Decision : Closed after initial enquiries
Decision date : 26 Mar 2020
The Ombudsman's final decision:
Summary: The Ombudsman will not investigate Mr B’s complaint about care provided to his mother, Mrs C, by her care provider. This is because it is unlikely he could add to the care provider’s response or make a different finding even if he investigated. The care provider has apologised for its failings and implemented additional procedures. The Ombudsman is satisfied this remedies the injustice caused to Mrs C from the fault.
- Mr B says his mother’s, Mrs C’s care provider failed to tell him when she fell, failed to get professional advice or help regarding the falls, overmedicated her and failed to stop giving her medication when she no longer required it. Mr B says he want assurances Mrs C’s former care provider has implemented the processes it says it has taken.
The Ombudsman’s role and powers
- 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:
- the fault has not caused injustice to the person who complained, or
- the injustice is not significant enough to justify our involvement, or
- 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
- we cannot achieve the outcome someone wants, or
- there is another body better placed to consider this complaint.
(Local Government Act 1974, section 24A(6), as amended)
How I considered this complaint
- I considered the information and documentation provided by Mrs C’s care provider, the Council and Mr B. I sent Mr B a copy of my draft decision and discussed his comments on it with him.
What I found
- Mrs C’s care home placement was funded by the NHS from 19 February 2019 until NHS health care ceased on 5 March 2019. The Council arranged for Mrs C to stay in the home and she funded the cost of her placement from 6 March until she left the home on 11 November.
- Mr B complained to Mrs C’s care provider in October and is unhappy with the delay in it providing him with a response.
- The care provider says it received Mr B’s complaint dated 28 November on 31 December but did not respond until 31 January as there was an ongoing safeguarding investigation.
- Mr B was concerned he was not told that Mrs C had fallen on two occasions and medical help was not sought for her following the falls. The care provider apologised for not advising Mrs C’s next of kin about the falls and explained this was because it was using an outdated form. It says this has now been rectified and confirmed it has disregarded all the old forms and they have been replaced by a new form which has tighter, robust processes in place for ensuring all falls are logged, discussed at meetings and overseen by a Manager, including contact with next of kin.
- The care provider says it contacted Mrs C’s GP when she was found to have bruising to her shoulder and thigh whilst being given a bath. However, it acknowledged the staff member did not follow the procedures correctly and advised Mr B the staff member concerned is no longer working at the home. The second fall Mrs C had was logged but did not result in any injury and did not require medical intervention. Following a safeguarding investigation, the care provider acknowledged its recording and documenting of the incident was not up to standard and it says it has implemented an additional eLearning module about documentation and record keeping for all staff.
- It is unlikely any further investigation into this by the Ombudsman could make a different finding to that already identified by the safeguarding investigation or achieve any more than has already provided. The care provider has implemented further learning for staff and more robust recording processes are in place.
- Mr B was concerned that Mrs C’s care provider gave her too much of one of her prescribed medicines and failed to stop giving another of her medicines when advised.
- The care provider investigated Mr B’s concerns. It says a weekly audit of Mrs C’s medical charts found she had been given her blood pressure medication twice a day instead of once for two consecutive days. It contacted her GP who advised the District Nurse should monitor Mrs C’s blood pressure for a further two days. The care provider contacted Mrs C’s GP again at Mr B’s request and asked for a blood test. The GP declined this request and said Mrs C was on a relatively low dosage of the medication and the additional dosage would not have adversely affected Mrs C.
- Mrs C’s care provider contacted her GP when the mistake regarding the giving of additional medication was highlighted and followed the advice of her GP. The Ombudsman could not add to this even if he investigated.
- Mr B says the care provider was advised to stop Mrs C’s medication in July and was concerned that Mrs C’s care provider continued to give her medication even though it had been stopped by a GP. The care provider says it was not advised at any time either by the Memory Team or Mrs C’s GP to stop the medication. In the absence of any instruction from Mrs C’s healthcare professionals advising cessation, the Ombudsman could not say Mrs C’s care provider was at fault for continuing to administer medication as prescribed.
- Mrs C has now moved to a different home. The care provider has apologised for its failings and has advised of the processes and procedures it has put in place to minimise the risk of a similar occurrence happening again. Further investigation by the Ombudsman is unlikely to add to the care provider’s response or make a different finding of the kind Mr B wants.
- Mr B is concerned that the care provider may not implement the additional robust processes it has advised him it has. Mr B can ask the Care Quality Commission (CQC) who is the regulator of care providers to consider his concerns when it next inspects the care home.
- The Ombudsman will not investigate this complaint. This is because it is unlikely he could add to the care provider’s response or make a different finding.
Investigator's decision on behalf of the Ombudsman