Summary: Mrs X complained about the care provided to her late mother, Mrs Y, at the care home. The care provider was at fault. It failed to note Mrs X’s concerns, failed to follow instructions regarding laundry, failed to record when it had followed up a continuing health care assessment, was short staffed on a day Mrs X visited and it used Mrs Y’s products on other residents. The care provider has agreed to apologise to Mrs X and pay her £250 to acknowledge the distress and frustration the faults caused. It has also agreed to provide evidence to the Ombudsman to show it has completed the actions it agreed to take to prevent the faults recurring.

The complaint

1. Mrs X complains about the care provided to her late mother, Mrs Y, at Glebe House Care Home. In particular, Mrs X says it failed to keep Mrs Y’s hands clean, failed to pursue a continuing healthcare assessment, lost her wedding ring, was short staffed and used her incontinence products on other residents. Mrs X says this caused her distress and worry.

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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) If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
3. Most local authorities and service providers have a two or three stage complaints procedure. These are designed to put things right for people quickly and efficiently when things go wrong. We would normally expect someone to be able to show they had exhausted such procedures before using the LGSCO service.
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)

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How I considered this complaint

5. I have considered the information provided by Mrs X in writing and on the telephone. I have considered the complaint responses by the care provider and the relevant law and guidance.
6. I gave Mrs X and the care provider the opportunity to comment on a draft of this decision. I considered the comments I received in reaching a final decision.
7. 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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What I found

8. 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.
9. Regulation 9 requires care and treatment to be appropriate and person-centred based on an assessment of their needs and preferences.
10. Regulation 18 requires providers to provide sufficient suitably qualified, competent and experienced staff to meet the needs of the people using the service at all times.
11. “NHS continuing healthcare (NHS CHC) is a package of care arranged and funded solely by the health service in England for a person aged 18 or over to meet physical or mental health needs that have arisen because of disability, accident, or illness.” (NHS Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012). Complaints about NHS CHC are dealt with by the Parliamentary and Health Service Ombudsman.

What happened

12. Mrs Y lived at Glebe House Care Home. She had dementia. In January 2019 Mrs X told the care home Mrs Y’s wedding ring was missing. The care home carried out a search but could not locate it. During 2019 Mrs X raised concerns with the care home about the care of her mother. In particular she raised concerns about the cleanliness of Mrs Y’s hands. In March 2019 Mrs X emailed the care home with concerns Mrs Y’s nails were dirty and items had gone missing from her room. She raised further concerns in July 2019 that it had taken her 15 minutes to find a staff member who told her there were only two staff on duty at that time. She also asked about a continuing health care (CHC) assessment she had requested months ago.
13. The manager responded and explained there were four staff on shift that day although one was on a break. They also agreed to follow up the CHC assessment with the District Nurse Team. Mrs Y died in August 2019.
14. In late 2019 Mrs X complained to the Ombudsman and we referred her complaint to the care provider to respond to through its complaints process.
15. In January 2020 the care provider responded to Mrs X’s complaint at stage one of its complaints process. It found:
• Hand hygiene: after Mrs X raised concerns, in March 2019 it introduced a hand hygiene chart. It said the evidence showed these checks were completed six times a day. In addition, it updated Mrs Y’s care plan to reflect this. It noted Mrs X met with the care home in April 2019 when she acknowledged Mrs Y’s personal care had improved. It noted Mrs X had logged further occasions when Mrs Y’s nails were dirty, however this could have occurred between checks.
• Missing items: it noted Mrs Y walked round the home and could be found in other people’s rooms putting on their clothes or taking off items. It made attempts to find the missing items but this was difficult to monitor as some items were washed at the care home and some were taken home to wash. It said it would learn from this and ensure a full inventory was maintained and reviewed every six months. It said it had made all attempts to locate the missing wedding ring but it had never been found.
• Staffing levels: they had reviewed the roster and said there were four carers and one care leader in the home on the date Mrs X referred to.
• CHC assessment: the care provider confirmed it had requested this of the district nurse and said it confirmed this in an email to Mrs X in March 2019. It could not evidence that this had been followed up in a timely manner by the care home.
• Incontinence products used by others: It apologised for this and said it was not acceptable. It noted the care home had taken action to stop this happening and said it would raise it at the next employee meeting to reinforce this.
16. Mrs X remained unhappy. She considered Mrs Y’s hand hygiene had not improved at all and that Mrs Y’s ring was not easy to remove so someone else must have taken it off her. She said Mrs Y was unable to put on others’ clothes as she could not dress herself. Also, the care home was aware Mrs X was to do all Mrs Y’s washing. She remained concerned about the staffing levels and that the CHC assessment was not followed up. A Director at the care provider considered the complaint at the next stage of its complaints procedure. At stage 2 the care provider found:
• Hand hygiene: they reiterated the response at stage one and considered the action taken was reasonable, accepting there would be times between checks when Mrs Y may have soiled her hands.
• Missing items: The Director said they spoke to several staff who all felt Mrs Y was able to remove her own ring. They could not explain how the ring was lost but confirmed they had carried out a thorough search. They acknowledged Mrs Y could remove clothes but not put them on herself which was an error in the previous complaint response. They noted that despite clear instructions Mrs X was taking the laundry, staff were sometimes putting soiled clothes in the care home’s laundry as they did not want to leave them in the basket. They apologised for this.
• Staffing levels: They noted the records showed the home had the correct staffing levels each day around the time of Mrs X’s visit. However, on the day in question they noted an hour gap when staffing levels were short of the expected level with only three staff in the home between 2pm and 3pm due to an agency worker starting late at short notice. It acknowledged Mrs X’s concern was valid and said this was an unusual and unavoidable situation.
• CHC assessment: The Director spoke to the Manager who confirmed they had spoken with the district nurse to chase up the assessment on more than one occasion. They had not recorded this but had learnt from this.
• Incontinence products: They apologised for the misuse of continence products and recognised this was unacceptable. They confirmed this was discussed with staff again by the Manager.
17. Mrs X remained unhappy due to several contradictions in the stage one and stage two responses. Mrs X considered Mrs Y could not remove the ring herself and the wedding ring was stolen. There were inconsistencies about the staffing levels and she had continued to raise concerns with the care leader on shift about Mrs Y’s hand hygiene.
18. The care provider considered the complaint at the final stage of its complaints process. It apologised for any distress caused by the previous responses. It found:
• General hygiene: It noted Mrs X had implied at the April 2019 review that Mrs Y’s hand hygiene had improved. It also noted Mrs X made reference in further correspondence to having to clean Mrs Y’s nails after this date and that she had raised this with the care leader. It apologised her concerns were not properly documented and so were not raised with the senior leadership team at the time. It said this was why they were not considered in the two previous complaint responses. It agreed to ensure repeated concerns were documented going forward and said it would address this in its current review of its complaints process.
• Missing items: It apologised for the missing ring. It referred to its Residents’ Handbook which advised residents to have insurance in place for any valuable belongings should someone lose or misplace any items. It reiterated it had carried out a thorough search, but without any evidence the ring was stolen it could not take any further action.
• Staffing levels: It stated there were three staff on duty on the date in question. There was a period when one of the agency staff was not present due to the short notice late start. It stated the issue was outside their control and not in line with how rotas were normally managed.
• CHC assessments: It stated the initial response was based on evidence at the time. It had clarified the district nurse was chased but accepted this was not noted.
• Incontinence products: It said it had already apologised for this but reiterated its apology. It confirmed this was addressed with all staff at a staff meeting.
19. It confirmed the actions it was taking following the complaints, which were:
• it was reviewing its complaints process and this would include how repeated concerns were dealt with.
• It would continuously try to improve and maintain staff levels.
• the home manager would ensure they recorded all contact with other organisations and agencies.
• the care home would ensure new staff members were reminded not to use a residents’ incontinence products on other residents.
• it would ensure its complaints process reassured residents and their relatives that feedback was welcome and would not have a negative effect on care or services.
20. Mrs X remained unhappy and complained to the Ombudsman.

Findings

21. The care provider has appropriately considered Mrs X’s complaints through the three stages of its complaints procedure. There were inconsistencies in its responses, but these were addressed through the later stages of the procedure which is what we would expect. It has identified areas of faults and proposed actions to address these. Taking each of Mrs X’s concerns separately:
22. Hand hygiene: the care provider introduced a hand hygiene chart when Mrs X raised concerns. This was appropriate. Although this may have led to some improvement Mrs X continued to have concerns which she raised with the care leader. I cannot now say whether the care provider’s monitoring of Mrs Y’s hand hygiene was sufficient. However, the failure to document Mrs X’s concerns is fault. This led to some inconsistency in its complaint responses and caused Mrs X frustration.
23. Missing items: The care provider failed to follow the agreed arrangements regarding Mrs Y’s laundry. This is fault. As a result, items of clothing went missing. In its stage one complaint response the care provider said it would ensure a full inventory was maintained of residents’ property in future and this would be reviewed every six months. This is appropriate.
24. The care provider says it carried out a thorough search but has been unable to find Mrs Y’s wedding ring. There was a difference of opinion between the care provider and Mrs X over whether Mrs Y could have removed the ring herself. I cannot resolve this or know what happened to Mrs Y’s wedding ring. If Mrs Y believed the ring was stolen that would be a police matter. There is nothing more I can achieve by investigating this matter further.
25. Staffing levels: There were inconsistencies in the care provider’s responses. However, it accepted the staffing levels were short of what it would normally expect and this is fault. There is no evidence to show Mrs Y was caused a direct injustice because of the shortage. The care provider has explained the circumstances and says it is continuously working to address staffing levels. There is nothing else I could achieve by further investigating this issue.
26. CHC assessments: It is for the NHS not the care provider to carry out an assessment for CHC. The care provider requested an assessment from the district nurse. Any delay in carrying out the assessment is a matter for the NHS and ultimately the Parliamentary and Health Service Ombudsman. The care provider accepts the manager failed to record when they chased this up. This is fault. The manager has agreed to ensure that in future they record all contacts with other agencies and professionals. This action is appropriate.
27. Incontinence products: Staff repeatedly used Mrs Y’s incontinence products on other residents despite Mrs X regularly raising her concerns about this with the office. This is fault. The care provider accepted this was fault and took action to prevent it recurring. It has reiterated this with all staff. However, in addition, this fault caused Mrs X inconvenience and frustration.

Agreed action

28. Within one month of the final decision on this complaint the care provider has agreed to apologise to Mrs X and pay her £250 to acknowledge the frustration and distress caused by its faults.
29. Within two months of the final decision the care provider has agreed to provide the Ombudsman with evidence that it has carried out the actions it agreed to take in response to Mrs X’s complaint. Namely:
• ensuring it completes a full inventory of residents’ belongings and reviews this every six months;
• reviews its complaints process and this would include how repeated concerns were dealt with.
• works to continuously try to improve and maintain staff levels;
• the home manager would ensure they recorded all contact with other organisations and agencies.
• the care home would ensure new staff members were reminded not to use a residents’ incontinence products on other residents.
• it would ensure its complaints process reassured residents and their relatives that feedback was welcome and would not have a negative effect on care or services.

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Final decision

30. I have completed my investigation. There is evidence of fault causing injustice which the care provider has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman