Summary: Mr X complained about the Care Provider’s communication because it had not let him know his mother’s (Mrs Y’s) health had worsened. He also complained about its handling of his complaint about this. Sadly, Mrs Y, died during these events. The Ombudsman finds the Care Provider caused Mr X distress, time and trouble. It will apologise and take action to prevent similar problems in future.

The complaint

1. The complainant, whom I shall refer to as Mr X, complains that when his mother (Mrs Y) died in hospital, Anchor Care Homes Ltd (the Care Provider):
• Failed to provide information about Mrs Y’s food and fluid intake when he asked for it.
• Failed to respond effectively to his complaints about this.
2. Mr X says the way he was treated left him very angry and frustrated, and suspicious that Mrs Y was not treated properly before she was admitted to hospital.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. If we are satisfied with a 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)
6. 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.
7. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

In this case, Mr X held powers of attorney for health and welfare for Mrs Y so he was her personal representative and a suitable person to bring this complaint.

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How I considered this complaint

8. I considered information from the Complainant and from the Care Provider.
9. 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

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. Regulation 9 of the Regulations is about person centred care. The guidance says “Each person, and/or person lawfully acting on their behalf, must have all the necessary information about their care and treatment”.
12. Regulation 16 of the Regulations says “Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation”
13. The CQC inspected Greenacres in May 2018 and rated the service “Requires Improvement” in all areas. Although some failings could reflect the general issues raised in this complaint, such as awareness of the Mental Capacity Act, no findings reflected the specific issues.

What happened

14. Mrs Y had sight loss and health conditions which caused her difficulty with cognition and daily living activities. She lived in Greenacres care home.
15. The Care Provider’s records show she could mobilise independently, though liable to bump into doorways and furniture. She was at high risk to her skin integrity and a medium risk of malnutrition. She was weighed weekly and given a high protein diet, and pressure relieving cushion. The GP had checked some purple spots or bruises on 2 July 2018.
16. On 12 July, staff put a food and fluid monitoring form in place. The Care Provider’s daily records note that Mrs Y bit a staff member and ate little breakfast despite encouragement. However, the food record chart says she ate all of her egg bacon toast and cornflakes. The Care Provider says the food and fluid charts were just a precaution but from 14 July she was refusing to eat or drink much. However, the fluid chart shows she was also refusing drinks on 12 and 13 July.
17. On 15 July, staff called the GP who advised staff to continue supporting to eat and drink and to obtain a urine sample for testing. He advised to call the surgery if she worsened. Staff did not tell Mr X about the call.
18. On 17 July, the Care Provider’s records note that Mrs Y stayed in bed all morning and refused all food, all day. She sat up all night then had three teaspoons of cereal and three of porridge and half a cup of tea but refused all food for the rest of the day.
19. On 19 July, staff felt Mrs Y’s health had worsened so called the surgery who advised to call an ambulance. Mrs Y was taken to hospital. On 20 July, staff contacted the hospital who advised they were still running tests. Mr X called into the home to pick up some items for Mrs Y and told two staff members who asked about Mrs Y, that she was not well.
20. On 23 July, Mr X advised the Care Provider that Mrs Y had died over the weekend. He complained to the manager as staff had not let him know when they had called her GP. He asked what she had eaten and drunk in the few days before she went into hospital. He thought the manager had gone to get the information but when she returned, she said nothing was written down. He asked her to find the information about what Mrs Y had drunk on 16 and 17 July before staff called the GP. However, he was there for over two hours and the Care Provider did not give him this information.
21. After ten days, Mr X had heard nothing from the manager so contacted the Care Provider’s customer relations department. He repeated his complaints and asked to speak to the investigating officer (IO) when appointed.
22. On 10 August, the Care Provider acknowledged his complaint by email giving the name of the IO. It referred to his complaint about “lack of communication in relation to the death of your mother”. The Care Provider’s internal correspondence shows it allocated the complaint to an officer and requested she respond to Mr X before Friday 13 August; the ten-day deadline. Mr X says he was told it would not be necessary for him to speak to the IO. When I made enquiries of the Care Provider, I asked for details of all communication with Mr X since 15 July 2018. This was the first communication with Mr X.
23. A week later, Mr X received another email apologising for not completing the investigation in ten days. It said “we will endeavour to respond to you as soon as we are able”.
24. On 24 September, Mr X asked to speak to customer relations about the complaint and was told they would ring him back. Four days later, he had still had no response.
25. On 1 October, Mr X brought his complaint to the Ombudsman.
26. On 2 October, the Care Provider emailed Mr X and advised it had arranged for him to meet with the IO on 10 October at midday. It did not say where. Mr X could not find out from the Care Provider so he was unable to attend. He did not get to speak with the IO at all.
27. On 26 October, the IO wrote to Mr X and apologised for the communication with the manager and the delay replying. It referred to his complaint about “lack of care”, though Mr X had not complained about this. It said Mrs Y had appeared more confused than normal although she had been eating and drinking well and mobilising as usual and staff had put a food and fluid chart in place as a precaution. The GP had attended Mrs Y and advised to call an ambulance if she worsened, which they did. It did not provide the information he had asked for and barely mentioned the lack of communication.
28. Because of this response, Mr X now has concerns why the Care Provider did not simply provide him with a copy of the food and fluid chart when he asked for this information.
29. The Care Provider says that the senior manager investigating Mr X’s complaint was on sick leave for several months had only made initial enquiries before going on sick leave. The complaint should have been picked up by another manager but this did not happen.
30. It says the home is now under new management and will ensure residents’ representatives are contacted should a resident’s health deteriorate. It also ensures food and fluid charts are reviewed daily by management and completes “frequent” personal plan audits to check the care plans.

Did the Care Provider’s actions cause injustice?

31. The Care Provider did not respond adequately, either to Mr X’s request for information, or to his complaint about this. The IO did not speak to Mr X and did not get the complaint right. There was no in-depth investigation required so the delay in dealing with this complaint was excessive; over three months when it said ten days. The Care Provider was at fault in the way it handled Mr X’s complaint and this was a potential breach of regulation 16.
32. The Care Provider also did not let Mr X know that Mrs Y’s health had deteriorated and it had called the GP. As Mrs Y did not have the mental capacity to decide about her care, Mr X was Mrs Y’s legal representative, and should have been consulted. This was a potential breach of regulation 9.
33. This lack of communication and failure to provide information caused Mr X avoidable and significant distress at an already difficult time. This was particularly frustrating because his initial request for information was so simple and easily dealt with. I am concerned why the Care Provider did not simply provide Mr X with a copy of the food and fluid charts when he first asked.
34. I am also concerned about the conflicting information in the records and the continuing delay providing the information. However, I cannot say that this caused any further injustice. Mr X will now receive the information he asked for enclosed with this statement.

Agreed action

35. To remedy the injustice caused, the Care Provider has agreed to:
• Apologise to Mr X for the faults identified above; ensuring it is clear what his complaint was, and what went wrong.
• Ensure verbal complaints are actioned properly.
• Ensure staff contact representatives when a resident’s health deteriorates, unless there is good reason not to.
• Ensure that complaint investigations look at the complaint made and provide a proper response.
• Ensure its records are accurate and consistent in future.
• It will complete these recommendations within two months of the final decision and submit a copy of the apology to the Ombudsman.

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Final decision

36. I have completed my investigation and uphold Mr X’s complaints that the Care Provider:
• Failed to provide information about Mrs Y’s food and fluid intake when he asked for it.
• Failed to respond effectively to his complaints about this.
37. The Care Provider has agreed to complete the recommended actions which will put right the injustice it caused as far as possible.

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Investigator's decision on behalf of the Ombudsman