Summary: Mrs B complained about the care her late father, Mr C, received at Robert Harvey House Nursing home where he lived for the last five weeks of his life. She considered the care fell short of reasonable standards. In particular she complained there was a failure to administer medication and other failings with hydration, toileting, pressure relief, nutrition and hygiene. There was fault by the Council and in the care it commissioned. It will apologise to Mrs B and make a payment to her.

The complaint

1. Mrs B complains about the care her late father, Mr C, received at Robert Harvey House Nursing home where he lived for the last five weeks of his life. She considers the care fell short of reasonable standards. In particular she considers there was a failure to administer medication and other failings with hydration, toileting, pressure relief, nutrition and hygiene. She says that her father was chronically ill but his death was unexpected.

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What I have investigated

2. The care was commissioned by the Council so although Mrs B’s complaint is principally about the actions of the care home the complaint is against the Council.

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The Ombudsman’s role and powers

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. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
5. 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’. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we could add to any previous investigation by the Council, or
• it is unlikely further investigation will lead to a different outcome, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, section 24A(6), as amended)

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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I considered the complaint and documents provided by Mrs B and spoke to her. I asked the Council and the care provider to comment on the complaint and provide information. I sent a draft of this statement to Mrs B and the Council and considered their comments.

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What I found

Summary of events

9. Mr C went to live at the home in May 2019. The home was not in the Council’s area. Mrs B had concerns about the care he was receiving and met staff in early June. Mr C was seen by the GP in the middle of June about a leg ulcer. He did not have any other concerns about Mr C. Mr C died the next day.
10. Mrs B complained to the care provider. The care provider responded and accepted some faults in the care provided to Mr C. It apologised that it had not provided the expected level of care and explained what actions it had taken to address the issues raised by the complaint.
11. Mrs B remained dissatisfied and complained further to the care provider. The care provider responded but said it could not add anything to the response already provided.
12. She then complained to the Council. The Council referred her to the local authority where the home was located to raise a safeguarding complaint about the administration of medication.

The care provider response

13. The care provider accepted there were failings in the care provided to Mr C. Most significant of these was a failure to administer his dementia medication for 16 days. The provider accepted some responsibility for this failing but said it was also partly because of failings by the community mental health trusts involved when he moved from his previous care placement. It has also accepted there were other failings in the records kept of Mr C’s care. This meant that it could not demonstrate that it had provided adequate care.
14. In responding to the complaint the care provider has provided further details of its investigation of the complaint. The Head of Care and Quality spent three weeks in the home investigating the concerns raised by Mrs B and then supporting the team to make the required changes. The following training was provided:
• All nursing and care staff received training on the documentation required in Caring for Me (supplementary care records) file;
• All registered nurses had to renew their medications administration training and competency;
• Newly appointed Senior Care Assistants received role specific training (i.e. Caring for Me Files / Record Keeping, Managing Teams, Reporting concerns, Mental Capacity and Best Interest Decisions);
• Manager, Care Manager and Medication Lead also received further training in the medications management systems; and,
• Registered nurses, Medications Lead and Care Manager – all received further training in Medication Supplementary Record Keeping – which included checking in of medications, dealing with out of stock medications, and the ordering process.
15. The care provider also appointed an additional senior carer per floor per shift to enable support and mentorship of the other care team members. And it has now adopted an electronic system for care management.

Analysis

16. There was fault by the care provider in failing to ensure Mr C had his prescribed medication. I recognise that there were contributory factors but the home could have taken action to address the situation and it did not do so. There were also other failings although some of these were in part around inadequate record keeping.
17. Where there has been fault it is important that appropriate action is taken to, as far as possible, ensure there will be no recurrence. I consider there was no fault in the response by the care provider to the faults found. But my view on this point is based on the information that has now been provided to me. This gives far more detail than was in the response to Mrs B. So while that did accept some failings, and apologised, it did not go as far as the information I have now seen. There may have been good reason for the response being briefer and more limited in its comments but further detail may have provided the reassurance Mrs B wanted to see that fault was accepted and lessons learnt. The care provider has commented that the identified failings have been a great catalyst for change. From the information I have seen I accept that to be the case.
18. The care provider in responding to Mrs B referred her to the Ombudsman. However the next step should have been a complaint to the Council as the commissioner of the care. Mrs B did in fact complain to the Council and I will now consider the Council’s actions.
19. By the time Mrs B complained to the Council a safeguarding referral had already been made by the Council to the home local authority, Council X. The Council’s comments to me now show that Council X’s investigation had been concluded some two months before Mrs B made her complaint. This does not appear to accord with the information Mrs B was being given from her contacts with Council X. However I am only considering Sandwell Council here so I will only comment on its actions.
20. The Council responded to Mrs B’s complaint by referring her to Council X. It was right that Council X was the responsible authority for the safeguarding response but given the information the Council already had about that I consider this response was unhelpful and lacked the information Mrs B could and should have been given. Mrs B’s complaint was driven by her concerns about the home and the standard of care provided. Although, as I say above, I am satisfied there had been an appropriate response from the care provider it was understandable that Mrs B was not reassured by the response she had received and wanted to know there had had some independent oversight. As the commissioning authority the Council had a role in considering her complaint and in ensuring that the home had responded appropriately. Although Mrs B’s complaint to the Council was brief it was clear she was seeking to raise her concerns about the care provision. An appropriate complaint response should have sought to establish the details of Mrs B’s complaint and then investigated and responded appropriately. That did not happen and is fault. The Council has commented it will take steps to ensure staff are reminded of the Councils obligations in respect of commissioned services and that these apply regardless of where placements are made.
21. So I consider there was fault in the care provided to Mr C by the home but I am satisfied there has been an adequate response by the care provider. Although I think the response to Mrs B could have been fuller I cannot say it was fault. I also consider there was fault in how the Council handled Mrs B’s complaint.
22. Where there has been fault I have to consider what injustice that has caused and how that should be remedied. In responding to the complaint the Council has offered to refund the weekly £50 top up fee paid by the family (which would be £250) and pay Mrs B a further £250.
23. I consider the most important outcome from Mrs B’s complaint has been the changes that the care provider has implemented. However the failings both in the care provided and in the Council’s complaint response will have increased the distress caused to Mrs B. I consider the payment proposed provides an appropriate acknowledgment of that distress.

Agreed action

24. The Council will, within a month of the final decision, apologise to Mrs B and pay her £500.

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Final decision

25. There was fault by the Council and in the care it commissioned. It will apologise to Mrs B and make a payment to her.

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Investigator's decision on behalf of the Ombudsman