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Mrs Linda Jane Harris (17 016 652)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 22 Mar 2019

The Ombudsman's final decision:

Summary: Mrs R complained on behalf of her uncle, Mr X. Mrs R complained about the care Mr X received at a care home between February 2017 and August 2017. The care provider was at fault. It failed to provide Mr X with a key worker, failed to update his care plan and risk assessments, and failed to react to maintenance issues with his room in a timely manner. The care provider agreed to pay Mr X £150 to recognise the distress and uncertainty the faults caused him. The care provider was also at fault for how it handled Mrs R’s complaint. The care provider agreed to pay Mrs R £150 in recognition of its poor complaint handling which caused her time, trouble and frustration.

The complaint

  1. Mrs R complained on behalf of her uncle, Mr X. Mrs R complained about the standard of care Mr X received at Abbey Grange care home, between February 2017 and August 2017. Mrs R said the care home failed to review Mr X’s care plan. She said it failed to complete a risk assessment when staff moved him to another room, which resulted in him falling and fracturing his femur. Mrs R said the failures meant the care home did not meet Mr X’s needs and could have prevented the fall. Mrs R also complained about the care home’s poor complaint handling which caused her time, trouble and uncertainty.

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The Ombudsman’s role and powers

  1. 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)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

  1. I spoke to Mrs R about her complaint.
  2. I considered the Council’s response to my enquiries.
  3. I considered the information the care home provided in response to my enquiries.
  4. I considered the Ombudsman’s guidance on remedies.
  5. Mrs R and the care provider had an opportunity to comment on my draft decision. I considered their comments before I made my final decision.

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What I found

  1. If someone has a contract for their care that is between them (or their representative) and the care provider then the Ombudsman can investigate and make findings against that care provider. If the contract is between the person (or representative) and a council then the Ombudsman can make findings against that council.

This complaint

  1. In this case, Mr X had a fall at home in October 2015 and was admitted to hospital. The Council assessed Mr X and he agreed to move into residential care. Mr X moved into the care home in October 2015. He agreed a contract directly with the care provider. The Council assisted with financial contributions until it completed a full financial assessment. In May 2016, Mr X became a self-funder after the sale of his home. Mr X remained on the contract which he signed with the care home in 2015.

Law and guidance

  1. 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:
    • They provide people with appropriate care, personalised to their needs. This includes taking account of the person’s preferences, and ensuring care and treatment is only provided with their consent. As part of this, care homes need to make sure assessments are regularly reviewed (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).
    • They have a system in place to handle and respond to complaints. The provider must investigate complaints thoroughly, and take action if it identifies problems (Regulation 16).
    • They have enough suitably qualified, competent and experienced staff to make sure it can meet the standards. Staff must be given the support, training and supervision they need to help them do their job (Regulation 18).
  2. The Care Act says care providers should write a care and support plan to explain how they will meet a person’s care needs. They should keep the plan under regular review and provide the care required by the plan.


  1. Councils play the lead role in co-ordinating work to safeguard adults. Anyone who has concerns for the welfare of a vulnerable adult should raise an alert.
  2. The purpose of the safeguarding process is to:
    • Find out the facts about what happened; and
    • protect the vulnerable adult from the risk of further harm.
  3. We will not normally reinvestigate a council’s safeguarding investigation. We can consider whether the council conducted a suitable investigation in line with its safeguarding procedures. If we find fault in how this happened we can look again at the matters covered by the investigation.

What happened

  1. Mrs R is Mr X’s niece. Mrs R has Power of Attorney over Mr X’s health and welfare, and was his next of kin contact on record with the care home. In 2017, Mrs R started raising concerns with the care home about the standard of care it was providing Mr X. Mrs R said the care home was experiencing a large turnover of staff and both managers had left. Mrs R said it was at this point, day to day issues started arising which the care home did not address.
  2. Mrs R wrote to the care home with her concerns between March 2017 and May 2017. Mrs R said the care home’s record keeping in relation to Mr X’s personal finances seemed wrong as he kept running out of money. Mrs R asked the care home to change Mr X’s care plan to reflect his needs for assistance with his hearing aids and his diet. Mrs R said Mr X had not been eating properly because he could not chew or bite certain foods and asked for his care plan to reflect this specific requirement. Mrs R also said Mr X’s room was regularly dirty and asked the care home to clean it on a more regular basis.
  3. The manager at the care home wrote to Mrs R in May 2017. She said she would update Mr X’s care plan to reflect his need for assistance with his hearing aids, and would inform the cooks about Mr X’s diet. The manager assured Mrs R that it would clean Mr X’s room.
  4. In August 2017, Mrs R met with the manager, in the presence of Mr X at the care home to discuss her concerns. The care home accepted it had made overpayments for newspapers from Mr X’s personal finances, and arranged to refund those overpayments. At the time of the meeting, Mr X was poorly. Therefore, the care home suggested it move Mr X to another room when he was better so it could thoroughly clean his room. Mrs R said she agreed to the proposal as long as the care home waited at least three days before moving him.
  5. The day after the meeting, Mr X suffered a fall at the care home while staff were moving him upstairs. The care home said Mr X was using his walker, and turned to sit on a chair but fell. The care home notes show Mr X declined the use of his wheelchair and instead wanted to use his walker. Mr X was taken to hospital and was found to have fractured his femur.
  6. The care home referred the matter to the Council who completed a safeguarding investigation. The Council completed its investigation in January 2018 which was inconclusive. The Council said based on the available evidence, it was not sure what caused Mr X’s fall or whether the level of care contributed to the fall. This was because of a lack of detail in the care home’s case notes. The Council said it had made recommendations to the care home. The Council said further investigation into the matter would not have led to it being able to obtain further information or a different conclusion.
  7. In September 2017, Mrs R formally complained to the care home. In her letter of complaint, Mrs R complained about several matters and asked for a written reply from the care home in response to her complaint.
    • Lack of transparency and inaccurate records of Mr X’s personal expenditure.
    • Lack of key worker for Mr X. Mrs R said Mr X’s allocated key worker was unaware they had responsibility to Mr X. Mrs R said every resident should have a named key worker.
    • Care plans. Mrs R said despite numerous requests, the care home did not update Mr X’s care plan to reflect his needs. Mrs R said she asked for the care plan to reflect Mr X’s daily need for assistance with his hearing aids, daily serving of prescribed nutritional drinks, daily application of prescribed ointment for pain relief and dietary needs.
    • Build-up of nutritional drinks in Mr X’s fridge which did not appear to have administered to him.
    • The care home’s decision to move Mr X upstairs the day after the meeting which she said resulted in his fall. Mrs R said the care home agreed to wait until Mr X was well enough to move, but moved him the following day.
  8. Mr X remained in hospital for several weeks following his fall. Mr X then moved into a new care home with a nursing wing in October 2017 more able to meet his needs after the fall.
  9. In January 2018, Mrs R complained to the Ombudsman. She said the care home had not responded to her complaint letter. The Ombudsman wrote to Mrs R and explained her complaint needed to go through the Council’s complaint process first, because we understood that the contract for care was still between Mr X and the Council.
  10. In March 2018, the Council agreed at the request of the Ombudsman to investigate Mrs R’s complaint and it wrote to her in May 2018. The Council upheld some of Mrs R’s complaints. It said the care home apologised for not updating Mr X’s care plan. The care home also recognised its site maintenance was not to the required standard. The Council said it had made recommendations to the care home in relation to falls at the home following its safeguarding investigation, after it found a lack of evidence within the case notes in relation to Mr X’s fall. The care home accepted it had overspent, and kept inaccurate records of Mr X’s personal expenditure and provided him with a refund.
  11. The Council said it would complete a monitoring visit by the end of September 2018 to ensure the quality of care to the residents was to a sufficient standard. The Council acknowledged Mrs R was unhappy with the care home’s lack of response, although it had offered Mrs R a meeting to discuss her complaint. The Council said it had provided the care home with a copy of its presentation on effective complaint handling to use as refresher training. The Council said it would monitor the care home to ensure it was following its key worker policy during its scheduled visit. The Council said the care home had apologised for the delay in updating and reviewing care plans.
  12. The Council said it recommended the care home write to Mrs R after the its monitoring visit to provide her with an outcome of both her complaint, and the monitoring visit.
  13. In October 2018, Mrs R complained again to the Ombudsman. She said the care home had still not formally responded to her complaint, and had not written to her after the monitoring visit which took place in July 2018. Mrs R said the Council had not fully investigated her complaints, and was unhappy with the Council’s findings in its safeguarding investigation.

My Findings

Care plan reviews

  1. The evidence shows the care home reviewed Mr X’s care plan each month between April 2017 and August 2017. The Council’s complaint response found that the care plan was not reviewed or updated regularly before this period. That was fault. The care home decided the plan did not need significant changes between April and August 2017. However, there were changes to Mr X’s mobility needs that were not reflected in the care plan. The plan did not show Mr X was using a wheelchair to mobilise. That is fault.
  2. The care plan contained Mr X’s needs in relation to his hearing aids, dietary requirements and ointment application. The records show Mr X was well cared for each day, and there were no other falls or safeguarding issues raised. There is no evidence that Mr X raised any concerns or complaints to care home staff about his needs or care so there is no evidence these faults caused Mr X a significant injustice.
  3. The care home decided the plan did not need significant changes between April and August 2017. However, the care home did give Mrs R the impression it would make changes to Mr X’s care plan. It therefore should have been clearer with Mrs R about its intentions and considerations and explained as part of its complaint response why it decided his plan did not need changing. That was fault, and added to Mrs R’s frustration.

Mr X’s medication

  1. Mrs R complained the care home let Mr X’s prescribed nutritional drinks build up in his room and did not properly administer them. Mrs R also queried whether the care home applied his ointment as prescribed. Mr X’s medication records from the care home show between February 2017 and August 2017, it did give him his nutritional drinks each day and so there was no evidence the care provider was at fault.
  2. The care home accepted it applied too much ointment which caused it to run out too quickly and so Mr X went without the ointment for a few days. However, Mr X was prescribed other medication which also acted as pain relief so I cannot know if this caused Mr X an injustice. Following Mrs R’s complaint about this the records show Mr X was given the ointment up to three times a day as required. I am satisfied that after Mrs R raised the concern, the care home gave Mr X the treatment when he required it.

General maintenance

  1. Mrs R complained about the cleanliness of Mr X’s room, and lack of general maintenance. The care home did not react to maintenance issues in a timely manner. The fault meant Mr X experienced the distress of having a room which was not clean, and blocked sink for a period longer than acceptable. The care home now has maintenance personnel on site each day to deal with any issues, and have placed a log book for residents to record concerns and report problems. I am satisfied these actions should prevent reoccurrence of that fault.

Lack of key worker

  1. The care home had a key worker policy, and Mr X should have had an allocated key worker. He did not, and that was fault. It meant Mr X did not have a point of contact within the care home who was responsible for liaising with management about any concerns or change of needs.

Mr X’s fall and the Council’s safeguarding investigation

  1. The case notes show the care home moved Mr X upstairs from his room using a wheelchair. The notes show Mr X declined further use of the wheelchair upstairs, preferring to use his walker, which he was using when he fell. Neither Mr X’s care plan or his risk assessment refer to, or state, he used a wheelchair to mobilise around the care home. This shows the risk assessment in place was not up to date, and did not accurately reflect Mr X’s mobility risks. That was fault, however as the evidence shows Mr X did not want to use the wheelchair. Mr X was entitled to decide to use his walker.
  2. Mr X’s care plan shows he needed to wear the correct footwear to reduce the risk of falls. The care plan did not explain what was meant by ‘the correct footwear’. That was fault. Mrs R said Mr X was wearing his slippers when he arrived at hospital after he fell. The care home said Mr X was wearing hard wearing slippers which he wore most days. I cannot say exactly what footwear Mr X was wearing, or whether the footwear contributed to his fall. However, given Mr X’s history of falls, his care plan and falls risk assessment should have detailed what footwear he should use when mobilising. It did not do so in enough detail and that was fault.
  3. The case notes did not show how staff decided they could move Mr X upstairs or why they moved him when they did rather than waiting as Mrs R had requested. That was fault. While staff completed a retrospective account of what happened when Mr X fell, there is no evidence of any prior consideration of the risk. While Mr X had capacity to choose not to use his wheelchair, the falls risk assessment in place at the time made no mention of wheelchair use, so it could not be relied upon in these circumstances. That was fault. The Council said it has made recommendations to the care home in relation to risks and around falls. However, I cannot say the lack of an up to date care plan or risk assessment caused or contributed to Mr X’s fall.
  4. The Council’s investigation was inconclusive in determining whether any negligence contributed to Mr X’s fall. The notes show Mr X thought the fall was an accident and he could not remember specific details about it. There is nothing further I could add to the Council’s investigation that would lead to a different outcome.

Complaint handling

  1. CQC standards expect care homes to thoroughly investigate and respond to complaints. Mrs R complained to the care home in September 2017. Although the care home offered Mrs R a meeting to discuss her complaint, which she declined, it has never formally responded to her in writing. This is despite the Council recommending it do so after the monitoring visit. That was fault, and caused Mrs R uncertainty and time and trouble in continuing to pursue her complaint.

The Council’s monitoring visit

  1. Following Mrs R’s complaints about the care home, the Council completed a monitoring visit there in July 2018. The Council found the care home was compliant against all its standards apart from some elements of staff training and complaint handling. It made recommendations to the care home following this.

Agreed action

  1. The care provider agreed, within one month of the final decision to:
    • apologise to Mrs R and pay her £150 for the time, trouble and uncertainty caused by it failing to respond to her complaint.
    • apologise to Mr X and pay him £150 for the distress and uncertainty caused by it failing to provide timely maintenance of his room, failing to update his care plan and falls risk assessment and for failing to provide him with a key worker.
    • write to Mrs R, and explain where it has improved its care practices following the recommendations made by the Council in its complaint response and its monitoring visit. It should provide the Ombudsman with a copy of this letter.

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Final decision

  1. I have completed my investigation. I found fault leading to injustice and the care provider agreed to my recommendations.

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Investigator's decision on behalf of the Ombudsman

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