Summary: Mrs X complained the care provided to her father Mr Y by Mayott House supported living was inadequate and neglectful. There were failings in management, leadership and care that had a significantly negative impact on Mr Y’s care. The care provider has waived fees for Mr Y’s stay. It has agreed our recommendations to also pay Mrs X £750 as a token remedy for distress caused by the faults. It has also agreed to send Mrs X and us a summary of actions taken to learn from the complaint.

The complaint

1. Mrs X complains the care her father Mr Y received whilst living at Mayott House for two months was inadequate and neglectful. She believes this poor care contributed to her father’s subsequent death, and to his and his family’s avoidable distress.

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The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We cannot investigate a complaint if it is about a personnel issue. (Local Government Act 1974, Schedule 5/5a, paragraph 4, as amended) This means that we cannot investigate how an adult social care provider has considered or taken action concerning the employment of a member of staff.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I spoke to Mrs X about her complaint and considered information she provided.
7. I considered the care provider’s correspondence, records of its investigation and its records of a council safeguarding investigation.
8. I considered the Ombudsman’s guidance on remedies.
9. I gave the care provider and Mrs X the opportunity to comment on my draft decision.

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What I found

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
11. The fundamental standards particularly relevant to this complaint concern:
• Person centred care – people using a service must have care and treatment that is personalised specifically for them.
• Safe care and treatment – providers must make sure medicines are supplied in sufficient quantities, are managed safely and administered appropriately to make sure people are safe.
• Good governance – providers must have effective governance arrangements, and maintain accurate complete and detailed records.
• Receiving and acting on complaints – by providing an effective, accessible system for identifying, receiving, handling and responding to complaints.

Background

12. Mr Y moved into Mayott House in 2017. This is a unit providing care and support to people living in specialist ‘extra care’ housing.
13. Mr Y’s care plan said he needed to have four calls per day, three meals a day, help with his personal care, showering and to give him medication.
14. His family, including Mrs X, quickly found that Mr Y was not getting the level of care they had agreed to and were unable to get the care home to take notice of their concerns. They said:
• His breakfast call was too early for him to get up and have breakfast. They repeatedly found him still in bed at lunch, having had no food or drink from the night before.
• Mr Y told his family that staff were sometimes treating him roughly. On occasion, they found him wet and cold.
• He had not been given his medication for a heart condition for nearly two weeks.
• His health was deteriorating, he was undernourished and dehydrated.
• He was staying in bed during the day and his doctor was concerned about his wellbeing.
• Daily records were not readily available to show the care given to Mr Y.
15. The family found it extremely difficult and, at times impossible to contact the responsible manager. They tried to arrange for meetings with key staff who were unavailable and unwilling to help. They later found the manager had not made any records of their concerns or calls.
16. After two months living in Mayott House, Mr Y became ill and was admitted to hospital. The family was not told about this promptly in accordance with the care home’s procedures. Having taken advice from social care professionals, the family decided Mr Y should not return to Mayott House. While in hospital, Mr Y died of pneumonia.
17. The only contact the family then had from the care provider was to refer to housing benefits matters which was not relevant to Mr Y. Mrs X and family complained to the care provider. It considered the complaint at a senior level and worked with the council on a safeguarding investigation into the events.

Investigation by care home and council

18. The care provider senior managers met with the family and carried out an initial investigation, running alongside the council’s safeguarding investigation.
19. In April 2018 the care provider wrote to the family with its initial findings. It said:
• The care home senior team had failed to check why Mr Y’s care package was not appropriate for him, and had failed to work with the family to address this problem despite their urgent requests.
• The team should have met with the family to discuss, at an early stage, whether Mayott House was suitable for Mr Y.
• It could not explain why the family had not been told promptly about the incident resulting in Mr Y going into hospital.
• It had not given Mr Y important medication set out in his care plan for eight days. It had only then given the medication because the family had alerted it to the problem. Some medication was out of stock and had to be ordered adding to delay.
• It had given Mr Y varied levels of care, sometimes because he had refused help. There were gaps in care records, including not referring to Mr Y’s oral hygiene. It therefore was unable to say whether staff had helped him with this, as required by his care plan.
• The care records did not refer to changes in skin integrity and pressure sores. Therefore, it could not corroborate or provide clear evidence on whether Mr Y’s condition had got worse. It accepted the family’s confidence in the adequacy of its care records had been damaged.
• The management team had not communicated effectively with the family throughout Mr Y’s care. It had not allowed the family to raise and escalate concerns appropriately.
20. The care provider apologised for the failings identified by the investigation. It referred to ongoing discussion about compensation and access to Mr Y’s care records. It also confirmed work with the council to develop an improvement plan. It said it was sharing findings with the council and considering how to raise matters with former staff who had since left employment.
21. The Council completed its safeguarding investigation. It had consulted with the CQC and confirmed the family was satisfied with its overall outcome that it partly substantiated their complaints.
22. It said the care provider had taken the matter seriously and investigated and responded in detail. It had not been defensive. It had failed to meet the expected standard of care in several respects with regard to Mr Y’s care.
23. It set out an action plan for the care provider to ensure that in future it gave:
• Adequate induction of staff and managers
• Adequate staffing
• Improved quality of client assessments, reviews and documentation
• Supervision plans and follow-up actions. Managers should have their own supervision.
• Ensure appropriate recording of issues and concerns, and implementation of actions.
• Ensure managers are trained to be able to communicate appropriately with families, especially when there is a death.
• The council contracts department would monitor developments at Mayott House.
24. The care provider wrote to Mrs X to apologise for the shortfalls identified. It said shortfalls in its leadership and management of Mayott House had a direct and negative impact on Mr Y’s care. It referred to what had happened regarding staff involved.
25. It explained it would cancel care fees for Mr Y’s time at Mayott House. Mrs X has confirmed it has waived the fees for Mr Y’s care. It referred Mrs X to the Ombudsman and asked us to consider whether compensation should be given for identified faults. Mrs X then complained to us.
26. Mrs X emphasised that the family’s requests for help had been ignored, leaving them extremely distressed, scared to leave Mr Y alone, trying to find an alternative placement. She said Mr Y’s health and wellbeing had dramatically suffered during his stay.
27. Although the care provider had accepted faults, Mrs X wanted action to be taken against staff involved. We explained that we could not take, or recommend the provider take specific action concerning current or former members of staff. She had hoped to meet further with the provider to discuss policies on recruitment and training of the management team.

Response to my enquiries

28. In response to my enquiries the care provider said:
• Its induction, mentoring and support for key staff had been poor. It now made sure the two senior roles at the location could not be new in post. At least one role needs to be covered by an experienced team leader or manager.
• It had reviewed and relaunched its performance management, appraisal and coaching approach.
• It had developed accredited training for care staff and team leaders
• It had improved leadership and oversight of the training scheme.
29. The care provider referred to the most recent CQC report, dating from an inspection in November 2018, after Mr Y’s stay. This rated each aspect of the service was “good”. Specifically, the report refers to safe management of medicines, staff treating people with dignity and respect, and an approachable management team.

My findings

30. The care provider accepts serious failings in its care for Mr Y during his two months at Mayott House. I have not reinvestigated details of this care because I cannot add to the findings of the comprehensive investigations carried out by the care provider, and Council.
31. These investigations, and the care provider’s response to my enquiries show it failed to meet the fundamental standards in respect of Mr Y’s care in respect of:
• Person centred care: Mr Y’s early, practical experience of problems with care at Mayott House was not discussed with the family or Mr Y to try to identify solutions to problems he was encountering. This was despite the family’s attempts to raise these concerns with managers.
• Safe care and treatment: the care provider failed to give Mr Y important medication for a sustained period. It only did so when the family drew attention to the problem. Its care records for skin integrity and oral hygiene did not provide enough information to enable it to reach a conclusion on the adequacy of its care for Mr Y in these areas. This means there was fault in record keeping causing uncertainty about whether Mr Y did get the care he should have.
• Good governance: the care provider had inadequate induction, mentoring and support arrangements for key staff involved in Mr Y’s care and its management. Managerial and supervisory staff did not respond to Mrs X and family’s important early concerns about Mr Y’s care. This caused them frustration and considerable distress at their inability to get answers to their serious concerns about Mr Y’s care.
32. These faults were shortfalls in leadership and management that had a direct and negative impact on Mr Y’s care. The service fell below the standard the care provider expected to give and that required by the Fundamental Standards. Mrs X understandably believes there is a strong link between failures in care for Mr Y and his subsequent death. We cannot conclude such a causal link exists as this would be a matter for a coroner’s inquest.
33. However, we can consider whether distress arising from uncertainty about the impact of the identified faults on Mr Y warrants a symbolic payment.
34. Our guidance on remedies suggests that where care providers are found to have failed to provide adequate care in line with regulatory standards, we should recommend they waive or refund fees.
35. The care provider has appropriately apologised to Mrs X and family for these faults. It has cancelled Mr Y’s care fees. It has worked with the council to complete a safeguarding investigation. It has taken, and is committed to seeing through, further management actions to prevent reoccurrence of these serious failings.
36. Its failure to communicate adequately with Mrs X about her concerns regarding Mr Y’s care plan, its inadequate care records and its failure to allow timely escalation of her complaint caused avoidable distress that merit a further payment of £750..
37. The CQC carried out an inspection of the home since investigation. This found it provides a good level of care and safe service. This indicates the care provider has learnt lessons from the experience.
38. The care provider should send us, and Mrs X a short report, three months after my final decision, setting out progress in implementing its action plan to give reassurance about the impact of that learning.

Agreed action

39. Within one month of my final decision the care provider has agreed to pay Mrs X £750 as a symbolic payment to remedy avoidable distress caused by faults identified in Mr Y’s care.
40. Within three months of my final decision the care provider has agreed to send the Ombudsman, and Mrs X a summary of progress implementing actions arising from its, and the council’s investigation of this matter. This should explain actions it has taken to ensure:
• It keeps accurate records of medication, ensuring all staff, including new/agency/temporary staff are made aware of what medication is needed.
• Managers respond promptly and responsively to concerns from residents and their families about the adequacy of care plans. It should ensure the adequacy of plans are reviewed shortly after they have had time to bed-in, as well as on an ongoing basis.

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Final decision

41. I have completed my investigation. There was fault causing injustice. The care provider has agreed recommended actions to remedy outstanding injustice.

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Investigator's decision on behalf of the Ombudsman