Summary: Miss X complains about the care her grandmother, Mrs Y, received at Greenacres Care Centre, where the Council placed her for respite care. The Council accepts there were examples of poor care and poor communication with Mrs Y’s family. It needs to apologise to her family and make a symbolic payment to Mrs Y for the avoidable distress caused to her.

The complaint

1. The complainant, whom I shall refer to as Miss X, complains about the care her grandmother, Mrs Y, received at Greenacres Care Centre (Greenacres), where the Council placed her. She says this resulted in a decline in her condition, being medicated for depression and identified as end of life.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
4. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the council and care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

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How I considered this complaint

6. I have:
• considered the complaint and the documents provided by Miss X;
• discussed the complaint with Miss X;
• considered the information the Council has provided;
• considered the Ombudsman’s guidance on remedies; and
• taken account of the comments received from Mr Y, the Council and Greenacres on a draft of this statement before making my final decision.

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What I found

What happened

7. Mrs Y has dementia and used to live in her own home. She went to stay at Greenacres on 14 June 2021 for respite and to decide her long-term care needs, after being in hospital following a fall. In line with the Government guidance in place at the time, Mrs Y had to isolate in her room for 14 days when she went to stay at Greenacres.
8. On 27 June Mrs Y found it difficult to get out of bed. She complained of backache and said a care worker had hurt her right arm. She said “a boy” grabbed and twisted her arm to keep her quiet. Mrs Y could grip her walking frame and walked to the toilet. Later in the day she said she did not want to see the same care worker again as “she” had tried to kill her. Around 15.00 Mrs Y complained of pain in her right wrists. A care worker noted it slight swelling in the wrist, red and hot. Mrs Y could move her fingers but it was clear she was in pain. She said “a boy” had twisted her arm to quieten her.
9. Greenacres called Mrs Y’s son, Mr W. It asked if he could take Mrs Y to an NHS Urgent Treatment Centre but he was not in Plymouth. Greenacres told Mr W what his mother had said about a care worker hurting her wrist. He said she could “accuse people of things”. Greenacres called NHS 111, which sent an ambulance. Mrs Y told the paramedics a care worker had injured her wrist but did not do it on purpose. The paramedics took Mrs Y to hospital to check if she had broken her wrist. On leaving Greenacres, Mrs Y said Care Worker A pestered her. Care Worker A had told Mrs Y she would have to wait for care staff when in her room that morning.
10. On 28 June the hospital told Greenacres Mrs Y’s wrist was a little swollen, but not fractured or broken. An ambulance returned her to Greenacres around 08.00. The paramedics said Mrs Y had accused them of hurting her arms and legs. Greenacres told Mr W his mother would have to isolate for another 14 days. It made a safeguarding referral to the Council.
11. On 9 August Miss X made a safeguarding referral to the Council over concerns Greenacres was neglecting Mrs Y by:
• not helping her as much as needed;
• not leaving water in her reach;
• not changing her pad for long periods of time; and
• not feeding her properly;

She said this had resulted in a GP saying Mrs Y was at the end of her life.

12. On 10 August Miss X told the Council Greenacres had agreed a family member would attend at mealtimes to help feed Mrs Y, until she moved to live with her daughter. She also said:
• a doctor had agreed to take Mrs Y off antidepressants;
• Mrs Y had declined while isolated, including her mobility which meant she could no longer walk independently;
• Greenacres was using incontinence pads as there were not enough staff to take Mrs Y to the toilet;
• Mrs Y’s skin was beginning to breakdown. Greenacres only provided a pressure relieving mattress after the doctor identified her as needing end of life care;
• when visited by her family Mrs Y would drink four cups of water because she was so thirsty; and
• Mrs Y had accused a female care worker of being rough with her, but the family was not sure if this happened or was part of her cognitive decline.
13. On 11 August, Greenacres told the Council:
• Mrs Y was not compliant with her care and made accusations against staff;
• she had not complied with physiotherapy, so the service had discharged her;
• it was caring for Mrs Y in bed, her feet were elevated, there was no skin breakdown and district nurses checked her regularly;
• Mrs Y’s food and fluid intake had decreased;
• Mrs Y had not had her prescribed food supplement as it was waiting for the pharmacy to deliver it, meanwhile it had bought an alternative food supplement;
• Mrs Y wanted to use a commode but was “extremely difficult to transfer” as she did not bend her legs. Staff regularly checked her incontinence pads; and
• Mrs Y had oral thrush and her eyes were “green and gunky”.
14. After discussing the concerns with Miss X and Greenacres, the Council ended its safeguarding enquiries on the basis:
• Greenacres had provided reasonable responses to the concerns; and
• following her meeting with Greenacres, Miss X felt it was more “responsive and receptive”; and
• the concerns related more to the quality of care than safeguarding issues.
15. Mrs Y left Greenacres on 20 August and went to stay with her daughter in another part of the country, where her condition has improved.
16. When the Council replied to Miss X’s complaint in November it said:
• a safeguarding investigation carried out in June and July found no evidence of abuse, harm or neglect to Mrs Y over an allegation that a member of staff had caused a swollen wrist;
• after sustaining the injury Greenacres contacted Mr W and then called NHS 111, which decided to send an ambulance which took Mrs Y to hospital;
• it accepted Greenacres had not made her family aware of the policy of not sending a member of staff with a resident to hospital, because of the risk of contracting COVID-19 which would have put other residents at risk;
• in line with Government guidance, Mrs Y had to isolate for 14 days after arriving at Greenacres, which it had to extend for another 14 days after she returned from hospital;
• during her isolation Greenacres offered to help Mrs Y with video or phone calls and updated her family about her health and wellbeing (but the Council could not say what information it had shared with them); staff visited regularly to meet her needs and chat with her;
• Greenacres could have managed the situation in a more empathic way when Mrs Y was identified as end-of-life and the family all visited together;
• it could not comment on Greenacres’ lack of consistency around COVID-19 protocols without more specific information;
• Greenacres did not always give Mrs Y a prescribed food supplement or record giving it to her;
• the Council had failed to tell Mrs Y’s family she would be receiving physiotherapy while at Greenacres;
• a doctor prescribed an antidepressant for Mrs Y so Greenacres had to give it to her, despite the family’s concerns;
• Greenacres was sorry to learn there were times when water and Mrs Y’s call bell were not left within her reach. Greenacres was monitoring this and reminding staff of the need to leave such items within reach;
• Greenacres had not been auditing the call bell report due to staff absence. It accepted there could be a longer response to a call bell at busier times (10‑20 minutes) and apologised;
• there had been a lack of communication between Greenacres and Mrs Y’s family over her need for help at mealtimes; and
• district nurses visited Mrs Y daily to monitor her skin integrity, alongside care staff, and recorded no concerns about blistering.
17. The Council identified the action Greenacres needed to take to address the problems Mrs Y had experienced.

Is there evidence of fault by the Council which caused injustice?

18. It is clear Mrs Y’s stay at Greenacres was not a successful one. She went there for respite following a fall, but her condition declined rather than improved. It appears the decline in her condition was a result of circumstances, which at least in part resulted from COVID-19 restrictions. It seems likely a significant factor was the need to isolate, which was extended because of her brief trip to hospital. Mrs Y did not engage with physiotherapy and ended up being cared for in bed.
19. There was no fault over the way the Council dealt with the safeguarding concerns. It did not find evidence to support them. It appears the allegations Mrs Y made against others were a product of her dementia. However, the Council did find evidence of poor care and poor communications with Mrs Y’s family. Mrs Y did not always receive the food supplement she had been prescribed. Sometimes her call bell and water were out of reach. Greenacres was not auditing responses to call bells, but accepted Mrs Y may sometimes have had to wait too long for staff to respond. These problems caused avoidable distress to Mrs Y.
20. Given the decline in Mrs Y’s condition it would have been helpful to review her needs with her family, to consider what could be done to halt the decline. Clearly the best outcome for Mrs Y was to move in with her daughter, as that reversed the decline.

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Agreed action

21. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of Greenacres and the Council, I have only made recommendations to the Council.
22. I recommended the Council within four weeks writes to Mrs Y’s family apologising for the problems she and they experienced while she was at Greenacres and pays Mrs Y £300 in recognition of the distress caused to her. The Council has agreed to do this.
23. Under the terms of our Memorandum of Understanding and information sharing agreement with the Care Quality Commission,

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Final decision

24. I have completed my investigation and the basis there has been fault by the Council causing injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman