Summary: Mrs F complains on behalf of her mother about several aspects of her care at the Provider's residential care home. The Ombudsman has found there was one action which caused injustice to Mrs J, but this has already been remedied by an apology.

The complaint

1. Mrs F complains on behalf of her mother, Mrs J, about several aspects of her care at the Provider's residential care home. In summary, Mrs F complains that:
1. The Provider's communications were poor and inconsistent;
2. There was no proper handover between shifts;
3. The staff were not adequately trained and did not have the right skills to meet Mrs J's needs;
4. The Provider did not have a sufficient overview of Mrs J's care to keep her safe;
5. The Provider did not make sure that the room and equipment were maintained;
6. The Provider did not properly investigate her complaints and would not meet with her following the investigation report and has not told her how it implemented recommendations to improve its service;
7. The Provider served an eviction notice on Mrs J following the investigation of her complaints.
2. Mrs F says, the lack of care meant that she had to visit her mother every day to make sure her needs were met. Mrs J lost over a stone in weight because the correct diet was not supplied. The eviction notice put undue pressure on the family, and a move would have a significant effect on Mrs J's health and wellbeing.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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)
6. 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.

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How I considered this complaint

7. Another investigator spoke to Mrs F about her complaint. I have considered the information she sent and the care provider’s responses to our enquiries.
8. The length of our investigation was affected by the coronavirus pandemic.
9. Mrs F and the care provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Fundamental Standards of Care

10. 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. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user's behalf in the planning of their care and treatment.
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user's health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Safeguarding from abuse (Regulation 13): Service users must be protected from abuse and improper treatment, this includes neglect.
• Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Premises and equipment (Regulation 15): Providers must make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located.
• Complaints (Regulation 16): The provider must have a system in place to handle and respond to complaints.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

What happened

11. Mrs J is elderly and has dementia and health conditions. She was admitted to West Hall Care Home (the Home) operated by the Provider in January 2018. Her daughter, Mrs F, has Power of Attorney for Health and Welfare since January 2019.
12. Mrs F was concerned about her mother's care and on 31 January 2019 she complained to the home about a number of matters, which I have summarised as:
• Mrs J had lost a significant amount of weight and had not been given the correct soft diet
• Carers did not follow the care plans, giving medication at the wrong times or incorrectly, and not ensuring Mrs J did necessary exercises
• Mrs J had fallen six times and the Home had not taken action to prevent falls, only making one referral to the falls team
• Staffing levels and handovers between staff were insufficient, meaning carers did not know what care to provide
• Repairs were not done on time, there were problems with laundry and other facilities
• There were safeguarding issues with the security of the Home, and another resident had entered Mrs J’s room
13. The Home met with Mrs F to discuss her concerns but Mrs F found that there was little progress on the issues she had complained about and so the Provider agreed to conduct an independent review, which was carried out by a senior manager. The local authority reviewed the issues relating to Mrs J’s falls.
14. The Provider’s review separated Mrs F’s concerns into 54 separate heads of complaint. It investigated each issue using information from the family, the daily care records, interviews with staff and the Provider's policies. The final review report was sent to Mrs F on 14 July 2019. It upheld some of Mrs F’s complaints and made recommendations for action by the Home.
15. One week later the Home served an eviction notice on Mrs J. It said it could no longer meet the family’s needs. Mrs F met the Home on 7 August 2019 to discuss this. She did not want to move Mrs J as she felt this would have a significant impact on her health and quality of life, would be very stressful and confusing, and she may not recover.
16. Mrs F complained to the Ombudsman in August 2019. She said the eviction notice had put undue pressure on the family and it was not possible to find an alternative placement in such a short timeframe.
17. Mrs F also said it was not clear what actions the Home would take to rectify matters. Mrs F had asked the Home and the local authority to meet with her to discuss this, but it would not. The Home said it had not produced the independent review report so it could not discuss it with her, the local authority said it had only played a small part and the Provider’s investigator said there was no merit in discussing it further as she had nothing to add to her report. Mrs F said she wanted the Provider to put an action plan in place to demonstrate it would make sustainable improvements to services.
18. Mrs J moved to a new care home on 29 October 2019.

Did the Provider's actions cause, or were they likely to cause, injustice to Mrs J?

19. I have not re-investigated Mrs F’s concerns in detail. I have considered the Provider’s review and decided whether the investigation appears to be adequate and whether there was any fault in the Provider’s actions which caused injustice to Mrs J. I have also considered whether the review’s recommendations addressed the issues, were proportionate and have been implemented.
20. Overall, I find the Provider’s review investigation is adequate. It addresses each issue with reference to the evidence gathered and the remedies are generally proportionate. I do not intend to set out the detailed findings on all 54 complaint elements, but in summary I have found:
• There was no fault in the way the Provider dealt with Mrs J’s weight loss. She started losing weight in April 2018, the Home referred Mrs J to the GP in July 2018 who referred her to the dietitian. The appointment with the dietitian did not take place until November 2018, but this was not due to fault by the Home. Although Mrs J lost a significant amount of weight, she did not fall below the ideal weight range for her BMI and her weight stabilised. There was one instance of Mrs J not being given her soft diet but this did not cause injustice as she was given a pureed meal instead. The family had concerns she was offered unsuitable food, but there is no evidence she was put at risk of harm.
• There were some issues in relation to Mrs J’s medication: not all the topical medication sheets reviewed carried the detail required and, whilst medications and treatments were largely administered in accordance with instructions, the communication around this and with the family and medical professionals was not always clear. Administration of an inhaler and some exercises were not properly recorded. Consent was not sought for a flu jab. However, these issues did not cause any harm or injustice to Mrs J.
• There was no fault by the Home in the way it dealt with Mrs J’s falls. It referred Mrs J to the Rapid Response team in July 2018 following three falls in line with its policy and again in October 2018. Mrs J was reviewed in July 2018 and November 2018. There was no fault by the Home in determining that bed rails, lowering the bed and crash mats would be too risky.
• There is no evidence the staffing levels or handovers were inadequate or that staff were not trained or lacked skills. Whist the care plans quickly became out of date due to the number of changes being made to Mrs J’s care, I do not find fault as they were updated and reviewed regularly.
• The Provider’s actions caused injustice to Mrs J in one element: there was a risk of harm caused by a broken emergency pull cord not being replaced for two days. The Provider has already apologised for this and I consider this to be a proportionate remedy.
• A resident entered Mrs J’s room and on one occasion there was a delay entering the Home, but this was not fault.

Actions taken following Mrs F’s complaint

21. I asked the Provider how it had implemented its review’s recommendations. It said:
• In relation to soft diets, patients’ needs are communicated to all staff using handovers sheets, weekly clinical meetings, and allocation sheets.
• Hospital discharge documentation had improved since a meeting held with senior hospital staff in February 2019.
• Disciplinary action had been taken with regards to the failure to get consent to give flu jabs.
• Review meetings with the family were held to review the care plans.
• It ensures staff reporting an issue with maintenance of equipment or furnishings place the request in an action book that is checked daily by the maintenance team and signed when the work is completed.
• Residents entering others’ rooms was managed by diversion techniques, keeping the doors closed when the resident is in their room, and redirecting as soon as it is observed.
22. The review recommended a decision was taken in Mrs J’s best interest to determine the best form of medication she required. There is no evidence this was done. However, I do not consider this caused injustice to Mrs J as Mrs F had power of attorney and was in discussion with the GP about Mrs F’s medication. The Home should ensure it records any best interest decisions taken.
23. The Provider said it had not met with Mrs F to discuss the review report as a Director and the investigator had met with the family before the review was completed and the Home was meeting with the family regularly to discuss any feedback or concerns. Whilst I understand Mrs F’s frustration at not meeting to discuss the report, and it may be good practice, there was no requirement on the Provider to do so and I do not find fault. I also note that there was a meeting after the review was issued to discuss the eviction notice.
24. The Home issued an eviction notice after the review was completed. The Provider said this followed discussion with the Council, independent investigator and senior management. It was agreed to serve notice as the relationship with the family had irretrievably broken down, and whilst the Home could meet Mrs J's needs it was evident that it was unable to meet the needs of the family. The Provider considered a lack of trust could result in poor communication, delayed actions and ultimately place Mrs J at risk.
25. I find there was fault here. Mrs J’s contract with the Home said it may serve notice if it could not meet her needs or if Mrs J broke any conditions of the contract, but this was not the case. However, I do not consider this caused injustice to Mrs J as she remained in the Home until Mrs F gave notice in October 2019.

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Final decision

26. Mrs J was caused an injustice when an emergency cord was not promptly repaired. The Provider has already apologised and I am satisfied this is sufficient to remedy that injustice. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman