Summary: Ms X complains about the care provided to Mr Y. She says these events were upsetting for the family and caused a lot of stress. The Ombudsman finds the Council at fault in some areas and recommends it apologise and ensure similar problems do not arise in future.

The complaint

1. The complainant, whom I shall refer to as Ms X, complains on behalf of the late Mr Y, that when he went into the Knoll nursing home for respite, the Council:
• did not provide information and essentials to hospital staff when he was admitted to hospital;
• did not return his personal items;
• did not make enough effort to advise family when he was unwell and admitted to hospital;
• did not notice when he lost weight;
• did not take him to a key hospital appointment;
• did not respond adequately to the family’s complaint;
• did not use his emergency pack of medication when he got a chest infection; and
• did not take appropriate action when he became dehydrated.
2. She says these events were upsetting for the family and caused a lot of stress. She would like an apology from Alder Meadow Limited (the Care Provider) and the Council, also to ensure lessons are learned so this does not happen to anyone else.

Back to top

The Ombudsman’s role and powers

3. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended). In this case, we have exercised discretion to consider these issues which date back to late 2017. This is because Ms X and Mrs Y spent many months pursuing the complaint and then a personal bereavement caused a break in this before Mrs X brought the complaint to us.
4. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
5. 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)
6. 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, Ms X is Mr Y’s daughter and we consider her a suitable person to bring this complaint on Mr Y’s behalf.

7. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
8. 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.

Back to top

How I considered this complaint

9. I considered information from the Complainant and from the Council.
10. I sent both parties a copy of my draft decision for comment and took account of the comments I received in response

Back to top

What I found

Background

The Care Quality Commission

11. 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.
12. Regulation 9 is about personalised care. The CQC’s guidance on the regulations says:
• “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
13. Regulation 14 is about meeting nutritional and hydration needs. The guidance says:
• “Staff must follow the most up-to-date nutrition and hydration assessment for each person and take appropriate action if people are not eating and drinking in line with their assessed needs”.
14. The CQC inspected The Knoll care home on 20 September 2017. This found the service was ‘Good’ in three of five areas, and ‘Requires improvement’ in the remaining two areas. This gave an overall rating of ‘Requires improvement’. Relevant findings in this inspection included:
• “People did not always receive their medicines as prescribed”.
• People’s dietary needs and preferences were documented and known by care and catering staff within the home”, “the chef and care staff were informed when people had lost weight or if their dietary needs had changed”.
15. There have been several changes of manager since these events and the Care Provider has made many improvements including an electronic recording system. The Knoll has since been inspected and given an overall rating of ‘Good’ by the CQC.

Council complaint procedure

16. Councils should have clear procedures for dealing with social care complaints. Regulations and guidance say they should investigate a complaint in a way which will resolve it speedily and efficiently. A single stage procedure should be enough. The Council should say in its response to the complaint:
• how it has considered the complaint; and
• what conclusions it has reached about the complaint, including any matters which may need remedial action; and
• whether the responsible body is satisfied it has taken or will take necessary action; and
• details of the complainant’s right to complain to the Local Government and Social Care Ombudsman.

(Local Authority Social Services and National Health Service Complaints (England) Regulations 2009).

What happened

17. Mr Y had various health conditions and disabilities which caused him difficulties with breathing, mobility and daily living activities. He lived at home with his wife, Mrs Y and had one care call a day.
18. At the start of December 2017, the Council placed Mr Y in Knoll care home for two weeks respite as Mrs Y was unable to continue providing the care he needed. The Council extended his stay and planned for him to stay there permanently. Mr Y’s pre-admission assessment noted “Offer breakfast in room at 08:00 to encourage him to rise earlier”.
19. Ms X says Mr Y had an emergency pack of medication for use when his breathing symptoms were not controlled by the regular medication. This contained antibiotics and steroids to take in the case of any cough, cold or chest infection. The Care Provider has no record of an emergency pack. Mr Y’s prescription, and his care plan, note only his regular medication. The care plan says staff should monitor Mr Y for signs of distress whilst breathing, tremors, headaches or palpitations. It sets out actions to ensure Mr Y’s medication was administered effectively. It does not set out any action to take in case of breathing difficulties beyond his regular medication but says to report any concerns to the senior on shift and manager.
20. The Care Provider’s care plans for Mr Y cover an appropriate range of support areas. They contain detailed and useful information to enable staff to provide the care he needed. I saw no suggestion that the Care Provider, or the professionals involved, had any concern that he could not make decisions for himself.
21. Mr Y’s care plan for nutrition says staff should weigh him fortnightly and record this. Staff completed food and fluid charts but I saw no weight charts. The fluid charts show Mr Y was on occasions over the target intake and below target on an equal number of days through December; the main deficit arose from 10 December. The daily records show the detail of fluid offered and how much he drank. The records also show the food offered to Mr Y and how much he ate. He mostly ate well though this varied and also reduced from 10 December. The daily notes and monitoring forms show Mr Y was often asleep at 8am and sometimes until late morning. He would also often sleep during the day.
22. On 12 December, Ms X visited and says Mr Y was still in bed and “in poor condition”. She says he had lost a lot of weight and when she raised this with the manager she said he had eaten 3,000 calories the previous day. The daily notes from 11 December state that he did not eat much at breakfast and lunch. They also note he had been sleepy on 8, 9, 10, 11 and 12 December. On 13 December, the notes show he was still sleepy and “seems very weak and will not try to eat his dinner”. They also show he was prompted with different foods. The Care Provider contacted the GP who prescribed some antibiotics.
23. Two days later, the Care Provider did not take Mr Y to a hospital appointment although Ms Y had given the details in advance. Mrs X says the Care Provider assured her it would organise transport and accompany him. The hospital advised Ms X that he had not attended and no one had cancelled the appointment.
24. In mid December, Mr Y was admitted to hospital as an emergency. The Care Provider left a message on Mrs Y’s phone just after 7am but Mrs Y was still in bed and could not hear the phone. Ms X says the Care Provider made no further attempts to contact her or Mrs Y to let them know Mr Y was in hospital. The hospital called Mrs Y at 09:30 to let her know he was there. Ms X says she was told Mr Y was probably nearing the end of his life. She says he was completely dehydrated and the hospital staff were concerned about the care he had received. I saw no evidence that the hospital staff raised safeguarding concerns about Mr Y’s condition or admission.
25. Mr Y travelled to hospital in an ambulance. Ms X complains that no one from the home accompanied him. The Care Provider sent no continence pad, medication, or personal belongings including his watch, spectacles, and hearing aids. It sent no information about his medical conditions or care needs with him. The hospital called the Care Provider and asked for his hearing aids; Mr Y could not see or hear properly without his hearing aids or spectacles. The Care Provider now has an electronic system which allows it to print a “hospital passport” which contains all the information needed by the hospital on admission.
26. The following day, a note says a member of staff took Mr Y’s hearing aids “and belongings” to the hospital. This was untrue as Mrs X continued chasing for these items for some time. Mrs X says family were with Mr Y all the time that day because he was at the end of life and no staff from the Care Provider visited. When the Care Provider did return some items, they still did not include his medication and spectacles, and the clothes were not his. She also says the hearing aids were not included.
27. Mr Y had creams for his skin but the hospital pharmacy had none in stock. The Care Provider would not release the medication without Mr Y’s signature. Seven days after Mr Y was admitted to hospital, the Care Provider faxed a form to the hospital for Mr Y to sign which Mrs Y signed on his behalf. A family member picked the cream up and took it to the hospital. Medication must be signed for by the person or authorised representative before being taken out of the home. Ms X also says the manager told him they didn’t have Mr Y’s watch as he had been wearing it; she says this was not true. She also says the Care Provider sent more clothes, many of which did not belong to Mr Y.
28. On 2 January 2018, when Ms X telephoned to chase the outstanding items, the manager advised that Mr Y’s spectacles and watch were on her desk and had been for weeks as she did not know they were Mr Y’s.
29. Sadly, Mr Y died a few days later.
30. On 12 January, Ms X wrote to the Care Provider asking it to return Mr Y’s watch, spectacles, some clothes and a walking frame and collect the clothes which did not belong to him.
31. On 19 February, Ms X wrote to complain about the care provided to Mr Y. She said Mr Y was often unshaven, unwashed and unkempt when they arrived at the home on unannounced visits. One morning, they found his cold breakfast was still in front of him at 11:30, and on two occasions he was still in bed at 3pm. He also had a urine bottle which he could not hold because of arthritis. Mrs Y gave notice of her visits and Mr Y was always up and dressed for these, as he was for the social worker’s pre-arranged visits. She said Mr Y had missed the hospital appointment and a haircut because he was not up in time.
32. Ms X also complained that, on one occasion, she had to bang and shout to get someone to close the lift door on another floor so she could use it. She needed a code to open the other doors and no one had given this to her. She also became trapped in the corridor for ten minutes on the way out because it happened again. She could not get back into the unit or leave without using the lift. She was concerned about the risk in case of a fire.
33. On 22 February, the Care Provider wrote acknowledging Ms X’s complaint and said it would respond in no more than 28 working days.
34. On 22 March, the Care Provider wrote with its response to Ms X’s complaint. It said it found:
• Mr Y had received help to eat and drink every morning and had showers daily until he began to feel unwell in the week before his admission to hospital. It said it would work with the manager to review how it instructs staff to provide help to people in the morning according to their preferences.
• It would review arrangements for making codes available for the lift area but there was no risk in case of fire as the doors would automatically unlock.
• It was working with the manager and her team on effective communication.
• It could find no record of staff advising the hospital when people could not attend appointments so it would work with staff to develop a system for this.
• Staff should have made more effort to contact family to advise that Mr Y had gone to hospital; it will work to review all records for communicating changes.
• Basic information was sent with the ambulance crew and there was no need for staff to accompany Mr Y. It was working with the manager to review how information is shared when a person is admitted to hospital.
• Staff had been closely monitoring Mr Y for hydration levels but due to his sleepiness and ill health he was not drinking much.
• Staff were not monitoring Mr Y’s breathing and the information available should he present with an infection was basic. Staff had not been trained in the management of COPD. It would ensure all staff received training and was working with the manager in improving how information is shared with staff about responding to changes.
• It is not usual for prescribed medications to be sent to hospitals. It was helping the manager to understand how to communicate essential skin care to hospital teams.
• The manager contacted the social worker who said they would call and collect the items but this didn’t happen and the manager did not communicate with Ms X. It was working with the manager around good customer care and how to respond appropriately to complaints. The items have now been delivered.
35. The Care Provider gave findings on each area of complaint “not upheld”, “partly upheld” or “inconclusive”. On 27 March Ms X wrote to the Care Provider as she disagreed with the findings. The Care Provider wrote on 23 April saying it had reviewed the decisions and confirmed the findings. It also told Ms X she could bring her complaint to the Ombudsman if she remained dissatisfied.
36. Several further communications took place between Ms X and the Care Provider and continued until November. Ms X said she was not happy with the outcome of her complaint and the Care Provider said it did not understand what more she wanted.
37. The Council undertook contract monitoring with the Care Provider. There have since been several management and procedural changes.

Was there fault which caused injustice?

38. When Mr Y went to hospital, the Care Provider should have sent an overview of Mr Y’s care needs, up to date medication chart and other relevant information. It should also have sent his personal items and enough pads and clothes for a short period. Practice varies around medication and not all hospitals accept medication from care homes. However, the Care Provider should have communicated with the hospital more clearly and made sure Mr Y had sufficient medication or creams for at least 24 hours. This was fault and is likely to have caused Mr Y avoidable discomfort. Any reasons for not sending medication should have been recorded on the case notes as should the information and items sent with Mr Y. The Care Provider did not fully respond to this issue in its complaint response and it is not clear what information it did send with the ambulance, if any. However, it did take action to improve this process in future.
39. The Care Provider could have avoided the problem with the return of Mr Y’s personal items had it sent these to hospital with Mr Y. I would expect Mr Y’s essential personal belongings, such as spectacles, hearing aids and clothes, enough for a short period, to be sent to hospital with him. Confusion about the items concerned was fault and caused avoidable stress to Mrs Y and frustration, time and trouble to Ms X.
40. The Care Provider’s response to Ms X’s complaint was adequate but was not communicated well. Whether the individual issues were upheld or not, did not all reflect the findings. However, I don’t agree with Ms X’s view of all these. I have not listed these because there were many discussions on many points, most of which were minor and it would not be proportionate to consider this in detail. The significant issues are addressed here separately. The Care Provider told Ms X she could come to the Ombudsman but she continued to pursue her complaint with the Care Provider who provided no further response. This caused no injustice because it had already advised her of the next step of the complaints process. I found no fault here.
41. The Care Provider should have kept a record of Mr Y’s weight as it set out in his care plan. Failure to do this was fault and put Mr Y at an undue increased risk of harm however, I saw no evidence that the Care Provider failed to feed him adequately.
42. I saw no record of a hospital appointment but it is accepted that Mr Y did not attend. Given his health at the time, and that he was admitted to hospital the following day, although this is fault, I consider it unlikely to have caused any injustice. The Care Provider acknowledged a flaw with its system and says it took action to improve this in future which is an appropriate response.
43. I saw no evidence of an emergency medication pack and anyway, I would expect the Care Provider to consult a GP before administering any medication. I would also not expect the Care Provider to administer medication without supporting evidence of a recent prescription. However, if the pack had been brought to the home on admission, the Care Provider should have recorded why if it didn’t accept it or consulted with the GP and recorded this. Some of the correspondence from the Care Provider suggests a pack was provided but there is no other record. This was fault and caused frustration and stress to Ms X but fortunately, I do not consider the absence of this pack caused any injustice to Mr Y. However, the lack of detail about action to be taken in the case of any increase in symptoms put Mr Y at an undue risk of harm.
44. Mr Y was unwell and had been sleeping a lot. His fluid intake dropped significantly in the days before his admission to hospital, so it is not surprising he was dehydrated. There is no record the Care Provider raised the reduced fluid intake when it consulted with the GP and it should have done this; this was fault. However, I do not consider the hospital staff’s concerns were as significant as understood by Ms X as they did not raise any safeguarding concerns. I would expect this to happen if they had concerns about his treatment and the cause of his dehydration.
45. The Care Provider accepted that it could have done more to advise family of Mr Y’s hospital admission. It did leave a message and the hospital contacted Mrs Y two hours later and the family were able to visit so although this could have caused significant injustice, I have concluded that on this occasion it did not. The Care Provider has taken action to improve communication in future and I consider that an appropriate response.
46. Unfortunately, Mrs Y has also since died and so we are unable to put right any injustice caused to either Mr or Mrs Y.
47. As I have identified potential breaches of regulations 9 and 14, I will send a copy of the decision statement to the CQC.

Agreed action

48. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council.
49. To remedy the injustice identified above, I recommended the Council:
• Within one month of the final decision, send letters to Ms X, from both the Council and the Care Provider, apologising for the faults identified above.
• Ensure the Care Provider now has a suitable process in place for transferring residents to hospital and advising residents’ families.
• Ensure the Care Provider has weight charts in place where required and is using this information appropriately.
• Ensure the Care Provider has a robust system for noting health appointments and ensuring people attend.
• Ensure the Care Provider is taking appropriate action when fluid intake drops.
• Complete these remaining recommendations and send a record of the checks made, and findings, to the Ombudsman within three months of the final decision.
50. The Council has agreed to complete these actions.

Back to top

Final decision

51. I have completed my investigation and uphold Ms X’s complaints that the Council:
• did not provide information and essentials to hospital staff when he was admitted to hospital;
• did not return his personal items;
• did not make enough effort to advise family when he was unwell and admitted to hospital;
• did not notice when he lost weight;
• did not take him to a key hospital appointment; and
• did not take appropriate action when he became dehydrated.
52. I do not uphold Ms X’s complaints that the Council:
• did not respond adequately to the family’s complaint; and
• did not use his emergency pack of medication when he got a chest infection.
53. By completing the agreed actions above, the Council will remedy the injustice it caused as far as possible.

Back to top

Investigator's decision on behalf of the Ombudsman