Summary: the care provider acknowledges it failed to update its information about Mrs X and so did not provide her with proper care and treatment during her stay. It has now apologised, reviewed its procedures and offered a full refund of her fees. That is a suitable remedy for the injustice suffered.

The complaint

1. Ms A (as I shall call the complainant) complains that the care provider did not update its information about her mother’s condition when she returned to the care home for a respite stay. As a result Mrs X received little personal care or assistance with her continence needs during her stay and her dignity was compromised.

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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))

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How I considered this complaint

4. I considered the written information provided by Ms A and the care provider. I spoke to Ms A. Both Ms A and the care provider had the opportunity to comment on an earlier draft of this statement before I reached a final decision.

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What I found

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. 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.
7. Regulation 9 says the care and treatment of people must be appropriate and meet their needs. The guidance says assessments must be reviewed regularly and whenever they are needed throughout the person’s care and treatment… “this includes when they transfer between services, use respite care or are re-admitted or discharged”.
8. Regulation 10 says service users must be treated with dignity and respect.

What happened

9. Mrs X previously stayed at the care home in August 2018. She booked in for a respite stay in March 2019 while Ms A went on holiday. In between the two stays at the home Mrs X suffered a stroke.
10. Ms A says when they met the deputy manager before Mrs X went back into the home in March she felt reassured that Mrs X would be looked after. She says she explained that since the stroke Mrs X needed more care and was not as able as before. She told the deputy manager that Mrs X struggled to get dressed, and needed assistance because of her incontinence. She says she was told that Mrs X’s laundry would be done.
11. The assessment which the deputy manager completed said that Mrs X wore pads during the day and would bring a supply with her. It noted she would need the assistance of a carer in the morning to help her dress. It said she may use her wheelchair to get to the dining room and would need the support of a member of staff.
12. Ms A says when she visited Mrs X two days after admission she noticed the bin in her room was overflowing with used incontinence pads. She says she asked who would normally empty the bins and was told it was the role of the care staff: she says she realised that no carers had been into her mother’s room since her arrival. She says Mrs X was also complaining she struggled to use the toilet as there was no grab rail.
13. Ms A says she telephoned Mrs X every day while she was away and Mrs X said no-one came to help her when she pressed the call bell. Ms A also says when her brother visited Mrs X she had tried to wash her own underwear and there were soiled pads around the room again.
14. Ms A collected Mrs X from the care home on her return from holiday. She says Mrs X was not dressed properly and was not wearing underwear. Mrs X said she never wanted to return to the care home, no-one had helped her and she could not remember how she had got to the dining-room.
15. Ms A telephoned and then emailed the manager to complain about her mother’s stay. The manager asked the deputy manager about the pre-admission assessment and the contact with Ms A during Mrs X’s stay. The deputy manager accepted she had not written enough in the pre-admission assessment to alert other staff to the changes. She said she had not formally liaised with other staff about Mrs X’s needs or asked Mrs X whether she had settled or if she had other needs.
16. The manager completed an investigation report. She said staff had not read the pre-admission assessment and had assumed Mrs X was returning as an independent resident. She could not find any evidence that Mrs X had received any personal care during her stay. She said the system for removing used continence pads was not always effective (although she added Mrs X sometimes hid the pads around the room). She said a grab-rail was installed for Mrs X’s use as soon as Ms A had raised concerns that her mother was struggling to use the toilet without help.
17. The manager also reported that Mrs X had not put dirty laundry in the bag provided for her use, although staff had removed dirty items they had seen. They said Mrs X told them Ms A would do her laundry. Finally the manager said Mrs X had used her call bell and the logs showed response times varied according to how busy staff were with other residents. She said the call bell had not been used in the latter part of Mrs X’s stay.
18. The manager upheld the complaint and said Mrs X had been admitted on a care package which was not then implemented. She recommended ‘reflective practice’ for the deputy manager and the care manager; discussion of the incident as a significant learning point at the monthly meeting, and the offer of a free two week stay.
19. The manager wrote to Ms A with an apology and the offer of a two week stay. Ms A discussed the offer with Mrs X who said she did not want to return to the care home.
20. The manager offered the sum of #400 instead as the reimbursement of the care element of Mrs X’s stay.
21. Ms A complained to the Ombudsman. She said she had been assured at the pre-admission meeting that her mother’s needs would be met but this had not happened.
22. In response to my enquiries the care provider says as a result of the complaint, the pre-admission assessment is now completed with all information and presented to the care team. She says a team leader is allocated to meet the resident on the first day of admission, go through the assessment and check it is correct. A more robust cleaning and housekeeping schedule has been implemented.
23. The care provider has also now refunded the whole payment for Mrs X’s stay.

Analysis

24. The care provider failed to act on information about Mrs X’s needs. That caused her injustice as she was left without personal care for the time of her stay.
25. The care provider failed to act on the evidence that Mrs X was hiding used incontinence pads and may need help. That affected her dignity.

Agreed action

26. The care provider has now reviewed its practices and put in place suitable measure to improve and to prevent a recurrence;
27. The care provider’s refund of the care fees is a suitable way to remedy the injustice caused to Mrs X.

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Final decision

28. Injustice was caused to Mrs X. The care provider’s actions are a suitable remedy.

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Investigator's decision on behalf of the Ombudsman