Summary: Mr B complains about the care his late mother received. The Provider failed to administer her medication properly, it did not encourage her to rise for breakfast, gave him false information about this, and did not address his concerns properly at the time. The Provider’s actions caused Mrs Y and the family injustice. It should refund half the fees paid by Mrs Y to her estate. It should also pay £500 to Mr B in recognition of the distress it caused him.

The complaint

1. Mr B complains about how the Care Provider managed his late mother’s care while she stayed at its residential care home. In particular, Mr B says the Provider:
• Allowed his mother to sleep and so was not giving her prescribed medication;
• Allowed her food and fluid intake to reduce as she also missed mealtimes;
• Told him that it would need a Deprivation of Liberty Safeguards (DoLS) authorisation to encourage her to get out of bed;
• Failed to ensure that Mrs Y was protected from falls; and
• Failed to ensure that she had clean bedding.
2. Mrs Y did not receive the care to which she was entitled. The family say she endured pain and suffering and significant emotional distress.

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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 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. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)

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How I considered this complaint

7. I have considered the information sent to me by Mr B including the safeguarding report and correspondence between the family and the Provider. I have also considered the law and guidance. Both parties have had the opportunity to comment on a draft of this statement and I have taken these into account before reaching a final decision.
8. I have shared this decision statement with the Care Quality Commission (CQC) in line with our information sharing agreement.

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What I found

The law and guidance

9. 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 CQC has issued guidance on how to meet the fundamental standards below which care must never fall. Relevant to this complaint is:
• Regulation 12 includes a requirement that medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. The CQC’s guidance says that staff must be competent to manage and administer medication and that staff must follow the relevant policies and procedures.
• Regulation 12 also covers safe care and treatment. The CQC understands that there may be inherent risks in carrying out care and treatment, but providers should demonstrate that they have taken all reasonable steps to manage the risks.
• Regulation 14 requires that the provider must meet nutritional and hydration needs. The CQC’s guidance says that arrangements should be made for people to receive their meals at a different time if they are absent or asleep when a meal is served. The guidance also says that people should be encouraged to be independent and should receive appropriate support, which may include encouragement when they need it.
10. DoLS provide protection for people who lack the capacity to decide about their accommodation where such arrangements amount to a deprivation of their liberty.
11. Where the care home believes the arrangements for a person may amount to a deprivation of liberty, they must apply to the local authority for an authorisation of that deprivation. If arrangements for a person’s care amount to a deprivation of liberty and this is not authorised by the local authority, it will be unlawful.

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What happened

12. Mr B’s mother, Mrs Y lived in a residential care home belonging to and managed by the Provider. Mr B became concerned about the standard of care soon after his mother started living there. Mr B and his family visited very frequently. They were concerned that Mrs Y’s health was deteriorating. Mrs Y’s care records showed that the Provider was not making sure she was getting her medication or her breakfast and instead allowing her to sleep. Mrs Y was already underweight when she was admitted to the home.
13. The family raised these issues with the Provider. The family say that staff told them they would need DoLS authorisation to wake Mrs Y for her medication. The family was also concerned that Mrs Y was not being supervised properly, as she had been found having fallen in a disused office and although she was continent, her bedding was soiled and smelled of urine.
14. Mrs Y had a number of falls and on one such occasion she was admitted to hospital. The medical staff identified that she had not had vital medication and the care notes said this was because she was asleep. The hospital advised that Mrs Y should not return to the home and so Mr B arranged for his mother to move to another care home on discharge from hospital.
15. Mr B complained about the standard of Mrs Y’s care whilst living at the original care home. The local Safeguarding Adults Board investigated these issues. In August 2018, it found:
• Medication had been missed and staff was not following the policy. The Provider’s own review had identified that there was a lack of leadership within that part of the staff. The records showed that in a period of one month, Mrs Y had not been given her thyroid medication or her aspirin around 20 times.
• The Provider had put in place new processes so that refusal of medication was reported to a manager, and support from senior managers from another part of the organisation was put in place.
• The Provider’s review found that record keeping was not detailed enough and so it raised this issue with staff and made clear what was required.
• The Provider delivered training and put more support in place around the Mental Capacity Act and best interest decisions.
• The Provider had taken action against key staff and dismissed the managers. The Safeguarding Board was satisfied with the outcome and agreed no further action was required.
16. The Provider’s manager wrote to Mr B. In summary:
• It was sorry and its staff should have done more to encourage Mrs Y to take her medication, and should have raised the issue with the family or clinical staff. It has replaced the key staff members involved and standards will be improved. It said the medication records between 31 May and 29 June do mostly say that Mrs Y missed her medication because she was asleep.
• It apologised for not doing enough to support Mrs Y to get up and have breakfast. It has changed its procedures. However, it said that its notes showed that Mrs Y had a varied diet and chose from a range of food at other mealtimes.
• Although Mrs Y was underweight, she was weighed monthly and did not lose weight while in its care. It had however, not identified her initially as at risk of weight loss and so had only latterly introduced weekly weighing.
• It could not investigate whether Mrs Y had been left in soiled bedding as there was no detail as to dates this happened. Mrs Y was not incontinent and was able to take herself to the toilet.
• It is unacceptable that staff told Mr B they would need a DoLS authorisation to allow them to encourage Mrs Y out of bed. It has given training to all its staff on this issue.
• It apologised that the former manager did not always adopt open and transparent communication with families.
17. Mr B complained again to the Care Provider’s head office. Sadly, by this time, Mrs Y had died. He said that her experience of care had been horrendous and left them feeling devastated and empty. He asked the Provider to refund the care costs his mother paid while in the home and some compensation to recognise the pain and suffering caused to Mrs Y and her family.
18. The Care Provider responded and although it provided a little more detail. It did not agree to make any payments or explain why it would not do so.
19. Mr B complained to the Ombudsman. He said:
• The Provider had accepted failings in how medication was administered. They had raised concerns about her deteriorating health. Mrs Y missed 13 doses of aspirin over a short period. Mr B points out that his mother developed a blood clot. Staff had told Mr B that Mrs Y did not refuse medicine but that she was not woken for this.
• He had raised his concerns with staff about his mother’s failing appetite and her fatigue. It took the Provider too long to implement food and fluid charts or weekly weigh ins. The family had to request a doctor’s blood test, which revealed that Mrs Y’s symptoms were due to hypothyroidism. He says the staff should have taken action earlier.
• In the last month, Mr B began to visit his mother twice a day because he was so concerned about the poor care. He would sometimes find her still in bed in the afternoon.
• The management did not deny that residents were left in wet or soiled clothing, but the Provider had not investigated this. The family had raised concerns with staff, management and the Social Worker about this.
• There was not enough staff to supervise residents properly and they often had to go to look for staff to see to his mother. His mother was struck by another resident but no staff witnessed this, and they could not always explain how or when Mrs Y had fallen. Her last fall happened in a disused office with no supervision. She should not have had access to this.
• Mr B would like a full refund of the fees his mother paid to be refunded to her estate in recognition of the pain and suffering she endured and the significant emotional distress following her hospital admission.

Was there fault by the Provider causing injustice to Mrs Y and her family?

20. The Provider has acknowledged significant fault in how it administered medication and how it kept records. It has also admitted that its staff did not deal with the family’s concerns properly and gave false information about DoLS. This was a potential breach of the fundamental standards.
21. The Provider did not investigate whether Mrs Y had been left in soiled bedding or whether the level of supervision was sufficient. The safeguarding investigation (completed after Mrs Y had moved to another home), found the recommended staff level of five carers had been met but the Provider did then increase this to six staff on shift.
22. It is not possible for me to ascertain whether Mrs Y was left in soiled bedding or clothes and the staffing levels were adequate. However, it cannot be acceptable that Mrs Y fell in a disused office, although there is a level or risk inherent in care work, on balance the Provider did not take all steps to make sure Mrs Y was safe, on that occasion at least.
23. The inadequate care caused an injustice to Mrs Y. She did not receive the care to which she was entitled, and this caused her to suffer unnecessarily. Mr B feels strongly that failures in his mother’s care led to her decline. He has sent me photographs of his mother on the first and last day she lived at the home. Mr B also stresses that the admissions to hospital were traumatic for his mother, both physically and psychologically.
24. The photographs do suggest a clear decline in Mrs Y’s appearance and health, and I realise this must have been distressing for her and her family. However, I cannot say to what extent any decline, or the impact on her of hospital admissions, were caused by the Provider’s shortcomings. I can say that Mrs Y did not get all the care she paid for.
25. The Provider had also acknowledged that its staff were not always open and transparent with the family. This means that the Provider’s actions also caused Mrs Y’s family distress and put them to more time and trouble than necessary when it failed to deal with concerns as and when they came to light. We cannot say that the Provider’s failings caused Mrs Y’s health to deteriorate but the family understandably suspect this to be the case and are left uncertain.

Agreed action

26. The Provider has apologised to Mr B and has put new processes and staff in place to make sure these problems do not occur.
27. In addition, the Provider has agreed to within one month of this decision show the Ombudsman that it has:
• Refunded half the care fees Mrs Y paid during her stay.
• Paid Mr B £500 in recognition of the distress he was caused and the time and trouble he was put to when the Provider failed to deal with his concerns.

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Final decision

28. I have completed my investigation. The Provider’s actions caused Mrs Y and her family injustice. The Provider has agreed to remedy the complaint.

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Investigator's decision on behalf of the Ombudsman