Summary: We have found fault in the way the Home communicated with Mrs C and her family about a lift being out of service, its failure to offer Mrs C any alternative way to leave the Home for three months and its failure to properly respond to Mrs C’s complaint. The Home has agreed to apologise, to provide a financial remedy and to write to other residents who may have been similarly affected.

The complaint

1. Mrs B complains on behalf of her mother, Mrs C who lives at Duncote Hall Nursing Home, Duncote, Towcester.
2. Mrs B says the Home’s lift did not work for three months. This meant that Mrs C, who uses a wheelchair and lives on the first floor, was trapped on the first floor of the Home.
3. Mrs C says the Home failed to maintain the lift, did not communicate properly about the problems, failed to sufficiently explore alternative ways for Mrs C to leave the floor and failed to fully respond to her complaint.

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The Ombudsman’s role and powers

4. 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)
5. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
6. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

7. I have discussed the complaint with Mrs B. I have considered the documents that she and the Home have sent, any relevant guidance and policies and both sides’ comments on the draft decision.

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What I found

Law, regulations and guidance

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
9. 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 CQC has issued guidance on how to meet the fundamental standards.
10. Regulation 12 says the care and treatment must be provided in a safe way for service users. Care homes should, among other things:
• Assess the risk of health and safety of residents receiving the care and treatment.
• Do all that is reasonably practicable to mitigate any such risks.
11. Regulation 15 relates to the premises and equipment of a care home. The CQC guidance says, among other things, that premises should be:
• Fit for purpose.
• People should be able to easily enter and exit premises and find their way around easily and independently. If they cannot, providers must make reasonable adjustments in accordance with the Equality Act 2010 and other current legislation and guidance.
• Providers must make sure that they meet the requirements of relevant legislation so that premises and equipment are properly used and maintained.
• Any change of use of premises and/or equipment should be informed by a risk assessment and providers must make appropriate alterations to premises and equipment where reasonably practical. Where this is not possible, providers should have appropriate contingency plans and arrangements to mitigate the risks to people using the service.
12. Regulation 16 says all complaints must be investigated thoroughly and any necessary action taken where failures have been identified.

What happened

13. Mrs C was 95 years old at the time of the complaint. She had severe mobility problems because of underlying medical conditions. She mobilised in a wheelchair whenever she left her bedroom.
14. Mrs C lived on the first floor of the Home and accessed the ground floor via a lift. Mrs B took Mrs C out to lunch every week and would also take her to all her medical appointments.
15. The lift was broken for 3 months from October 2018 until January 2019 and Mrs B said the Home did not make any alternative arrangements during this time to allow Mrs C to leave her floor or the care home.
16. Mrs B complained to the Home on 18 January 2019 and said:
• The lift frequently broke and it should have been apparent that it needed to be replaced.
• She first found out that the lift was broken on 17 October 2018 when she went to pick up Mrs C for a hospital appointment. She was not given any warning that the lift was not working and had to cancel Mrs C’s medical appointment.
• On 2 November 2018 she found out the works to the lift would not be completed until January 2019. She told the Home she expected them to make arrangements to allow Mrs C to leave the first floor as she always spent Christmas and Boxing Day with Mrs B and the family. Mrs C also had other medical appointments which she had to attend. The Home assured her that ‘contingency arrangements’ would be made.
• Mrs B had an informal meeting with one of the Home’s directors on 16 November 2018 and the director assured her again that contingency arrangements would be put in place to allow Mrs C to visit her family for Christmas.
• The Home did not give her any written information about the situation, apart from one email on 20 November 2018.
• Mrs B sent a further email on 21 November 2018 asking what the contingency arrangements were as Mrs C had a hospital appointment on 11 December 2018. She received no reply.
• During the week before Christmas, Mrs B asked again what the contingency arrangements were, but received no reply.
• On Christmas day, no arrangements had been made for Mrs C to leave the floor, so two staff decided to ‘support’ Mrs C down the stairs. This caused Mrs C pain and breathlessness and left her feeling anxious.
• Apart from the two days over Christmas, Mrs C was confined to the first floor of the Home and was unable to leave the Home. She missed out on meals out, shopping and visits to Mrs B’s home and family.
• Mrs C also missed important medical appointments during that time. She had to re-schedule an appointment with the cardiac clinic three times and the appointment was now four months overdue. She had to reschedule an appointment to the Hospital Chest Clinic two times and this would be two months overdue.
• The lift had broken down regularly and it was apparent that equipment would need replacing. This should have been planned to minimise the time when there would be no lift.
• The Home could have used evacuation chairs, or alternatively, powered stair climbers which could be hired during lift breakdowns.
17. The Home’s manager replied on 25 February 2019 and said:
• There had been a continuous programme of maintenance and inspection of the lift which should have minimised the risk of breakdown. The lift needed a complete refurbishment which had now been completed.
• The Home had evacuation sledges but they would not have been appropriate to use. The Home could not use evacuation chairs because of the curved staircase. The manager was unaware of powered stair climbers. She asked Mrs B to forward the information regarding stair climbers and she would find out why they were not considered and let her know.
• The Home put information on its notice boards, but it acknowledged that there could have been more information, especially for families. It said it would improve its communication to be more transparent with residents and their relatives.
• The Home accepted that Mrs C had been confined to the first floor during this time (apart from Christmas) but said that it had created an upstairs lounge to minimise the impact of the disruption and held a Christmas party on the first floor.
18. Mrs B wrote to the Home on 22 March 2019:
• The works were only carried out when the situation was irretrievable. Presumably because the Home wanted to avoid costs. Considering how much Mrs C paid to live at the Home, she should not have had to suffer a restriction on her freedom to leave to Home.
• She provided the Home with the information on powered stair climbers. She looked forward to hearing why the Home did not use them.
• She said that, as the Home was not even aware of the existence of powered stair climbers, she could only conclude that the Home had made no real effort to find an alternative way for Mrs C to leave her floor.
• She noted the CQC was aware of the lack of lift. She wanted to know how the Home had responded to the CQC’s question about alternative arrangements for transferring residents downstairs.
19. The Home did not reply so Mrs B chased them on 25 April 2019 and 8 May 2019. She said that, if she did not receive a reply, she would escalate her complaint to the CQC and the Ombudsman.
20. The Home then replied on 22 May 2019 and offered a meeting about the complaint which was held on 6 June 2019.
21. Mrs B said that, at the meeting, she was told that the staff and the director who told her that the Home would put in alternative arrangements for Mrs C to leave her floor, had no authority to do so. She was informed that the Home could not use the powered stair climbers because they were ‘not suitable’. Mrs B questioned this as there were three staircases at the Home and powered stair climbers could cope with most configurations.
22. Mrs B said that, at the end of the meeting, she told the Home she expected a written apology and an offer of compensation. One of the Home’s directors, Mr D, agreed to write to her, but she received no further letter from him.
23. Mrs B said there was also a relatives’ meeting on 6 August 2019 as the Home had been put into special measures by the CQC. She said other relatives of residents who had been negatively affected by the absence of the lift raised the issue of the lift and compensation. She said Mr D told the attendants at the meeting that the Home was negotiating a compensation payment with its insurers and, if that was unsuccessful, the Home would pay compensation themselves. However, she received no communication from the Home after that meeting.

My investigation

24. I sent my letter of enquiries to the Home on 2 July 2020 and asked the Home to reply within four weeks, which is the Ombudsman’s standard practice. I received no reply from the Home and chased them in August. I still did not receive any reply.
25. I wrote to the Home in September threatening to escalate the matter which included the possibility of a witness summons. The Home replied. It offered £200 compensation to Mrs C and explained what works had been done to the lift but the Home did not provide most of the information and documents that I had asked for in the letter of enquiries. So I chased the Home again.
26. On 29 October 2020, the director, Mr D, finally provided some of the information I had asked for in July. He said:
• It was not possible to install evacuation chairs or powered stair climbers at the Home because of the design of the stairs (curved). This information was sent to Mrs B on 25 February 2019.
• The Home had displayed updated information on the noticeboard but acknowledged it could have done more to inform families who did not visit the Home regularly. It had: ‘improved our communication standards going forward by ensuring that he Home’s managerial staff promote the sharing of information and are transparent in their dealings with residents and relatives.’
• I asked the Home to send me minutes of the meetings it held on 6 June 2019 and 6 August 2019. If there were no minutes, I asked the Home to confirm the outcome of those meetings. Mr D said he had been unable to find any minutes and he was unable to answer my questions as ‘the management team who dealt with the situation all left the business.’
• He responded to Mrs C’s complaint that the Home’s complaint response was late and incomplete. He said the Home responded to Mrs C’s initial January 2019 complaint in February 2019 and Mrs C had accepted this response, but ‘despite our detailed response [Mrs C] sent another complaint regarding the same matter on 22 March 2019.’
27. The Home had still not provided the following information I asked for:
• The Home’s assessment of Mrs C’s mobility and her care plan.
• Any risk assessment of Mrs C to decide it was safe to ‘support’ her up and down the stairs.
• Any evidence the Home had contacted providers to explore alternative ways to move residents up and down the stairs in the absence of the lift.
• Any information on what compensation it was offering to all the residents who had been affected by the situation.
28. Mrs B also provided me with further information on the impact the problems had on Mrs C. She said Mrs C has a pacemaker and the initial appointment she missed on 17 October 2018 was with the cardiac unit. She missed several other medical appointments which added to Mrs C’s and the family’s stress.
29. Mrs B also said that she was very worried about Mrs C after she was ‘supported’ up the stairs after Christmas. She said Mrs C was breathless and unwell and Mrs B stayed with for a long time as she was so concerned about her presentation.

Analysis

30. It would be difficult for the Ombudsman to comment on the history of the lift and to decide whether the lack of maintenance contributed to the need for repairs. The CQC inspects and monitors care homes. The requirement to maintain accessible premises is one of the key standards that is monitored. I will share this decision with the CQC so that it can inform any future inspection.
31. I have concentrated my investigation on what actions the Home took once it became aware the lift would be out of service.

Explore alternative ways to leave the floor

32. It may well be that the curved stairs made it difficult to find an alternative way for residents to negotiate the stairs. However, I note there were three staircases and that most companies offering alternatives to a lift (such as evacuation chairs or powered stair climbers) claim that most stairs can be negotiated and that an assessment of the premises is needed to make the decision of what is the most appropriate equipment.
33. The Home has not provided me with any evidence that it contacted any provider to find an alternative method to transport the residents up down the stairs. It has not provided me with any evidence that an assessment took place by the provider to say that equipment could not be provided. I therefore find fault as the Home did not sufficiently explore alternatives, even though it told Mrs B that it had done so.
34. The Home has failed to provide me with its assessment of Mrs C’s mobility or its care plans so I cannot say what was in the documents. However, I presume that Mrs B is telling the truth when she says that Mrs C could only mobilise in a wheelchair outside of her bedroom.
35. The Home failed to make any arrangements for Mrs C to leave the care home, despite several assurances that it would do so. On Christmas day, the Home then ‘supported’ Mrs C down the stairs. As the Home has not provided any answer or evidence how it assessed that it would be safe for Mrs C to do this, with her medical problems and mobility issues, I can only conclude this decision was made without assessment which is further fault.

Communication with the family

36. The Home has already upheld the complaint that it failed to properly communicate with Mrs B and the residents’ families while the lift was not working. I agree there was fault.
37. The Home had a duty to keep residents and their family informed and a notice on the notice board was not sufficient. Mrs C had medical and other appointments which she had to attend. Mrs B took her to these appointments which then had to be cancelled because of the failure to notify her of the fact that Mrs C was unable to leave her floor or the Home.
38. The problem was also that the Home continuously gave Mrs B the wrong information as it said it would find an alternative way for Mrs C to leave the Home, but then did not do so.

Response to complaint

39. The Home has said it responded to Mrs B’s initial complaint and it did not have to respond to any further complaints as they were the same complaint.
40. The Home also said it told Mrs B in its letter dated 25 February that it could not use powered stair climbers because of the stairs, but Mrs B insisted on sending more information about the stair climbers.
41. That last statement is not correct. In its letter dated 25 February 2019, the Home told Mrs B that it had never heard of the powered stair climbers and asked Mrs B to provide information about powered stair climbers so it could find out why they were not used. Mrs B then received no further reply until she threatened to go to the Ombudsman and the CQC, when the Home offered the meeting in June 2019.
42. In addition, the Home then made promises at the meetings of 6 June 2019 and 6 August 2019 to write to Mrs B and failed to do so.
43. Therefore, there was fault in the Home’s failure to properly communicate with Mrs B about the complaint after March 2019 and to promise her further letters which it did not send.
44. In addition, the Home told the Ombudsman that it could not recall anything about the meetings on 6 June 2019 and 6 August 2019 as the management team which attended the meetings had left. I question this as the director, Mr D, attended both meetings and then provided the responses to the Ombudsman.

Injustice and remedy

45. Mrs C and her family have suffered an injustice. The failure of the lift effectively constrained Mrs C’s freedom so that she was confined to the first floor of the Home. She repeatedly missed important medical appointments and her usual routine of social visits was stopped. Mrs B has described Mrs C’s worrying presentation after she was ‘supported’ to go up the stairs.
46. The Ombudsman’s remedy aims to put the complainant in a position they would have been if the fault had not happened. In cases such as this one, where this is not possible, the Ombudsman can offer a symbolic amount for the distress and the loss of service the complainant has suffered. As the injustice is significant in this case, I recommend that the Home pays Mrs C £500. I also recommend the Home pays Mrs B £200 to reflect the time and trouble she incurred in pursuing the complaint.
47. I also note that there may be other residents who were affected by the lack of lift and who have complained to the Home. I recommend the Home writes to the residents who have complained and offers them a review of the complaint and a remedy in line with the Ombudsman’s guide to remedies.
48. The Home says it has learned from the mistake in terms of communication but has not actually said what it would do differently if a similar problem occurred. I recommend the Home reviews its communication guidance to decide in which circumstances it needs to write to residents and their families to inform them of a problem.

Agreed action

49. The Home has agreed to take the following actions within one month of the final decision. The Home will:
• Write to Mrs B and Mrs C and acknowledge the faults the Ombudsman has found and apologise for the faults.
• Pay Mrs C £500 for the distress and loss of service and Mrs B £200 for the time and trouble in pursuing the complaint.
• Write to the other residents who have complained about the lack of lift to offer them a review of their complaint and a remedy in line with the Ombudsman’s guide to remedies. The letter should also inform the residents of their right to go to the Ombudsman if they are not satisfied with the outcome of their complaint.
• Reviews its communications guidance to decide in which circumstances it needs to write to residents and their families to inform them of a problem.
50. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Final decision

51. I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman