Summary: Mrs C complains the Care Provider failed to support Mrs D properly during a short stay. It also lost belongings, failed to provide feedback, properly dress Mrs D or transfer medication properly when she left. There is no evidence to suggest the care home did not support Mrs D properly while she was at the care home. However, the Care Provider did not make appropriate arrangements for when Mrs D left the care home or correctly explain how Mrs C could escalate her concerns. The Care Provider has agreed to apologise for the failings identified, make a payment to Mrs D and make procedural changes.

The complaint

1. The complainant, whom I refer to as Mrs C, complains on behalf of her sister, whom I refer to as Mrs D about services provided by Charing Dale Limited, the “Care Provider”, at Chippendale Lodge, a residential care home. Mrs C complains that during Mrs D’s stay: -
• items went missing;
• slippers and leggings were soiled and smelt of urine;
• Mrs D was not supported with eating and she left the care home hungry;
• medication was not properly managed;
• staff failed to provide feedback on the stay.

Back to top

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. If we are satisfied with a care 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)
5. 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)

Back to top

How I considered this complaint

6. I read the documents Mrs C provided and based on this information made enquiries of the Care Provider. This included asking questions about the services provided and documentary evidence of the actions taken. I considered this information alongside Mrs C’s complaint documents before reaching a draft decision.
7. I have written to Mrs C and the Care Provider with my draft decision and considered their comments.

Back to top

What I found

What should have happened

8. 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. I have used the Care Quality Commission (Registration) Regulations 2009 when considering this complaint. I have referred to these as the “Regulations”.
9. Regulation 12 says care providers should manage and administer medicines safely and appropriately to ensure that people are safe. The Care Provider’s medication policy says when a person leaves a care home it should complete a transfer document.
10. Regulation 14 says care providers need to ensure service users have adequate food and drink to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment.
11. Regulation 15 and the associated guidance says care providers should secure residents’ personal property.
12. Regulation 16 says care providers must have a system for identifying, receiving, handling and responding to complaints. All complaints should be investigated, and necessary action taken where a care provider has identified fault.

What happened

13. Mrs D had a three night stay at the care home. Mrs D does not have capacity to make decisions about her care. The care home completed a pre-admission assessment and care plan. The care plan says Mrs D needed a carer to support her with personal care, medication, continence and at mealtimes.
14. Mrs C says that she was unable to attend the pre-admission assessment due to ill health but her nephew told the care home that she was the first contact point. Mrs C says he also told the care home that it did not need to do any washing for Mrs D as she had plenty of clothes.
15. Mrs C collected Mrs D from the care home on a Monday morning so she could attend her regular day centre. Mrs C says she contacted the care home twice beforehand to let them know when she was coming. Staff therefore had an opportunity to tell her if the time was inconvenient.

16. Mrs C says the Care Provider failed to give her any feedback on Mrs D’s stay. She would have liked a written report reflecting Mrs D’s stay.
17. Mrs C says the care home gave her Mrs D’s medication without providing any hand over. Mrs C says Mrs D’s care plan identified a need for help with eating and drinking and that she would not eat unless someone gave her food or drink. Mrs C says Mrs D was hungry when she left the care home and as a result, she had to stop so Mrs D could eat a sandwich and cakes. Mrs C therefore does not consider Mrs D had enough food at the care home.
18. Mrs C says Mrs D was not wearing a bra or incontinence pad when she left the care home. Her leggings smelt of urine but were dry. Mrs C says the deputy manager of the day centre commented that Mrs D smelt. The care home packed Mrs D’s belongings. When Mrs C unpacked she noticed several missing items including clothing and toiletries. Mrs C also complains that a pair of new slippers were soiled with urine.
19. Mrs C complained to the Care Provider who provided a substantive response to the complaint saying Mrs C could escalate her concerns to CQC.
20. The Care Provider accepts that it did not complete a transfer form when handing over Mrs D’s medication. It also accepts that Mrs D was not wearing a bra when she left the care home. It has apologised for this and raised the issues with the staff members involved.
21. The Care Provider says Mrs C picked Mrs D up early during a busy time at the care home. It therefore did not have enough opportunity to provide feedback and considers this was in part why it did not follow its usual medication procedure.
22. The Care Provider says Mrs D ate well at the care home. It says it told Mrs D’s son that he should label her clothing. The Care Provider has managed to find some of Mrs D’s clothing but not the remaining toiletries. It has contacted Mrs D’s son to collect the clothing but so far this remains at the care home. In response to a draft of this statement Mrs C says due to the concerns about the care provided to her sister she does not feel able to go back to the care home to collect the found belongings.
23. The Care Provider also contacted the day centre. The day centre manager has said that neither she nor her staff noticed that Mrs D smelt when she went to the day centre.

Was there fault causing injustice?

24. The Care Provider has accepted it was at fault for failing to complete a medication transfer report. The Care Provider has apologised for this omission and raised the issue with the member of staff involved. There is nothing to suggest the omission caused Mrs D significant injustice. I therefore consider an apology is sufficient to remedy this element of the complaint.
25. There is dispute about the instructions for washing Mrs D’s clothing. It is difficult to show the Care Provider was at fault because conversations were not recorded at the time and I cannot reconcile the different versions of events. Further investigation would not allow me to reach a safe conclusion on the point and so I do not propose to pursue it further. While I appreciate how Mrs C feels, Mrs D had an opportunity to mitigate her loss by picking up the found items.
26. Mrs C says that Mrs D’s leggings smelt of urine, and Mrs D was not wearing an incontinence pad. There are conflicting accounts from the day centre about Mrs D’s appearance. The Care Provider has accepted that Mrs D was not wearing a bra when she left the care home which would have resulted in some discomfort and loss of dignity. It also casts doubt on whether Mrs C was wearing a pad that day or was wearing soiled leggings.
27. There is also conflicting information about whether Mrs D ate enough during her stay. The care records evidence that Mrs D ate well while she was resident. Mrs C disputes this because of Mrs D’s behaviour when she left the care home. The Care Provider in its response says that Mrs C picked Mrs D up when she was eating breakfast. Mrs C disputes this and says Mrs D was looking out of the window when she collected her and was not eating her breakfast. I cannot say based on the information that I have, that on balance, Mrs D’s behaviour was due to the lack of food at the care home. This is because the daily records evidence that Mrs D ate well during her stay.
28. The Care Provider has accepted that it did not provide information to Mrs C when Mrs D left because of the timing of her visit. It appears the Care Provider did not have any concerns about Mrs D’s stay. While frustrating for Mrs C, it is unlikely that it caused her or Mrs D significant injustice. I therefore consider the apology is sufficient to remedy this part of the complaint.
29. The Care Provider told Mrs C to escalate her concerns to CQC. This was fault. The Local Government and Social Care Ombudsman (LGSCO) investigates individual complaints about privately arranged and funded care homes. As a result of this advice Mrs C was put to the time and trouble of complaining to CQC rather than directly to the LGSCO.

Agreed action

30. The Care Provider had apologised to Mrs C and Mrs D for some of the faults identified. In addition it has agreed to: -
1. apologise to Mrs C and Mrs D for the further failures I have identified;
2. make a payment to Mrs D of £100 in recognition of her loss of dignity and uncertainty about the actions taken on the day she left the care home;
3. remind staff and if relevant amend the complaints process to ensure that residents and their families are properly advised about how to escalate their complaints;
4. remind staff about the importance of completing medication transfer forms and in dressing residents properly.
31. The Care Provider should complete (a)-(b) within one month of the final decision and (c)-(d) within three months of the final decision.

Back to top

Final decision

32. I consider there was service failure by the Care Provider which caused injustice. I have completed my investigation and closed the complaint based on the agreed actions above.
33. As there has been a potential breach of a regulatory standard 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

Investigator's decision on behalf of the Ombudsman