Summary: The Care Provider acknowledged failings in Mr Y’s care during his stay in a residential home. It failed to offer a remedy for the injustice caused. We have made recommendations to address this.

The complaint

1. Mrs X complains about the quality of care provided to her late father, Mr Y, in Darwin Court residential care home.

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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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. If we are satisfied with the care provider’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)

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How I considered this complaint

5. I have considered the complaint and discussed it with Mrs X. I have also considered the correspondence between Mrs X and the Care Provider, including its response to the complaint. I have taken account of relevant legislation. Mrs X and the Care Provider have had the opportunity to comment on a draft of this statement.

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What I found

Relevant legislation

6. There are standards for safety and quality care homes need to meet, which I will call the Regulations (The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). The Care Quality Commission (the CQC) has written guidance to help care homes meet these standards, known as the Fundamental Standards (Guidance for providers on meeting the regulations, March 2015). As part of these, care homes need to make sure:

• The care and treatment of service users must be appropriate and meet their needs. This means that a care provider should, amongst others, review care plans when needed (Regulation 9).
• People are kept safe from avoidable risk and harm, and from unsafe care and treatment. This includes assessing risk and making plans to manage it. Care homes also need to make sure staff are appropriately trained, and that equipment is suitable and available (Regulation 12).

What happened

7. Mr Y needed residential care at short notice, because his wife, his main carer, had a stroke. The family chose a care home where Mr Y previously had respite care. Because of the urgency of the admission the care home was unable to complete a pre-admission assessment.
8. Mr Y went into the care home on a residential basis on 28 August 2019.
9. Mrs X says Mr Y was diagnosed with a chest and urine infection and care staff told her they did not have enough staff available to collect the medication from the pharmacy, so it would have to wait. Mrs X collected the medication.
10. Mrs X was concerned Mr Y was not getting out of bed and needed assistance with eating and drinking. Following a discussion with care staff it was agreed Mr Y would be moved to the nursing floor.
11. Following the move Mr Y remained in bed for a prolonged period. On one occasion Mrs X arrived at the care home at 10.20am, she found Mr Y had not been offered a drink and he said he was desperate for one. It also appeared he had not been given any breakfast. Mrs X says care staff had not recorded Mr Y’s fluid intake chart despite being aware he had a urine infection. She says meals were left by Mr Y’s bed, but he was given no assistance with eating.
12. Mrs X asked care staff why Mr Y was still in bed, they said a hoist assessment could not be completed for another five days so Mr Y could not be transferred from his bed. Mr Y complained of pain in his ankles, on inspection black discolouration was found under the skin. Mrs X was concerned about pressure sores. She reported this to a carer, the carer said she had noticed it and would find some ‘pressure boots’. The carer said she would report it to senior staff.
13. When the hoist assessment was completed, care staff told Mrs X that Mr Y would need a ‘special mattress’ because of pressure sores on both feet.

Mrs X was concerned about Mr Y. She telephoned him on the care home’s ‘roving phone’ this can be taken into residents rooms, on the day in question the phone lost signal in Mr Y’s room and care staff told Mr Y they were too busy with paperwork to help him use his mobile telephone.

14. Mrs X and the wider family became so concerned they decided to move Mr Y to a different care home. When Mrs X’s brothers went to collect Mr Y to transfer him to the new care home, they found him in the eating area in just his underwear with a towel over his legs. Mrs X says care staff said they had lost all of Mr Y’s trousers. One pair was found. Mrs X’s brothers purchased new ones. Mrs X says Mr Y was transferred from the home with the wrong wheelchair, her brothers had to return the wheelchair and find the one belonging to Mr Y.
15. Mrs X complained to the Care Provider on 23 September 2020 about the quality of care provided to Mr Y.
16. The Care Provider responded in detail on 24 October 2019. The author of the letter said, it was not acceptable that care staff refused to support Mr Y to use his mobile telephone and apologised to Mr Y and Mrs X. He confirmed care staff had supported Mr Y to call his wife two days later. The author confirmed there was an occasion when Mr Y had not been offered a drink until 11am, and the fluid recording chart showed Mr Y had consumed 990mls throughout the day. Records show he had been offered breakfast but declined, and later ate half his lunch, all his pudding and all his evening meal that day.
17. The author said Mrs X’s understanding around the delayed hoist assessment was incorrect. He said the delay was due to a nurse failing to follow a management instruction to undertake the assessment, and that the nurse no longer worked at the care home. He also acknowledged the care home failed to assess Mr Y for a hoist sling when he transferred from the residential section of the home to the nursing floor, and said the need for the equipment “…should have been identified and acted upon promptly after his transfer. Please accept my apologies to yourself and [Mr Y] that this was not done. I have addressed this failing with the staff and the management team within the home”.
18. The author also apologised that a carer had failed to alert senior staff about the developing pressure areas on Mr Y’s ankles and said, “I apologise to [Mr Y] and yourself that this situation was allowed to develop and that no action had been taken in relation to preventing his heels from deteriorating”.
19. The author acknowledged and apologised for the events on the day Mr Y left the care home and said, “sitting in the dining room with no trousers on is unacceptable. [Mr Y’s] dignity had not been maintained and I find this very upsetting to read. Again, I can only apologise to [Mr Y] and yourself about the failings that you have endure in this service”.
20. He concluded by saying “I am so sorry that that Darwin Court has failed to provide [Mr Y] and your family with the high-quality service that you all deserve. [Mr Y’s] stay appears to be a series of errors that are simply not acceptable… please accept my sincerest apologies for any distress or upset that this service has caused [Mr Y] and you as his family members during his short stay at Darwin Court Care Home”.

Analysis

21. People are entitled to safe, effective and high-quality care. In Mr Y’s case, the Care Provider fell short of these standards. It failed to reach the Care Quality Commission’s fundamental standards particularly in terms of person-centred care and safety.
22. The Care Provider upheld Mrs X’s complaint about the service Mr Y received during his stay. It apologised to Mrs X. This does not go far enough.
23. Mr Y funded his care privately although there are some fees still outstanding. He did not get the service he should have done. The home’s actions caused him a substantial injustice and impacted on his wellbeing. The Care Provider has agreed to, along with other actions, waive 50% of fees which remain outstanding.
24. Under the terms of our Memorandum of Understanding and Information Sharing Protocol, I will send CQC a copy of the final decision statement.

Agreed action

25. The Care Provider will within one month of the final decision:

• waive 50% of the fees which remain outstanding
• provide Mr Y’s wife with a formal written apology for the shortcomings in the care provided to Mr Y
• apologise to Mrs X for the time and trouble she has been put to pursuing this complaint

26. Within twelve weeks of my final decision, the home will also:

• explain to the Ombudsman what action it has taken to improve working practices at the care home

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Final decision

27. The Care Provider acknowledged failings in Mr Y’s care during his stay in a residential care home. It failed to offer an appropriate remedy for the injustice caused. The above actions are a suitable way to settle the complaint.
28. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman