Summary: Mr B complained the care provider commissioned by the Council failed to provide his father with satisfactory care, failed to contact other relatives when his father’s mobility declined and failed to properly investigate his complaint. There were missed opportunities to discuss Mr B’s father’s deteriorating mobility with family members and the complaint investigation failed to identify that. An apology and payment to Mr B is satisfactory remedy.

The complaint

1. The complainant, whom I shall refer to as Mr B, complained the care provider commissioned by the Council:
• failed to provide his father with satisfactory care;
• failed to contact other relatives when it could not contact his mother to report a decline in his father’s mobility; and
• failed to properly investigate his complaint.
2. Mr B says failures by the care provider meant his father was admitted to hospital straight after leaving the care home with dehydration and this led to his premature death.

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The Ombudsman’s role and powers

3. 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)
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)

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How I considered this complaint

5. As part of the investigation, I have:
• considered the complaint and Mr B's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
6. Mr B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Background

7. Mr B’s father was living in his own home with a package of care. He needed his property adapting and the Council contacted the care provider to ask it to assess him for a one-week respite stay. The care provider visited Mr B’s father on 12 July 2019 and carried out an assessment. Mr B’s father entered the respite placement for seven days on 22 July 2019. At that point Mr B’s father had been assessed as able to weight bear with support of one carer.
8. Mr B’s father had a fall on 25 July 2019 and the care provider tried to contact Mr B’s mother. However, the care provider only had the landline telephone number and Mr B’s mother was away from home at the time. Other family members visited Mr B’s father during this time, including Mr B. The care provider did not discuss concerns about Mr B’s father’s deteriorating mobility during those visits. It did, however, complete a revised assessment which noted Mr B’s father was not weight-bearing and needed two carers to assist him.
9. On 27 July 2019 the care provider noted blisters on Mr B’s father’s arm and telephoned 111 the following morning. The care provider was advised to monitor and contact the GP the following week if the situation deteriorated. The care provider again tried to contact Mr B’s mother but received no response.
10. Mr B’s mother collected Mr B’s father from the home on 29 July 2019. As she had concerns about his deteriorating mobility Mr B’s mother took his father straight to the GP and then to the hospital. Mr B’s father sadly died on 5 September. Mr B says poor care by the care provider contributed to his father’s death.

Analysis

11. Mr B says the care provider the Council commissioned to provide respite care for his father failed to provide satisfactory care. Mr B says because the care provider gave his father inadequate care he declined rapidly over the week he spent in the care home. Mr B says his father was admitted to hospital with dehydration and untreated blisters.
12. For Mr B’s father’s mobility, it is clear from the assessments completed by the care provider there was a significant decline in his mobility. The assessment completed before Mr B’s father went into the care home said he could mobilise with support from one carer. However, by 25 July 2019, three days after he went into the care home, his mobility had declined. Updated assessments at that point showed he could no longer weight-bear and needed two carers to transfer. The care provider says that decline was obvious at the point at which Mr B’s father entered the care home and therefore the decline did not happen in the care home itself.
13. However, there are no documentary records recording the decline in Mr B’s father’s mobility on his entry to the care home. Instead, the care provider only updated the assessment three days after he entered the care home. I would have thought if the reduced mobility was obvious on entry to the care home the care provider would have updated the assessments at that point. As it did not I consider it likely, on the balance of probability, Mr B’s father’s mobility declined between 22 July when he was admitted to the care home and 25 July when the care provider completed a new assessment. I cannot speculate though about whether fault by the care provider contributed to that decline.
14. Mr B says the care provider failed to properly feed and hydrate his father, with the result that when he went into hospital he was dehydrated. Mr B does not believe the home properly monitored his father’s food and fluid intake as a result. Having considered the documentary records from the home I am satisfied the care provider completed detailed records for food intake each day, which included the amount of each meal Mr B’s father ate. I am also satisfied the home completed daily fluid charts. Those charts recorded Mr B’s father’s fluid intake each day, including the amount of fluids he was offered, the amount he drank and at what time. Given those records are comprehensive I am satisfied the care provider properly monitored Mr B’s father’s food and fluid intake and that food and fluids were given daily. I therefore have no grounds to criticise it.
15. Mr B says his father developed blisters in the home and the home failed to act. The documentary evidence I have seen satisfies me the home identified the issue with blisters on 27 July 2019. I am satisfied the home acted by contacting 111 for advice the following day. I am satisfied the home recorded the advice which was to monitor Mr B’s father and to contact the GP if the problem got worse by the following Monday, which was the day Mr B’s father was due to go home. As I am satisfied the care home took appropriate action when it identified the blisters I have no grounds to criticise it.
16. Mr B says the care provider failed to contact other relatives when it could not get in contact with his mother to report concerns about his father’s deteriorating mobility. In contrast the care provider says it only had a landline contact number for the next of kin and telephoned that number and did not receive a reply. While there is no evidence the care provider had access to alternative telephone numbers I am satisfied members of the family, including Mr B, visited the home during the seven days his father was there. Given the care provider had enough concerns about his father’s declining mobility to warrant trying to telephone Mr B’s mother I would have expected the care provider to address its concerns with the family members that visited. If the care provider did not feel able to do that I would have at least expected the care provider to seek an alternative telephone number for Mr B’s mother. The care provider also missed an opportunity to try and get additional contact details when the Council’s case officer visited the home. Failure to discuss the concerns with the family or seek an alternative number to contact Mr B’s mother on is fault. I cannot speculate about what the outcome would have been had the care provider been able to speak to Mr B’s mother about the issues. I therefore consider Mr B’s injustice is limited to the time and trouble he has had to go to pursuing the complaint and his uncertainty about whether the outcome would have been different had the care provider acted appropriately.
17. Mr B says the care provider failed to properly investigate the complaint. Having considered the documentary records I am satisfied the care provider investigated Mr B’s concerns twice. On both occasions I am satisfied the care provider considered the documentary records held by the home and, on the second occasion, interviewed staff involved in Mr B’s father’s care. Those are the actions I would expect the care provider to have taken to investigate the complaint and I therefore do not consider the complaint investigation flawed in that respect. I am, however, surprised the complaint investigation did not identify the missed opportunities to discuss the care provider’s concerns with the family about Mr B’s father’s deteriorating mobility. In those circumstances I can understand why Mr B does not consider the care provider properly considered the complaint.
18. So, I have found fault as the care provider failed to discuss its concerns about Mr B’s father’s deteriorating mobility with family members or the Council’s case officer when it could not contact the next of kin. I am also concerned that issue was not identified during the complaint investigation. I could not speculate about whether the outcome for Mr B’s father would have been different had the care provider acted as it should have done. I am satisfied though the failure to discuss the issues with the family caused them distress, have left them with some uncertainty about whether the outcome would have been different and led to Mr B having to go to time and trouble to pursue the complaint. I recommended the Council apologise to Mr B on behalf of the care provider and pay him £350 to reflect his distress, uncertainty and time and trouble to pursue the complaint. The Council has agreed to make recommendations. As I am satisfied the care provider has identified the need to get alternative contact details for residents following this complaint I make no service recommendation.

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Agreed action

19. Within one month of my decision the Council should apologise to Mr B for the faults identified in this statement which caused him distress, uncertainty and led to him going to time and trouble to pursue his complaint and pay him £350.

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Final decision

20. I have completed my investigation and found fault by the Council in part of the complaint. I am satisfied the action the Council will take is sufficient to remedy Mr B’s injustice.

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Investigator's decision on behalf of the Ombudsman