Summary: Mrs X complains about the respite care provided to Ms Y. She says when she left, Ms Y was in pain and said she did not want to go there again. Ms X will have to find a less convenient option in future. The Ombudsman finds the Council at fault in the actions of the Care Provider. The Council will pay Ms Y £200, and Mrs X £100 for the distress and risk of harm it caused. It will also take action in addition to action already taken, to prevent similar problems in future.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains on behalf of her mother, Ms Y. She says the Care Provider commissioned by the Council did not care for Ms Y in line with its assessments and care plans. It:
• failed to advise in advance that she needed to complete a form for her injections.
• gave Ms Y medication daily when it was only to be given as required.
• did not give Ms Y a bath or shower during her stay.
• did not apply Ms Y’s creams to her bottom as stated on the care plan.
• used the home’s stock of continence pads rather than Ms Y’s own pants provided.
• allowed Ms Y’s equipment to be used by others leaving her using inappropriate equipment and her own cushion was mislaid.
2. Mrs X would like to know the reasons for these problems and to know how similar problems will be prevented in future. She would also like a financial remedy.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. 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, section 30(1B) and 34H(i), as amended)
5. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
6. Ms Y has consented for Mrs X to complain on her behalf.

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How I considered this complaint

7. I considered information from the Complainant and from the Council.
8. I sent both parties a copy of my draft decision for comment and took account of the comments I received in response.

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What I found

9. 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.
10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
11. The guidance for Regulation 9 states:
• “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
12. The guidance for Regulation 12 states:
• “Providers must do all that is reasonably practicable to mitigate risks. They should follow good practice guidance and must adopt control measures to make sure the risk is as low as is reasonably possible. They should review methods and measures and amended them to address changing practice”.
13. The guidance for Regulation 15 states:
• “The premises and equipment used to deliver care and treatment must meet people's needs and, where possible, their preferences”.
14. The CQC inspected Clarendon Hall in May 2016, and rated the service ‘Good’. It inspected again in November 2018, and rated the service ‘Requires Improvement’. At this inspection, the CQC identified issues around the management of medication, monitoring food and fluid intake, and quality monitoring.
15. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

What happened

16. Ms Y has disabilities which cause her difficulty with mobility. Mrs X is her main carer and arranged for Ms Y to stay at Clarendon Hall, run by HC-One Limited (the Care Provider) for nine days in June 2018, while she went on holiday. She says she chose Clarendon Hall because it was convenient. The respite package was fully funded by the Council.
17. Two weeks before the stay was due to begin, the manager of Clarendon Hall visited Mrs X and Ms Y at home, to complete a care plan for Ms Y’s stay.
18. Ms Y needed a daily injection which district nurses usually gave her. The Care Provider needed a form signed so its staff could do this instead. On 8 June, when Ms Y’s stay began, the Care Provider called to ask about the form, which Mrs X knew nothing about. The Care Provider managed to get the form completed in time but Mrs X was concerned that this should have been completed by the manager when she visited.
19. Mrs X says Ms Y took all her medication and creams that were included in the care plan to the care home; she also took toiletries. Ms Y said she was happy with her room and the staff who cared for her but said she did not have a shower or bath while there and staff did not apply her creams. Ms Y’s bathing toiletries were unopened.
20. Mrs X says that when a family member wanted to take Ms Y out, another resident was using Ms Y’s wheelchair, and the wheelchair cushion was missing. Ms Y had to use a pillow instead, so she could go out.
21. Mrs X also says:
• Ms Y also had the wrong walker, which had no wheels and was difficult for her to use; another resident had hers.
• Staff put some flowers Ms Y had been given, in a vase without water so they died.
• Only four pairs of Ms Y’s disposable pants were used in nine days although she had enough for every day and night, and some to spare.
• On leaving the home, Ms Y said her back hurt and she did not want to stay at Clarendon Hall again.
• She was not clear about the outcome of the traffic light assessment or that Ms Y had been cared for in line with this.
• Staff offered Ms Y one of her medications routinely although it was to be given as required. She said she refused to take it three times daily but did take it once a day. Mrs X says this is thought to have caused constipation and the back pain she complained about.
22. On 17 September 2018, the Council responded to Mrs X’s complaint. It said:
• it apologised for the manager’s oversight in not ensuring the form for the injections was completed before admission.
• a supplementary book states Ms Y had a shower on 11 June, and the Care Provider apologised that she had not been offered a bath as stated in her care plan.
• Staff say they did apply the cream. The Care Provider apologised as there was no evidence of this.
• Staff used the wrong wheelchairs to transport residents as these, and the walking frames were stored in a communal area. The Care Provider apologised and has now put a procedure in place to label all wheelchairs and walking frames and store in the person’s own room.
• It is the Care Provider’s policy to offer ‘as required’ medication at each round. However, the Care Provider apologised that Ms Y’s bowel habits were not assessed during her stay. The Care Provider raised awareness of this with those staff responsible for administering medication so it should not happen again.
• The traffic light assessment was high (amber) and Ms Y was cared for in line with the guidelines which require at least four hourly moves.
• Staff used the Care Provider’s own continence pads rather than Ms Y’s.
• The Care Provider made improvements and the contract manager responsible for assessing and monitoring the quality of care, will monitor the service. It believes the Care Provider has taken on board the issues and taken appropriate action.
23. I looked at the records from the Care Provider and found the following:
• The position change form was completed. I understand Ms Y should have had her position changed at least every four hours, but the form did not evidence this. Where Ms Y had been in bed, it was often clear her position had been changed. However, on several occasions, consecutive entries state she was in the same position, and no reason given. Also, where she was not in bed, it was even less clear. Although the form is used in varying circumstances, a better layout and improved prompts would support better recording in similar situations.
• The elimination record was completed. Relevant codes include ‘dry’, ‘BO’ (bowels opened), ‘T’ for toilet used, and ‘S’ for soiled. However, I was unable to tell which codes had been entered. For example: ‘D’ or ‘O’ – for ‘dry’ or ‘BO’? Where ‘BO’ was entered, it should have referenced the Bristol stool chart type which might have helped decipher the entries; I saw no reference to this at all. Some entries were overwritten, some contained ‘TPU’, including ‘TPU soiled’, and ‘TPU BO’ and others contained ‘I’. There was no reference to a code containing ‘P’, ‘I’ or ‘U’ in the instructions so it was not clear what these meant. The column for codes also occasionally contained quantities though this was not clear. The design of the record sheet did not provide sufficient space or guidance for effective completion.
• Evidence that the Care Provider addressed issues raised in this complaint with staff.
24. The Care Provider developed an action plan to address areas of weakness identified following Ms X’s complaint. This included pre-assessments, continence assessments, monitoring showers and baths, checking the supplementary book daily and labelling and registering all equipment. It has also increased management oversight and monitoring.

Was there fault which caused injustice?

25. While the form required for Ms Y’s injections should have been completed sooner, the Care Provider did get it completed and Ms Y did not miss an injection. It also apologised which was a suitable remedy for this error. I found no outstanding injustice here.
26. Ms Y could make her own decisions about whether she needed medication, so it was right that she was offered this. The Care Provider did monitor her bowel habits but did not do this effectively. I have concluded that, on the balance of probabilities, the Care Provider’s failure to effectively monitor her bowel habits meant she unnecessarily became constipated. This caused her avoidable distress.
27. Ms Y did not have a bath at Clarendon Hall, but it is not clear whether she had a shower. Ms Y is certain she did not, but the records say she did. Either way, the support provided was not in line with the care plan or her preferences. The Council was at fault here and caused Ms Y avoidable distress.
28. There is no record that Ms Y’s creams were applied and she says they were not. On the balance of probabilities, I have concluded they were not applied. This was also not in line with her care plan and the Council was also at fault here. This added to Ms Y’s distress and, although I saw no evidence she had come to harm as a result, this unnecessarily increased the risk of harm to her.
29. Staff also used the wrong continence pads and the wrong equipment. The Council was at fault here, and this caused more distress. Though there is no evidence she experienced actual harm from this it caused Ms Y to be at an increased, and unnecessary, risk of harm.
30. These faults suggest potential breaches of Regulations 9, 12 and 15. I will therefore provide a copy of this statement to the CQC.
31. Mrs X arranged for Ms Y to stay at Clarendon Hall because it was convenient. The outcome of Ms Y’s stay there, is that she does not wish to return and Mrs X will need to arrange for respite in a less convenient location. Mrs X needs to take a break from caring from time to time. She needs to be confident that the care she arranges for Ms Y will be safe and reliable, the experience at Clarendon Hall has undermined this and caused Mrs X avoidable distress.

Agreed action

32. 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 the Care Provider, I have made recommendations to the Council.
33. The Council has already taken action to improve and monitor the service so I have taken this into account in making my recommendations.
34. In cases like this, where someone has been put at risk or experienced poor care, we usually recommend a refund of care costs, or a payment to recognise this. However, Ms X did not pay for the care provided; it was fully funded by the Council. We may also recommend a payment to recognise any distress, harm or risk of harm.
35. Therefore, to put right the injustice identified above, I recommended the Council:
• Apologise to Mrs X and Ms Y, setting out the faults identified above and what it has done, or will do, to address these.
• Pay Ms Y £200 for the distress and risk of harm.
• Pay Mrs X 100 for the distress.
• Develop an action plan specifying the actions taken, or to be taken, to address each of the faults identified. To include a check on the action already taken to ensure it is adequate and has achieved the required outcome.
• The Council will complete these recommendations within two months of the final decision, and submit evidence to the Ombudsman. Suitable evidence will include confirmation of payments, a copy of the apology letter and a copy of the action plan.

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Final decision

36. I have completed my investigation and uphold Mrs X’s complaint that the Care Provider commissioned by the Council did not care for Ms Y in line with its assessments and care plans. It:
• failed to advise in advance that she needed to complete a form for her injections.
• did not give Ms Y a bath or shower during her stay.
• did not apply Ms Y’s creams to her bottom as stated on the care plan.
• used the home’s stock of continence pads rather than Ms Y’s own pants provided.
• allowed Ms Y’s equipment to be used by others leaving her using inappropriate equipment and her own cushion was mislaid.
37. I have not upheld Mrs X’s complaint that the Care Provider gave Ms Y medication daily when it was only to be given as required.
38. The Council was at fault and caused Ms Y and Ms X injustice. The Council has agreed to complete the recommended actions, which will put right the injustice as far as possible.

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Investigator's decision on behalf of the Ombudsman