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London Borough of Ealing (17 003 284)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 28 Mar 2018

The Ombudsman's final decision:

Summary: Miss X complains about the quality of respite care the Council provided to the late Mrs Y. The Ombudsman found the Council was not at fault.

The complaint

  1. The complainant, whom I shall refer to as Miss X, complains on behalf of her late grandmother, Mrs Y. Miss X says that when she raised concerns about the quality of care provided to Mrs Y at Chestnut Lodge, it failed to properly consider and respond to her complaint.

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The Ombudsman’s role and powers

  1. 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

  1. I considered information from the Complainant and from the Council.
  2. 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

  1. On 13 February 2016, Chestnut Lodge run by Viridian Housing (the Care Provider) contacted the Council to advise that it had assessed Mrs Y for a respite stay. It said there was a small wound on Mrs Y’s ankle that it judged to be grade 1 but on the way to grade 2. It said it would worsen quickly as Mrs Y was diabetic but she wore special boots and district nurses were visiting regularly.
  2. On 17 February and, Mrs Y went to stay at Chestnut Lodge.
  3. On 19 February, Miss X wrote to the Council advising she had seen a flea at the home and was uncomfortable about having left her there. She rang the Care Provider to ask if Mrs Y was eating and to ensure they used the tinned food she had supplied if not. Miss X says the Care Provider said she was not eating much and that the meal was battered fish, chips and tomatoes which she felt was inappropriate. The Care Provider says Mrs Y did not lose weight while in Chestnut Lodge.
  4. Mrs Y’s ankle wound was covered with a dry scab but on 22 February, it was swabbed because it appeared to be infected. The GP prescribed antibiotics. The Care Provider had a suitable wound care plan in place.
  5. On 25 February, Miss X visited Mrs Y and found her in bed in someone else’s clothes. She says Mrs Y’s “scent was high”; she “fed and changed her” and plaited her hair. Miss X complained that the toothpaste and mouthwash she had provided had not been touched for the nine days Mrs Y had been there. Staff told her that they used water and a sponge for people with dentures and that in future they would use the mouthwash to wet the sponge. The Care Provider updated its care plan to reflect this. The Care Provider says it also apologised to Miss X for using the wrong clothes.
  6. Mrs Y’s care plan stated two carers were to support her with washing and changing using a slide sheet.
  7. On 26 February, the scab came off Mrs Y’s ankle wound and the GP was informed because of the wound beneath. The Care Provider updated the wound care plan correctly.
  8. On 29 February, the Care Provider wrote to the Council and said the sore was now grade 3 and the GP had referred her to the vascular clinic. This was because there was a problem with circulation in her foot and he could not feel the pulse. The Care Provider referred her to the tissue viability service and then to safeguarding and CQC as required.
  9. On 4 March, Mrs Y returned home. The Care Provider referred her to the district nursing service asking them to see her as soon as possible and noting the dressing had been changed that day.
  10. Miss X complained when she arrived to pick Mrs Y up, that she had a swollen lip. She says staff could provide no explanation and it was so swollen they could not see the dentures which they had thought were missing. The Care Provider says Miss X was in a hurry as she had a taxi waiting so staff did not have the opportunity to deal with this.
  11. On 9 March, Miss X contacted the health service because Mrs Y had vaginal bleeding which she had not previously experienced. She felt this was due to the care she received at Chestnut Lodge.
  12. On 15 March, the Council spoke to the Care Provider. The lead nurse advised they had used swabs to clean Mrs Y’s mouth as she had swallowed the toothpaste and mouthwash provided by Miss X. It had not seen any evidence of vaginal bleeding and the only concerns had been the pressure area on her foot.

Was there fault which caused injustice?

  1. The most significant issue that Miss X complained about was the wound care. I found no fault in this and the Care Provider had taken suitable action alerting the Council, GP, tissue viability service and CQC as required. There was no fault here.
  2. The Council made fitting enquiries of the Care Provider under its safeguarding procedures. The Care Provider had suitable records in place to evidence the care it had provided was appropriate and sufficient to satisfy the Council’s investigation. I found no fault here.
  3. It is not good practice to use other people’s clothes but the Care Provider dealt with this suitably and apologised. This did not cause any injustice.
  4. The vaginal bleeding occurred some time after Mrs Y had left Chestnut Lodge. I see no reason to suggest this was linked to her stay or that further investigation by the Council would clarify the cause, so I found no fault here.
  5. Mrs Y did not lose weight and had no medical reason to eat the tinned food supplied by Miss X. In fact, Miss X asked the Care Provider to use this food if she was not eating adequately. I cannot say that the one occasion on which Miss X says the food was inappropriate, caused any injustice to Mrs Y. This is a subjective view which the Care Provider did not agree with; I found no fault here.
  6. The Care Provider’s approach to oral hygiene was satisfactory and it dealt properly with Miss X’s complaint when it agreed to wet the sponge in the mouthwash. I found no fault here.
  7. As Miss X did not alert staff to Mrs Y’s need to be changed on 25 February, the Care Provider did not have the opportunity to see the problem and deal with it. I found no fault here.
  8. Similarly, Miss X did not give staff the opportunity to consider Mrs Y’s swollen lip and the possible cause before she left. Further investigation by the Council would not reveal any more information and the cause is unlikely to ever be known. I found no fault here.

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Final decision

  1. I have completed my investigation and have not upheld Miss X’s complaint that the Council failed to properly consider and respond to her complaint.

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Investigator's decision on behalf of the Ombudsman

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