Summary: Ms X complains the care provided for her late mother in Seely Hurst Care Home was inadequate. The care home failed to provide a proper response to the complaint or to tell Ms X she could make a complaint to the Council. The Council has now investigated the issues via a safeguarding investigation and has found neglect.

The complaint

1. Ms X, on behalf of her deceased mother, Mrs Y, complains the care provided at Seely Hurst Care Home was inadequate and about delay in the safeguarding investigation into the care provided. She also complains the care home did not instigate agreed actions following a complaint about bullying and intimidation.
2. Ms X says the failure to properly investigate her concerns and the delays have caused stress and frustration.

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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 the documents provided by the complainant;
• made enquiries of the Council and considered the comments and documents the Council provided;
• discussed the issues with the complainant;
• sent my draft decision to both the Council and the complainant and taken account of their comments before making my final decision.

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What I found

6. Ms X’s mother was resident in Seely Hurst Care Home until her death in February 2018. This care was commissioned by the Council. In September 2018 Ms X complained about the standard of care it had provided. Ms X says she did not complain while her mother was alive because she was worried this may make the situation worse. The care home responded in October 2018. Ms X says the care home’s response is inadequate and does not properly address her concerns.
7. Ms X made complaints about the following:
• Nutrition and weight loss
• Lack of help with personal hygiene
• Response to health issues including heart failure/breathlessness, urinary tract infections, salt deficiency and transient ischemic attach (TIA) and falls
• Lack of an end of life care plan
8. In its response to the complaint, the care home failed to provide any detailed information or evidence. For example, in response to the issue about nutrition and weight loss the care home focussed on the issue of low fat yoghurts being provided. It did not provide any evidence such as daily record sheets to indicate what food was offered and whether Mrs Y accepted or declined this. No evidence of the care home recording her weight loss or how it addressed this with medical professionals.
9. The complaint response did not signpost Ms X to what further action she could take if dissatisfied. The care provider should have given information about complaining to the Council and/or the Ombudsman.

Safeguarding investigation

10. In October 2018, the Council received a safeguarding referral from the Care Quality Commission. This was allocated to a social worker who then contacted Ms X. She explained her role and what a safeguarding enquiry would involve. Ms X said she was happy for the enquiry to proceed.
11. In November 2018, the social worker visited the care home and spoke to the manager and one of the Board of Directors. The social worker also inspected the records for Mrs Y.
12. The social worker continued to make further enquiries about Mrs Y’s care. This included seeking information on Mental Capacity Assessments, information from the Dietician Team and Mrs Y’s GP.
13. In January 2019, the Council wrote the care home concluding the enquiry. It stated the view that there were acts of omission/neglect in respect of the care provided to Mrs Y. The care home responded in February expressing its dissatisfaction with the Council’s findings.
14. The Council explained that as the care home was not satisfied with the safeguarding enquiry findings it was required to hold a further intervention meeting. It said it would produce a report with the enquiry findings and this report would be discussed at a meeting chaired independently by a safeguarding co-ordinator.
15. The Council tried to arrange the meeting for 7 March. Ms X said she could attend but the care home asked for an alternative date as one Director was unable to attend. An alternative date of 21 March was agreed. The Council shared the reports that would be discussed at the intervention meeting with Ms X and other family members. The meeting did not take place on 21 March due to confusion between the parties about the date.
16. The intervention meeting took place on 24 April. Ms X told me the representatives from the care home attended but refused to participate and left the meeting. The meeting continued without them and upheld the report and found neglect in respect of the care provided to Mrs Y. Ms X is still waiting to receive a copy of the minutes and any recommendations.

Bullying and intimidation

17. Ms X says the family were invited to a meeting in October 2017 by the directors of the home. Ms X understood this was to discuss an incident relating to her mother’s health. She says the directors wanted to discuss other issues and that she felt ambushed into discussing issues she was not prepared for.
18. The directors wanted to discuss the ongoing relationship between the home and the family. The care home produced minutes after the meeting. One of the agreed actions stated “it was agreed to set time limits and parameters within a new probationary working arrangement between the family and the home until Christmas 2017, followed by a review.”
19. Ms X says no details were ever provided explaining the new parameters of the relationship. Ms X says the care home said it would give notice on Mrs Y’s placement if the family continued to work against it and it was felt it could not meet Mrs Y’s care needs. Ms X says she did not make a complaint or raise this issue as she felt bullied and intimidated.

Analysis

20. Ms X made complaints, after her mother’s death, about the standard of care provided by Seely Hurst Car Home. The complaint response from the care home lacked detailed information and failed to properly address the issues raised. The care home did not provide any information to Ms X about how to escalate the complaint to the Council. It would have investigated the complaint if Ms X was dissatisfied as it commissioned Mrs Y’s care. The failure of the home to provide this information is fault.
21. Ms X saw information on the Care Quality Commission’s (CQC) website about the standard of care in the care home. She contacted CQC about her mother’s care and it made a safeguarding report to the Council. The Council investigated the complaint.
22. I have seen a copy of the report prepared by the social worker investigating the safeguarding referral. This report indicated neglect by the home in a number of areas. I am told the further intervention meeting has now taken place and the findings of neglect were substantiated. I do not know what, if any, recommendations have been made as a result of this finding.
23. It is possible that Ms X’s complaints have now been satisfactorily answered as a result of the safeguarding investigation. I am therefore not persuaded there are any recommendations I should make or unresolved issues to identify. It is open to Ms X to make a new complaint to the Council if she is dissatisfied with the outcome and considers there is any injustice that has not been adequately remedied.
24. Ms X says the safeguarding investigation has been delayed. The information provided includes a chronology of events in respect of the investigation. The investigation started in October 2018 and has only just concluded, seven months later. While this is longer than would normally be expected, there is no evidence of unavoidable delay by the Council. The chronology shows the actions taken and there is nothing to suggest periods where nothing happened. The Council regularly updated Ms X of the progress of the investigation.
25. Ms X also complained about the care home’s failure to implement an action agreed at a meeting in October 2017. The Ombudsman does not normally consider complaints unless they are made within 12 months of the person first becoming aware that something had happened which affected them. Ms X knew by Christmas 2017 that this agreed action had not been put into place. I note she felt intimidated and unable to raise issues about her mother’s care because of the threat she would be evicted.
26. Ms X complained to the Ombudsman on 31 December 2018. This is just outside the 12 month limit but it is not so late that I consider it outside the Ombudsman’s jurisdiction. However, I am not persuaded it would be a good use of public money to now investigate this further. It was open to Ms X to raise this sooner than she did. She knew in October 2017 that details of the time limits and parameters for raising issues should have been provided to her. There is nothing to suggest she raised the failure at the time.
27. Mrs Y died in February 2018 and so there is no longer any direct relationship between the home and Ms X. I appreciate Ms X’s frustration that the care home failed to do something it said it would and that this affected how she raised issues about her mother’s care. However, I am not persuaded any useful outcome can now be achieved by considering this further. I am therefore using my discretion and will not pursue this aspect of the complaint further.

Agreed action

28. The Council has emailed all care homes providing commissioned care to make them aware of its complaints process and ensure that this information is made available to all residents and their families.

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Final decision

29. I will now complete my investigation as a suitable remedy has been carried out.

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Investigator's decision on behalf of the Ombudsman