Summary: Some areas of the day to day care provided to Ms Y at a care home were below an acceptable standard, and staff failed to keep records of complaints made. Complaint responses from head office failed to address all points of complaint

The complaint

1. Mrs X complains about the quality of care provided to her late aunt, Ms Y, in Ashgrove Residential Care home during the last six months of her stay.
2. Mrs X also complains she has not had a satisfactory response to her complaint about these matters.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)

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How I considered this complaint

4. I have:

• considered the complaint and discussed it with Mrs X;
• considered the correspondence between Mrs X and the care provider, including its response to the complaint;
• made enquiries of the care provider and considered the responses;
• taken account of relevant legislation;
• offered Mrs X and the care provider an opportunity to comment on a draft of this statement, and considered the comments made.

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What I found

Relevant legislation

5. 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.
6. One of the fundamental standards (regulation 9 of the regulations for service providers and managers) is about person-centred care. Each person should receive person-centred care and treatment, based on their individual needs.
7. Standard (regulation 12) is about safety. Care providers should not put people receiving care at risk of harm that could be avoided. It says care providers should be able to show they have taken all reasonable steps to ensure the health and safety of those receiving care.
8. Standard (regulation 16) is about complaints. This says staff must know how to respond when they receive a complaint, and this can be verbal. Care providers must thoroughly investigate complaints. This includes keeping records of complaints and actions taken.
9. Standard (regulation 17) is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.

Background

10. Ms Y went into the care home for respite care after a hospital stay in October 2017. She decided to stay permanently.
11. Mrs X says she became increasingly concerned about the quality of care provided to Ms Y in the last six months. Amongst other concerns, she was particularly concerned about pain Ms Y suffered, which increased in severity until she was admitted to hospital in May 2018. Mrs X says the care home failed to challenge the GP or seek further medical advice about this.
12. Mrs X says some of the day to day care was not to an acceptable standard. Ms Y was sometimes left in soiled pants. If she requested a commode around mealtimes, she could be left for 15-30 minutes before carers responded because staff were busy with meals. On one occasion Mrs X arrived at the care home around tea-time to find Ms Y distressed because she had asked for a commode and had been told to wait. Mrs X says she reminded the carers, but it was another 15 minutes before carers responded. When they did, a carer challenged Ms Y about her request and she had to intervene.
13. Mrs X says Ms Y was often upset because of the way carers dealt with her. Ms Y believed carers were whispering about her, and on one occasion she overheard care staff talking about not wanting to deal with her.
14. Mrs X also says Ms Y did not receive adequate pressure area care and a pressure sore on her foot deteriorated.
15. Mrs X contacted the Care Quality Commission (CQC) to complain. The CQC advised Mrs X to put her complaints to the care home manager Mrs X did so and says the manager assured her she would address the issues and that improvements would be made. Mrs X says there was no improvement.
16. In April 2018, Ms Y said she “couldn’t stand it any longer” and asked Mrs X to find her a different care home. Mrs X says the care home were aware Ms Y wanted to move.
17. Ms Y was admitted to hospital on 7 May 2018. Two days later she received a diagnosis of terminal cancer with bone metastasis.
18. Mrs X wrote the care provider on 24 July, 28 August and 24 September 2018. I have seen copies of these letters. In the letter of July 2018, Mrs X complains about the quality of care provided and asks for a “reduction in the amount payable due to the poor standard of care she experienced… I had numerous conversations with [Manager] and her Seniors plus various Carers and the registered GP about my concerns at the poor standard of care - all of which I assume was documented as I had previously raised a safeguarding concern with CQC”.
19. Mrs X received responses to her complaints in August and September 2018. I have seen copies of both documents. Mrs X is dissatisfied with both responses, saying they do not address all the points of complaint.

The Care Provider’s response to the Ombudsman’s enquiries

20. The Care Provider is unable to locate any assessments or care plans for Ms Y. It says “There is no evidence the whole file was ever logged or archived. The file records available are incomplete. It appears that potentially these were separated from the original records in August 2018”. 
21. It has been unable to locate any records or information of liaison between the care home and the GP. It says, “However, any comprehensive records in relation to health professional visits rely upon the visiting professional recording these within the care records”.
22. It says referrals and contact with health professionals are set out in its letter to Mrs X in September 2018. This shows the involvement various NHS health professionals had with Ms Y, including physiotherapists, an advanced nurse practitioner and a GP. There are 16 recorded contacts between 30 November 2017 and 7 May 2018. Opiate pain relief was prescribed and increased. Referrals were made for scans, and bloods were taken on 6 February 2018.
23. The Care Provider has provided me with copies of daily care records, positional change charts and wound care plans. These records show the daily checks on pressure areas. Carers measured the pressure area on Ms Y’s foot and took regular photographs. Referrals were made to a tissue viability nurse on three separate occasion. Carers recorded the advice given on each occasion.
24. The daily care records show Ms Y sometimes refused to comply with physiotherapy recommendations about mobility because she was experiencing increasing pain. She wanted staff to hoist her when transferring. On 13 April 2018, a carer recorded Ms Y was upset that three carers tried to get her to stand in the toilet, and that she had accused staff of whispering about her. The carer recorded staff were not discussing Ms Y. Records show Ms Y was at times distressed and that she was sometimes unhappy with how care staff dealt with moving and handling and using the toilet.
25. The Care Provider says it is unable to locate any notes of the complaints, discussions and meetings Mrs X had with the care home manager and care staff. It says the manager no longer works for the company.
26. The Care Provider says it first received a written complaint from Mrs X on 24 July 2018, but this related to care fees, and does not reflect the complaint made to the Ombudsman. The Care Provider’s response to Mr X in August 2018 says it had reviewed Ms Y’s care records, including relative’s communications and contact between the care home and health professionals. The author says the care home “sought advice and support for [Ms Y] when any concerns became apparent about her health and wellbeing, whether identified by colleagues, family or Ms Y herself. I was also able to evidence that we were in regular contact with the GP, Advanced Nurse Practitioner, Physiotherapist and Tissues Viability nurses regarding [Ms Y’s] health needs. In addition, some medical screening in the form of a scan was also undertaken, at the request of the G.P”.

Analysis

27. There are numerous issues to consider here. Was the care provided to a satisfactory standard, did care staff do enough in seeking advice about Ms Y’s pain, and did the care home deal with Mrs X’s complaints about this properly.
28. The complaints about the care provided relate primarily to two issues, how care staff responded when Ms Y requested the toilet, and particularly, how staff managed her mobility.
29. It appears from the records there were occasions Ms Y was unhappy about how carers responded to her requests for the toilet. Mrs X recalls one occasion Ms Y was kept waiting at least 15 minutes after she arrived at the care home and reminded carers about Ms Y’s request. This is poor practice and not acceptable.
30. Ms Y believed carers did not want to deal with her, and that she overheard them whispering about her. Carers recorded they were not discussing Ms Y. It is not acceptable for a service user to hear carers whispering. This leads to suspicion and bad feeling. Any discussion which cannot be had in a service user’s presence should be conducted elsewhere.
31. The evidence shows the care home responding properly to Ms Y’s complaints of pain. It referred her to NHS professionals. Ms Y had input from GP’s, advanced nurse practitioner, and physiotherapists. Bloods were taken and scans ordered. Physiotherapist advised care staff how to manage Ms Y’s mobility. Care staff followed this advice. Unfortunately, Ms Y had an undiagnosed condition which was the cause of her pain. This was not discovered until she was admitted to hospital. Had this information been known earlier the care plan for Ms Y would have been different. At the time, the care home acted in good faith and followed professional advice, it is not at fault for doing so. Mrs X believes the care home should have challenged the GP when Ms Y’s pain did not ease. The care home is not at fault here. Ms Y had contact with numerous health professionals, and tests and scans had been ordered, the care home had no reason to doubt or challenge this.
32. It is understandable Ms Y did not want to comply with mobility advice when she was in pain. This was crux of some of the discord between the carers. Mrs Y wanted more help than the carers had been advised to give. This must have been very difficult for Ms Y but it was not because of any fault by care staff it was due to Ms Y’s undiagnosed condition.
33. The care home failed to keep proper records of Mrs X’s complaints, and the discussions she had with the manager and care staff. This is fault and in breach of standard 16 of CQC’s fundamental standards. This added to Mrs X’s frustration at a difficult time. The Care Provider should apologise for this.
34. After Ms Y left the care home Mrs X made formal written complaints to head office. I have seen copies the complaint response letters. The initial complaint response in August 2018, acknowledges Mrs X “raised a number of complaints”. The author of the letter says during her investigation she considered records of ‘relatives communications’ from the care home. It is not clear why such records were available to the author, and not to the Ombudsman. The letter adequality explains how the care home responded and managed Ms Y’s pain, but it does not address the complaints made about day to day care, some of which were indicated in the daily care records.
35. The Care Provider says Mrs X’s first complaint does not reflect the complaint she made to this office. I do not agree. Although Mrs X is seeking a reduction in care fees, her complaint about the quality of care provided is clear.
36. The complaint response of September 2018 lists all clinical advice/intervention for Ms Y. This was an appropriate response to the complaint about Ms Y’s pain but it did not address all the points Mrs X raised. Had it done so Mrs X may have been reassured her complaint had been dealt with properly.

To summarise

37. There is no fault in the way the care home responded to Ms Y’s complaints of pain. It sought appropriate NHS intervention.
38. There is evidence of poor practice in some of the day to day care issues, staff whispering in earshot of Mrs Y, and not responding to requests for the toilet in a timely manner. The care home failed to keep proper records of complaints/discussions between Mrs X and care staff.
39. The Care Provider failed to address all points of complaint in its complaint responses to Mrs X.
40. There was some injustice caused to Ms Y by the poor practice identified above. However, this cannot now be remedied because Ms Y has sadly passed away.
41. There is also some injustice to Mrs X. The care home failed to record her complaints. This would have informed later investigations by head office. The complaint responses she received failed were unsatisfactory and caused her additional frustration.
42. Under the terms of our ‘Memorandum of Understanding’ I intend to send a copy of the final decision statement to the Care Quality Commission.

Agreed action

43. The Care Provider will with within four weeks on the final decision:

• provide Mrs X with a written apology for its failure to record and respond fully to her complaints.
• consider staff training in relation to record keeping
• ensure complaints are dealt with in line with company policy.

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Final decision

44. There is evidence of fault in this complaint.
45. The above recommendations are a suitable way to remedy the injustice caused to Mrs X. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman