Summary: Mrs X complains about the care provided to Mrs Y and the lack of response to her complaints about this. She would like a response to her complaints. The Ombudsman finds the Council at fault in the lack of adequate response to her complaints. The Council has agreed to apologise and provide a response to Mrs X’s complaints.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains that the care provided to Mrs Y, by the Council, was not adequate and she received no response to her complaint.
2. Mrs X would like a response to her complaint and answers to the questions she asked.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. 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)
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.

7. (Local Government Act 1974, section 26A(2), as amended). In this case, we have decided Mrs X is a suitable person to bring this complaint on Mrs Y’s behalf.

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How I considered this complaint

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

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What I found

Background

Complaint handling

10. 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).

11. This also applies where a Council has commissioned a Care Provider to provide a service on its behalf. If the Care Provider deals with a complaint, the complainant should not then also have to go through the Council’s complaints process.

What happened

12. Mrs Y lived at home and received support from Mrs X and a care package arranged by the Council. On weekdays, she went to a day centre by herself on a minibus, using a walking frame and observed by Mrs Y and the bus driver in case of need. She moved to Ashley Court Care home in August 2018 initially on a two week emergency placement, because her carer gave notice suddenly. Mrs Y had poor eyesight and a health condition causing difficulties with cognition and challenging behaviour.
13. Towards the end of November, Mrs Y fell at the care home. The Care Provider said she had been unsettled during the night and had been walking around the unit using her walking frame. The nurse on duty had given her Diazepam around 22:30 but “it had little effect”. She did not sleep and began walking around again. At just after 7am, she let go of the frame with one hand and fell to the floor. She was in pain and had injured herself so a nurse called 999 and Mrs Y was taken to hospital where she had an operation on her injury.
14. The Care Provider raised a safeguarding referral the day after the fall and the Council began a safeguarding enquiry.
15. A few days later, Mrs X also wrote to the Council with several concerns. These included:
• Staff repeatedly gave Mrs Y the wrong flavour of nutritional supplement drinks; Mrs Y would only drink one flavour. Mrs X had raised this with the manager because staff continued to give the wrong flavour. The Council found the GP surgery had not prescribed the one flavour. The GP corrected this in October and Mrs X was advised.
• That staff had not washed Mrs Y properly and she had two urinary infections in less than one month. Two male carers were washing Mrs Y and staff were not giving the cream her GP had prescribed. The Council found no one had advised the Care Provider that Mrs Y would prefer female only carers and it arranged this towards the end of November. It also found the cream chart showed staff had applied the prescribed cream regularly. Mrs Y was susceptible to urinary infections and on each occasion the Care Provider had taken suitable action.
• Mrs Y had a cut on her leg which Mrs X believed had come from the bed. Mrs X says the social worker had told her this could not be investigated as no-one witnessed it. The Council looked into it through the safeguarding enquiry and found it was possible Mrs Y had caught her leg on the side of the bed. The Care Provider asked all staff to ensure they always tucked in the bed wheels. Mrs X’s partner had also padded the bed legs which the Council felt would sufficiently reduce the risk.
• Staff responded poorly to a fire alarm which triggered while Mrs X was visiting, leaving Mrs X and others unclear what was happening. The Council subsequently found the Care Provider had improved the procedures and information significantly. It had also allocated more staff as fire marshals and reiterated the procedures to staff.
• Mrs X wanted to know the following about the fall:
1. why staff gave Mrs Y Diazepam 30 minutes after having Trazadone.
2. why there were no rails on the bed as Mrs Y was at risk of falls, and
3. why two members of staff were following Mrs Y, but not next to her.
• The Council found that staff had given Mrs Y the Diazepam as prescribed and the Trazadone also as prescribed, half an hour later. The Trazadone was to be taken when needed. The Council said Mrs Y was unlikely to have been over sedated and anyway, the fall happened nearly eight hours later.
• Mrs X was concerned when she realised Mrs Y was noted to be at risk of falls but this is not surprising given her sight loss and health conditions. The Council reassured Mrs X that Mrs Y had not had any falls which the family had not been notified about.
16. The Council decided Mrs Y should return to Ashley Court when she was discharged from hospital at the end of December. While she was in hospital, the intermediate care service for dementia had supported hospital staff with her care because of her challenging behaviour.
17. The Council also looked at a further injury to Mrs Y’s leg and issues around bed rails, a call bell and a pressure pad not working, and Mrs Y not changing clothing. It found the Care Provider responded properly to these issues and completed its enquiry.
18. In early March 2019, the GP prescribed antibiotics for Mrs Y. Her medication was all soluble and covertly administered in her nutritional supplement drink, by agreement with her GP. However, one of the nurses decided the antibiotics should not be taken in the drink and offered it to Mrs Y overtly. When Mrs X asked daily if Mrs Y had taken her antibiotics, the nurse said she had. However, it later transpired that Mrs Y had not taken the antibiotics offered in this way. Mrs X had no response to her questions about why medication had not been given covertly.
19. Mrs X noticed that staff were not changing Mrs Y’s continence pad often enough and her skin was becoming sore. Mrs X did this herself every three hours and asked the GP about better cream.
20. In mid March, Mrs X gave the Care Provider a list of issues which she had complained about since Mrs Y’s admission; these included the issues noted above. The Care Provider said it would respond within 28 days. The Care Provider gave Mrs Y notice and advised Mrs X she would have to move to another home. It said this was due to “breach of trust and confidence”. Mrs X says she never received this response.
21. At the beginning of April, Mrs X says she found Mrs Y in her room with four untouched drinks on the table including the nutritional supplement with medication. A cold, congealed, and untouched dinner was also on the table. She says when she raised it with a staff member, they told her they were short staffed. A few days later, Mrs X took Mrs Y out as she says there were no activities all week.
22. Soon after this, Mrs Y moved to another home. Mrs X says no staff spoke to her when she left although she had lived there for over seven months.

Was there fault which caused injustice?

23. I am satisfied the Council considered the issues properly and therefore have not investigated those issues, such as the medication, further. The care provided to Mrs Y was not perfect but the Council has already investigated much of this and taken suitable action through its safeguarding procedure. Mrs Y was often challenging and resistant to care. It is clear the Care Provider was having difficulty meeting Mrs Y’s needs and the relationship had broken down with Mrs X. I do not consider this caused significant injustice to either Mrs Y or Mrs X.
24. The Care Provider or the Council should have responded to Mrs X’s complaints as it appears no one properly communicated the Council’s findings to her. This was fault and caused Mrs X avoidable stress and frustration.

Agreed action

25. To remedy the injustice identified above, I recommended the Council:
• apologise to Mrs X for the failure to provide a response to her complaint and
• ensure she receives a response to the issues she raised with the Care Provider.
• Send a copy of the apology and complaint response to the Ombudsman within one month of the final decision.
26. The Council has agreed to complete these actions.

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Final decision

27. I have completed my investigation and have upheld Mrs X’s complaint about complaint handling. I have not upheld her complaint about the care provided.

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Investigator's decision on behalf of the Ombudsman