Summary: Ms B complains about the care her mother, Mrs C, received at a Bupa care home. Ms B further complains about a lack of communication about her mother’s care and the way the care home responded to her complaints. The Ombudsman finds fault which caused Mrs C and Ms B an injustice. The Council has agreed actions to remedy the injustice.

The complaint

1. Ms B complains about the care her mother, Mrs C, received at a Bupa care home. She complains that:
• there was a deterioration in her mother’s care;
• the care home did not communicate with Ms B about her mother’s care and health concerns; and
• there were inconsistencies in the care home complaint responses.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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)
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
5. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
6. 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)

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How I considered this complaint

7. During my investigation I:
• reviewed the information provided by Ms B;
• made enquiries with the Council and considered its response; and
• reviewed relevant law, guidance and policy.
8. Ms B and the Council had the opportunity to comment on my draft decision and I carefully considered all the comments I received.

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What I found

Law and guidance

9. The Care Quality Commission (CQC) has published guidance on meeting the fundamental standards expected of care providers. Care and treatment must reflect the needs and preferences of residents, who must be treated with dignity and respect. Care providers must meet resident’s nutritional and hygienic needs and protect them from abuse. We consider this guidance when deciding complaints about poor standards of care.
10. Section 27(1) of the Care Act 2014 places a general duty on local authorities to keep care and support plans under review.

Background

11. Following a hospital admission in 2012 Mrs C and her family decided she needed to move into a care home. The Council carried out a care assessment and assisted with finding a suitable placement. Mrs C was eligible for Council funding for the placement. The care home is run by Bupa.
12. The Council carried out a review of Mrs C’s support plan in 2013.
13. Mrs C remained at the placement until she sadly passed away in March 2019.
14. Ms B says she was very happy with the care her mother received at the care home, and the communication, until October 2018. From this date she developed concerns about some aspects of her mother’s care and the lack of communication from the care home.

What happened

15. I have provided the below chronology and analysis under the headings of Ms B’s complaint and the complaint response. This is not a full chronology of everything I reviewed during my investigation but the key information relevant to the complaint headings.

Mrs C’s hearing

16. Ms B says that in October 2018 she noticed her mother was struggling with her hearing and this was affecting her ability to socialise and communicate with other residents.
17. The care home record says this was discussed with Mrs C in January 2019 and the GP prescribed eardrops. In February 2019 the GP prescribed further eardrops because he was reluctant to syringe Mrs C’s ears at the home.
18. An appointment was made to take Mrs C to have her ears syringed in April 2019.
19. In her complaint Ms B says:

‘My mother had always had presence within the home, supporting other residents but her frame of mind had changed. I assumed this was because she was struggling with her hearing; something which in retrospect could easily have been sorted out but never seemed a priority. Leaving a vulnerable person unable to hear for want of having her ears syringed seriously impacted on my others emotional state’.

20. In its stage two complaint response Bupa said:

‘please accept my apologies for the distress that this may have caused to your mother, the delay in time is completely unacceptable and this should have been made a priority’.

My findings

21. I find fault with the way the care home responded to Mrs C’s care needs in respect of her hearing issues. The home was aware of the issue and the impact on Mrs C’s hearing. By failing to prioritise Mrs C’s attendance at the GP surgery it meant Mrs C suffered with hearing issues for longer than necessary. Ms B says this impacted her ability to socialise with other residents in the home, which also affected her emotional wellbeing.

Recording of information

22. Ms B raised several issues in her complaint which relate to the accuracy of case recording and information in Mrs C’s care records. She says Bupa:
• failed to record the fact Mrs C had a swollen right arm the day before she passed away;
• told her the Tissue Viability Nurse (TVN) visited Mrs C at the home when this visit did not take place; and
• informed her, in the stage one complaint response, that the day before Mrs C passed away she:

‘had a settled day… there were no concerns raised from your mother or by the care team’.

23. Ms B says:

‘my mother did not have a settled day prior to her death….. when I visited my mother on that afternoon, my mother was in bed…. She had a pillow under her right arm…. When I asked her why she showed me her right hand and arm which was swollen and cold to touch. She said the care staff first noticed this swelling the previous day so I would have expected this to be in her notes’.

24. In relation to recording about Mrs C’s swollen arm the Bupa stage two response said:

‘Upon reviewing the notes, I can see that this has not been recorded which is clearly unacceptable and I apologise for this omission’.

My findings

25. Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) relates to good governance. It says the provider must securely maintain an accurate, complete and contemporaneous record in respect of each service user.
26. I find fault with the way the care home recorded information about Mrs C’s care. Prior to her death Mrs C had a swollen hand/ arm and this was not recorded in her notes. There was also no record of whether the care home considered seeking medical advice about her swollen hand/arm.
27. I can understand the distress this has caused to Mrs C’s family, as it means there is uncertainty with the accuracy of Ms B’s records about the care she received and if that care was sufficient.
28. I agree with Ms B that the comments made in Bupa’s stage one response about the day before her mother passed away are misleading. The response suggests there were no issues or concerns. As well as the issue of Mrs C’s swollen arm the case notes also recorded the following comment:

‘Mrs C seems a bit off in her mood’

29. I find fault with Bupa for providing a misleading and inaccurate response to Ms B’s concerns about her mothers condition the day before she passed away. This issue was not clarified in its stage two response. This caused Ms B distress because she felt Bupa were not being honest in the responses it provided.

Communication

30. Ms B says she was a very regular visitor at the care home and always felt well informed about her mother’s health and care. She noticed a change in 2018 and did not feel she was kept as well informed.
31. In her complaint Ms B specifically raises the fact she was not told about her mother’s weight loss or a change in her pain relief.
32. In its stage two response Bupa said:

‘I am sorry for the failure to mention your mothers weight loss and poor appetite. There is evidence that this had been documented in the care records but had not been communicated to yourself. This is not acceptable, and I sincerely apologise’.

33. In response to my enquires Bupa provided its resident and relative communication record for Mrs C. There are only two logs in this record. One relates to the discussion about Mrs C’s hearing issue. The other is the communication with Ms B on the day Mrs C was transferred to hospital in March 2019.
34. I cross referenced the communication record with the care records and can see there was a lack of communication with Ms B about her mother’s health and care. It may be the case that care home staff were communicating with Ms B when she visited her mother, but this has not been recorded.

My findings

35. I find fault with the way Bupa communicated with Ms B about Mrs C’s health and care. It must have been very distressing for Ms B to read information in her mother’s care records she had not been aware of prior to her death. This distress was avoidable.

Time in bed

36. Ms B was concerned Mrs C was spending too much time in bed.
37. In its stage two response Bupa said:

‘Mrs C went to bed in the afternoon as she spent her mornings in the lounge or attending activities with other residents. There is evidence of this in her daily notes. Whilst the staff always encourage our residents we do also have to respect their wishes should they wish to return to bed. However, your mother was able to make her own decisions and often chose to go to bed in the afternoon’.

My findings

38. The evidence I reviewed during my investigation supports this statement from Bupa.
39. I do not find fault in relation to this aspect of the complaint.

The Council

40. The Council carried out a care needs assessed with Mrs C in 2012 after she was admitted to hospital. It arranged and funded the care home placement.
41. There is a copy of a review from 2013.
42. I have seen no evidence of any further reviews. In 2015 The Care Act 2014 came into effect. There are no records Mrs C’s support plan was transferred or reviewed considering these changes.
43. I asked the Council for evidence of how it monitored the quality of care provision for Mrs C. It said:

‘I am aware having looked through electronic records no review was completed for this client and there has been no correspondence with the late Mrs C’s family throughout Mrs C’s stay at the care home. I accept and acknowledge this is not the expected standard or practice of the Council and for this I apologise’.

44. Chapter 13 of the care and support statutory guidance provides guidance on section 27 of the Care Act 2014 in respect of reviewing care and support plans. It says:

‘Keeping plans under review is an essential element of the planning process. Without a system of regular reviews, plans could become quickly out of date meaning that people are not obtaining the care and support required to meet their needs. Plans may also identify outcomes that the person wants to achieve which are progressive or time limited, so a periodic review is vital to ensure that the plan remains relevant to their goals and aspirations’.

and

‘It is the expectation that authorities should conduct a review of the plan no later than every 12 months, although a light-touch review should be considered 6– 8 weeks after agreement and sign-off of the plan and personal budget, to ensure that the arrangements are accurate and there are no initial issues to be aware of’.

My findings

45. I find fault with the Council for failing to keep Mrs C’s care and support plan under review. By failing to carry our regular reviews it could not be satisfied the plan or the placement at the care home was relevant and sufficient to meet Mrs C’s needs.
46. I also find fault with the Council for the way it monitored the quality of care provision at the care home where Mrs C was placed. The Council says it has a process for monitor and review, but it was unable to provide any evidence this was carried out in Mrs C’s case.
47. I do not consider the above caused Mrs C a significant injustice. Prior to the issues outlined in Ms B’s complaint the family had been happy with the care Mrs C received at the home. I have seen evidence the care home had assessed Mrs C’s care and support needs and kept these under regular review.
48. I have also seen evidence the home was inspected by the CQC in October 2018 and the Council in February 2019.

Complaint handling

49. Bupa responded to Ms B at stage one and two of its complaints process. Ms B says there are discrepancies between the responses. She feels Bupa were not being truthful and were trying to cover up what happened leading up to her mother’s death.
50. I asked the Council how it monitors complaints about its care providers and evidence of how this was carried out in Mrs C’s case. It said:

‘The Council monitors complaints in relation to providers by working with the Care Quality Commission and Quality Assurance Manager who is employed by the Council. If a complaint is received the Quality Assurance Manager will visit the provider and report any concerns to the Locality Team. The Council will also support the provider to make any necessary improvements. Please find enclosed the most recent quality assurance report’.

51. The quality assurance report the Council provided is from November 2019, several moths after Mrs C passed away. The Council was not aware of Ms B’s complaint until it was contacted by the Ombudsman as part of this investigation.

My findings

52. I did not find any evidence Bupa deliberately misled Ms B or were untruthful. However, I agree with Ms B that the complaint responses contain different findings.
53. Both complaint responses are based on Bupa’s complaint investigation report (May 2019). I cannot see any reason why the information given to Ms B in the stage two response could not have been communicated in the stage one response.
54. This caused Ms B additional time and effort to escalate her complaint at what was already a very difficult time. I can also understand why the different responses caused Ms B concern about the reliability of the information she was given by Bupa.
55. I find fault with the way the Council monitors complaints about its providers. It does not have a robust system in place for complaints notification and monitoring for care providers. It could not provide evidence it is aware of complaints against the providers it commissions to deliver services on its behalf.

Remedy

56. Where we find fault causing injustice, we may suggest a remedy. Bupa have already accepted fault in relation to some aspects of this complaint and offered the following remedy:
• an apology for:
1. failing to prioritise Mrs C’s GP appointment;
2. failing to keep Ms B informed; and
3. failing to keep accurate records.
57. It also proposed the following service improvements:
• an action plan to improve communication with relatives;
• additional training and supervision in relation to record keeping; and
• sharing the learning from this case within the care home and Bupa team.
58. The Council have apologised for failing to review Mrs C’s care and support plan and communicate with the family.
59. The Council has not provided any explanation for the faults I have identified or reassurance of how it will ensure these faults do not happen again. For this reason, I have made service improvement recommendations below.
60. The examples of poor care Mrs C experienced and the lack of communication with Ms B caused her avoidable distress. She was also caused additional time and trouble by having to escalate her complaint to stage two.
61. I acknowledge the distress caused to Ms B at an already difficult time. I recommend a financial payment to Ms B to remedy the injustice she has been caused by the faults I found with Bupa and the Council during my investigation.

Agreed action

62. 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 Bupa, I have made recommendations to the Council.
63. Within four weeks of my final decision the Council agree to:
• Pay Ms B £300 in recognition of the avoidable distress caused, and time and trouble pursuing the complaint.
64. Within 12 weeks of my final decision the Council agree to:
• provide evidence the service improvements listed at (57) have been completed;
• ensure a procedure is in place to monitor complaints about its care providers;
• conduct an audit of Council funded care home residents to identify any other cases with out of date care and support plans; and
• review the care management system to ensure there is a mechanism in place to alert the Council of cases which require a review.
65. The Council should provide the Ombudsman with evidence the above actions have been completed.

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Final decision

66. I find fault with the Council, which caused Mrs C and Ms B an injustice. The Council has agreed actions to remedy the injustice and improve the service.

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Investigator's decision on behalf of the Ombudsman