on an earlier draft of this statement and I took those comments into consideration before I reached a final decision.

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What I found

Relevant law and guidance

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
6. Regulation 10 says when people receive care and treatment, all staff must treat them with dignity and respect at all times.
7. Regulation 12 says care providers are responsible for the proper and safe management of medications.
8. Regulation 13 says people should not be left in soiled sheets (or clothes) for long periods of time. People should not be ridiculed in any way by staff.
9. Regulation 16 says providers must have adequate systems to ensure complaints investigations are carried out proportionately and without delay.
10. Regulation 17 says care providers should maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.

What happened

11. Mrs X, Ms A’s late aunt, was admitted to the care home in July 2019. She was 99 years old. Ms A says within weeks it became clear to her the care home was not providing proper care and treatment for her aunt and was failing to complete hygiene charts, medication charts and food and fluid intake charts properly. Mrs X suffered her first fall on 14 August.
12. Ms A says a catalogue of failures at the care home meant that she visited more often than she would normally have done and did not take on any work personally at that time so she could devote herself to the wellbeing of her aunt. She says Mrs X complained about staff being ‘rough’ with her and so she installed a recording device: She says Mrs X was verbally abused and mocked when she cried out in pain. She says Mrs X was left neglected for long periods of time, although the care provider says there is no evidence of this except at night.
13. In December Ms A emailed the home manager to discuss her increasing concerns, which included the failure of care staff to remove soiled clothes and pads two days after Ms A herself had changed Mrs X’s clothes and put the soiled clothes in a bag in her bathroom.
14. Mrs X then suffered a fall on 23 December. A doctor visited on 24 December and diagnosed a chest infection and UTI, and a possible fractured coccyx. Ms A says when she went to visit her aunt on 25 December, she was alarmed to find her in her room with her door wide open, the sensor not set and no call-bell to hand. She returned later that morning shortly before lunch to find Mrs X still in bed and weak from lack of food and drink.
15. Ms A says when she visited her aunt on 3 January 2020 at 11.30 am she was sitting in the dining room in front of the table but had not been given breakfast. She visited again that evening at 6.30 to find her aunt in the same place: she asked carers to put Mrs X to bed as she was exhausted. When she telephoned the home two hours later a member of the care staff told her Mrs X had been chatting and eating and drinking well all day. Ms A says she had already been told Mrs X had only had five teaspoons of food all day. She returned to the home and witnessed her aunt in considerable distress as carers tried to move her inappropriately by using a stand aid. Ms A photographed the MAR chart which showed Mrs X had not been given her prescribed painkillers.
16. On 7 January Ms A emailed the care home manager. She said since the fall Mrs X’s care had been “alarming and inadequate”. She said her aunt’s condition had deteriorated rapidly and there were gaps in recording her pain relief. The home manager emailed in acknowledgement on 8 January and then again on 17 January with an apology that staff absences had prevented her concluding the investigation.
17. Mrs X died on 13 January.

The complaint

18. On 20 January the care home manager responded. She acknowledged there were “gaps” in the records. She said Mrs X had suffered an unwitnessed fall on 23 December when she was trying to use the toilet but had not sustained any injury. She said the MAR chart which Ms A had photographed was a discontinued chart. She said all staff had now been instructed to remove soiled items from rooms on a daily basis. In respect of Ms A’s allegation that her aunt had not been given food, she said Mrs X’s memory had been poor but there were food and fluid charts. She said Mrs X had asked to return to the same seat on 3 January. She also said the staff who had allegedly used the stand aid had since left the home and could not be interviewed.

The second complaint

19. Mrs X responded on 27 January. She said there were actually 19 “gaps” in a three-month period in the personal care notes. She said in contradiction of the manager’s assertion that Mrs X had not sustained any injury in the 23 December fall, the GP had diagnosed a suspected fractured coccyx. She said she had asked that Mrs X’s food and fluid intake was monitored but had been told by staff this could only be done at a doctor’s request – she asked for copies of the charts the manager said were completed. Finally she said the carers who had attempted to “drag lift” her aunt and then use a stand aid showed a lack of handling skills as well as a lack of compassion to a vulnerable elderly lady.
20. An Area Manager responded on 5 February. She acknowledged there were 35 occasions in a three-month period when no record was made of personal care: she apologised and agreed it was unacceptable. She said it appeared Mrs X’s room sensor had been deactivated at the time of her fall on 23 December and no-one could explain why. She apologised, and also apologised that the care staff who had completed the records had not noted Mrs X was in pain. She said during the time Mrs X was not taking paracetamol, she was taking another pain killer.
21. The Area Manager also apologised for the poor standard of cleanliness in Mrs X’s bathroom and the failure to remove soiled clothes. She apologised that Mrs X had been complaining of being hungry and said she had reminded the manager to keep offering food and drink to residents who had poor appetites. She said the manner in which staff had tried to move Mrs X was unacceptable at any time and she had reiterated to staff the importance of checking residents’ moving and handling plans.

The third complaint

22. Ms A contacted the care provider again on receipt of the complaint response. She said so many points she raised had been missed, including the evidence she had provided that her aunt had been roughly handled.
23. The care provider commenced its own safeguarding investigation.
24. The care provider issued a report. It noted that Ms A had passed to the care provider 55 hours of tape recordings from her aunt’s room during which it could clearly be heard that a carer mimicked Mrs X’s cries and said “you’re crackers, you”. The recordings also evidenced that on one occasion a carer had stated to the 111 service that Mrs X was ‘fine’ and said it was “just the family”, although there was no evidence the call had been cancelled.
25. The report concluded there were “clear failings” in the care and treatment of Mrs X and shortcomings in the Stage 1 and Stage 2 complaint responses. It said there had since been significant staff changes and robust disciplinary action had been taken. It said it had improved training in medication protocols, documentation of all areas of care, training for senior staff and an improvement action plan had been put in place.

The fourth complaint

26. Ms A remained unhappy with the response to her complaint and asked the care provider to pursue it further.
27. The care provider wrote to Ms A in January 2021 after a complaints appeals panel and involvement of one of the trustees. It said that “steps were taken to give assurance concerning standards of care in the home. These include: training and increased supervision to ensure better record keeping in respect of residents care needs, medication training and improved management oversight of medication administration, purchase of new equipment, and staff changes.” It said it had liaised with the local council’s safeguarding team and received confirmation the safeguarding alert had been closed.
28. The care provider apologised again to Ms A for the issues which gave rise to her complaint. It said “Elements of the behaviour of staff did not match the level of care MHA expects from its employees. We acknowledge that the quality and consistency of record keeping was sub-standard, and this has created understandable uncertainty about the way care was delivered to your Aunt.”
29. Ms A complained to the Ombudsman. She said her aunt had suffered abuse and neglect. She said she herself had suffered financial loss during that time as she had been unable to work because of the need to make such frequent visits to the home.
30. The care provider acknowledges the moving and handling practices in place at the time of the complaint were not up to an acceptable standard. Although the local information said all training had been completed by all staff, this was not true. It accepts staff training was not all complete despite local documentation confirming it was complete. It acknowledges there was no “ownership” of responsibility for maintaining clear and accurate care records which led to inaccurate records being kept. It has provided details of the steps put in place to improve the home.

Analysis

31. The care provider failed to provide proper care and treatment for Mrs X. It failed to adhere to correct moving and handling techniques. It failed to ensure she was also offered adequate nutrition. Those failures caused Mrs X actual pain and suffering.
32. The care provider failed to protect Mrs X from ridicule by staff and failed to ensure her dignity by leaving soiled clothing in her room. Those failures were fall below the standard of care expected.
33. The care provider did not keep proper records as it was obliged to do. Carers recorded false information (that Mrs X was “not in pain” after she fell, for example) and gave Ms A false information about her aunt’s state of health when she telephoned.
34. The care provider failed not once but several times to carry out a timely and thorough investigation of the complaint. The first response was not only inadequate but also gave incorrect information. It was up to the tenacity of Ms A to ensure she received a proper response.
35. Not only Mrs X but also Ms A suffered injustice in consequence of the failures of the care provider, in terms of the distress caused by seeing her aunt suffer unnecessarily in the care home.

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Agreed action

36. The care provider has provided me with details of the training implemented as a result of this complaint, the progress of the improvement action plan, the progress of the review of care plans in this home, and confirmation of the purchase of new sensors. It has also provided the notes of its last three “huddle” meetings in this home.
37. Mrs X has sadly died and the injustice she suffered cannot now be remedied.
38. Within one month of my final decision the care provider should offer Ms A £1000 in recognition of the distress caused to her personally and in recognition that the complaint took far longer than was necessary to complete.

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Final decision

39. I have completed this investigation on the basis that the actions of the care provider caused injustice to Mrs X and to Ms A.

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Investigator's decision on behalf of the Ombudsman