Summary: Mrs W complained to us about the residential care the Council arranged for her late husband. We found there were several shortcomings with the support Mr W received, which would have been distressing for him as Mrs W. The Council has agreed to apologise and pay a financial remedy to Mrs W for the distress she experienced.

The complaint

1. The complainant, whom I shall call Mrs W, complains about the residential care the Council arranged for her (late) husband, whom I shall call Mr W. Mrs W said that:
• The care home failed to manage his medication properly.
• A nurse from the care home lost her temper once with her husband, snatched his nebuliser off his face and caused his glasses to break.
• Her husband’s clothes went missing for a second time.
• The shower broke in her husband’s room, and it took an unreasonable time to repair it.
• Staff failed to give her husband frequent showers.
• Staff failed to take her husband to the toilet during the day and at night.
• Secret camera footage recorded by the family showed that carers would regularly shout at her husband, would not wash him and would not leave a light on as requested by the family.
• The Council and the care home failed to ensure there were relevant care home representatives at a meeting to answer her questions.
2. Mrs W also complained the Council failed to consider / provide a financial remedy for the distress she suffered due to the above, at the time and since then.

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The Ombudsman’s role and powers

3. 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’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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).
5. 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)

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How I considered this complaint

6. I considered the information I received from Mrs W and the Council. I shared a copy of my draft decision statement with Mrs W and the Council and considered any comments I received, before I made my final decision.

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What I found

7. Mr W moved into the care home (Island Court, which was owned by Orchard Cares Homes at the time) in January 2019, initially as a temporary resident.

The alleged failure to manage his medication properly

8. Mrs W complains the care home failed to manage her husband’s medication properly, in terms of ensuring he received his medication at the frequency he should receive them. Mrs W said her husband had been prescribed an inhaler since mid-March. However, staff often left his inhaler on the table instead of giving it to him four times a day. He was lucky if he received it twice a day. She said her husband struggled to breath as a result. This showed he had not received his medication properly, because on other days he would be better.
9. The Council said:
• The care home changed ownership and the previous owner has not responded to the Council’s requests to provide certain documents in relation to the care Mr W received from them, including his Medicine Administration Records (MAR). As such, it is unable to determine now, to what extent Mr W received his medication in line with requirements.
• The social worker who carried out the safeguarding investigation said there were some discrepancies on the MAR sheets for the nebuliser.
• The care provider had acknowledged failing.
10. A CQC inspection during mid-2019 found that:
• Medication administration records (MARs) viewed indicated people had not received their medicines as prescribed. There were occasions when people had not received their medicines, received the wrong dose, or received their medicines at the wrong time. This caused people to experience unmanaged symptoms including pain.
• Medication records were not always clearly documented, and some entries were changed making them illegible. This meant the provider could not be sure medications were being received in a safe way or as prescribed as records were not clear.
• Staff administering medicines were not receiving regular practice supervision. This lack of supervision meant that staff did not have the opportunity to discuss their practice and the provider could not be assured that practice was safe and effective.
• The failure to prevent people from receiving unsafe care and treatment and prevent avoidable risks of harm was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.
11. The home reported in March 2019 at a meeting that previous medication issues were found to be related to a previous manager who was inexperienced and asked for a change in the MAR charts. It said this had since been resolved, and there were regular MAR audits now. The care home says it introduced weekly medication audits to determine potential concerns. All senior members of staff and nurses had attended medication training and had their competency assessed. The Pharmacist had visited the home to complete reviews and did not identify any concerns.

Analysis

12. Based on the available information, and in the absence of any records that state otherwise, I found that on the balance of probabilities Mr W failed to receive the consistent support he should have received with regards to his medication management. However, I am unable to come to a view how often this happened, if this was the case with regards to all medication he should have received (or only with regards to the nebuliser complained about by Mrs W), or how much impact this had on Mr W.
13. However, it would undoubtedly have had some impact on Mr W with regards to the way in which his conditions and symptoms were managed at the time. It would also have been distressing to Mrs W at the time to know her husband was not receiving his nebuliser as often as he should have.

The nurse’s behaviour (one incident)

14. Mrs W complained that a nurse from the care home lost her temper with her husband once, snatched his nebuliser off his face and caused his glasses to break.
15. The Council asked the care provider / home manager to respond to this. However, the incident happened two years ago, the care provider and home manager have since changed, and the nurse involved is no longer working at the home. As such, the care provider was unable to provide a response and I have not received any information with regards to this.

Analysis

16. Taking Mrs W’s statement into account, and in the absence of any response or information provided by the Council that state otherwise, I concluded there was no reason why Mrs W would have made up this incident. As such, on the balance of probabilities, I found this incident happened. This would have caused Mr and Mrs W distress at the time.

Mr W’s missing clothes

17. Mrs W complains her husband’s clothes went missing for a second time, and the care home failed to reimburse this (£60).
18. The Council asked the care provider / home manager to respond to this. However, the incident happened two years ago, the care provider and home manager have since changed, and it was therefore unable to provide a response. As such, I have not received any information with regards to this.

Analysis

19. Taking Mrs W’s statement into account, and in the absence of any response or information provided by the Council that states otherwise, I found that on the balance of probabilities some of Mr W’s clothes went missing after this had happened once before.

The frequency at which Mr W had a shower

20. Mrs W says staff failed to give her husband frequent showers. She said the home promised to give him a shower once every two days. However, he only got one perhaps every fortnight.
21. The care home’s records state that:
• Mobility and Function document: two staff members are needed for support with a shower.
• Current comprehensive assessment:
1. I prefer to have a bath once a week.
2. I am able to make choices verbally.
• Long term care plan:
1. I need one staff member to help with all washing.
2. I like to have a shower on a weekly basis and to have my hair washed.
3. I can communicate my basic needs at times.
• Mental Capacity Assessment: He did not have capacity to make day to day decisions such as washing, showering and mobility.
• Dependency assessment: Mr W always needed assistance with bathing and washing and was not resistant to receiving care.
22. I reviewed several weeks of the care home’s daily carer records for the period February to April 2019, to see how much support Mr W received with having a wash/shower. The records showed that, in terms of personal care, staff regularly shaved him in the morning and combed his hair. Mr W also received a wash almost every day, but it would only be recorded as taking one to two minutes to complete. In four weeks, he once received a shower and once refused one.
23. After Mrs W raised a concern about this, the care home had a meeting with her at the end of April 2019 to discuss this. At the meeting, the manager promised that staff would shower Mr W every other day and record this as a MUST DO action. Management would monitor this daily by running hygiene reports. I reviewed a week from May 2019, which showed that staff continued to provide short 1-2 washes. Staff only once provided a ‘full body wash’ of three minutes but did not give him a shower, and certainly not every other day.

Analysis

24. There is no evidence in the records that says the home agreed, at the start of Mr W’s stay, that he would receive a shower every other day.
25. There was a discrepancy between the home’s Current Comprehensive Assessment, which said Mr W was able to make choices verbally, and his Mental Capacity Assessment that said he did not have capacity to make day to day decisions about washing and showering. This is fault.
26. I found Mr W did not receive the support he should have received with regards to his hygiene; having a shower / thorough wash in the morning. As such, his personal hygiene needs were insufficiently met. This is fault. He did not receive a shower once a week, as mentioned in his care plans, and this did not improve at the end of April 2019 despite promises to address this.
27. This would have been distressing to Mr and Mrs W.

Mrs W’s complaint about (the delay in fixing) the broken shower

28. Mrs W complained the shower in her husband’s room broke early April 2019; the drain was blocked, and it smelt awful. She reported it and the home said it would fix it. However, it took three weeks until the home started to even look into this. This was an unreasonable delay.
29. According to records from the care provider, the home requested repairs on 30 April 2019, which were completed on 3 May 2019.

Analysis

30. There was a delay in the care home arranging the repairs to the shower. This is fault. Once the care home requested them, they were completed quickly. This would have caused Mr and Mrs W some distress at the time.

The alleged failure of staff to support Mr W with toileting:

31. Mrs W says her husband needed some assistance to go to the toilet, because he could not walk very well. However:
• Staff failed to take her husband to the toilet during the day, when he needed / wanted to. At times he was too scared to use his call bell to ask for help, because staff would often just come and tell him off for using the bell all the time.

• Staff failed to take her husband to the toilet at night. They simply put pads on and told him to pee in them. He did not need this (he could call for and go to the toilet with help) and did not want this. This was undignifying.
2. The care home’s records state that:
• Current comprehensive assessment: I am fully continent and able to use the toilet. I would prefer a urine bottle at night because I occasionally wake up at night.
• Long term care plan: I can become very anxious at times and will shout out. Staff should listen to my care needs as I can get agitated when I need the toilet.
• Dependency assessment: Mr W was continent and always needs assistance with toileting day and night. He recognises when he needs to use the toilet.
3. I reviewed several weeks of the care home’s daily carer records for the period February to April 2019, to see how much support he received with regards to toileting. It showed that staff did provide Mr W with regular support in this area during the day. However, although staff would sometimes assist Mr W with toileting at night, they also used pads for him at night, even though this was not mentioned in his care plan and there was no valid reason to do this.
4. A CQC inspection from mid-2019 found that:
• We saw evidence that people who were continent were being placed into pads instead of being taken to the toilet.
• People said there were not enough staff to meet their needs. Staff would not come quickly when pressing the buzzer, and residents would have to wait a long time.
• Staff said there were not enough of them to meet people's needs and ensure the safety of the residents.
• The home had incorrectly completed its dependency tool, which calculates how many staff are needed. It showed 11 hours per day understaffing. This meant there were not enough staff hours to meet people's needs.
• Failure to provide sufficient numbers of suitably qualified, competent, skilled and experienced staff was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Analysis

35. The records showed that, although staff were overall providing support with toileting to Mr W during the day and night, there were incidents when staff would put him into a pad during the night. This was fault and undignifying, because Mr W was continent and nit not need pads. This would have been distressing to Mr and Mrs W.
36. On the balance of probabilities, there would also have been incidents where Mr W would have had to wait a long time to be taken to the toilet. However, it is not possible to determine how often this happened.

The poor care captured on the family’s hidden video

37. Around April 2019, Mrs W’s daughter put a hidden camera into her father’s room for a month. It showed that:
• Carers regularly shouted at him.
• On one occasion, he called out for two hours to be taken to the toilet, without anyone responding. Carers were passing by but told him to ‘shut up’. He tried to go to the toilet in a bin in his room and fell cutting his head open with blood pouring.

• Staff not washing him in the morning and instead spraying him with deodorant to give an appearance he was clean.

• They never left the lamp light on that the family had brought him (because he did not like the dark)
4. A CQC inspection during mid-2019 found that:
• Residents had not been safeguarded from alleged abuse. Where the service had received serious allegations of abuse against people, and been provided with evidence, appropriate and effective action had not been taken to protect people whilst the matter was investigated.
• Staff had witnessed people being placed at risk of harm and not reported this. An example of this is where a person was shouted at by a staff member, in the presence of another staff member.
5. The CQC confirmed in June 2019 that the video footage showed: “clear evidence of neglect taking place involving various members of staff”. The care provider acknowledged later that this was due to staff culture. The staff did not treat residents with dignity and respect. (…). However, it said the new managers would conduct dignity and respect observations on the floors.

Analysis

40. The care provider investigated the incidents included in the video footage and suspended / disciplined staff involved. The incidents would have been distressing to Mr W, and seeing the footage would have been distressing to Mrs W.

The way the Council dealt with the concerns

41. Four weeks after Mr W moved into the care home, the Council carried out a placement review with Mrs W present. The records state that: “No concerns raised with placement. Mr W has settled well and would like to remain at the home as a permanent resident. Mrs W was very happy with the placement and advised that she was happy for the placement to continue”. Mrs W visited her husband every day from 12 until 5/6pm.
42. Mrs W complains the Council failed to inform her that, if she had concerns about the care provided and/or the care home not responding to her concerns (and improving things) it should contact the Council. As such, she was not aware of this.
43. However, the Council says Mrs W was aware it could contact the Council if she had any concerns about her husband’s care. The family has been involved with the Council since 2017 and clearly understood the Council’s role in assessment and management of care. It is clear from recordings that lines of communication have always been in place between the Council and the family.
44. The first time Mrs W raised a concern with the Council was mid-April 2019. She said:
• When her husband went to hospital and they swabbed his groin, they found a lot of faeces, which they felt had been there a long time.
• She found out his shower had not been working since early April 2019, but she thought this had now been fixed.
• Some days the carers were not changing his clothes, and there had been an odour.
• Staff told her husband to press his call bell if he needs support. However, there were times he waited 1.5 hours before anyone came to him.
• A care worker was overheard shouting at him in his room.
• Since 15 March 2019, he had a Nebuliser which he was supposed to get four times a day. However, it appears he only receives it now around twice a day.
• The family recorded secret videos that showed the night carers could be quite cruel, shouting at him. They saw staff also did not wash him in the morning but only sprayed him with deodorant.
45. The Council carried out a safeguarding investigation as a result. The safeguarding lead from the local Clinical Commissioning Group (CCG) arranged for the Nursing Enhanced Care Team to visit Mr W and check on his health and wellbeing. The team did not report any concerns with his health or presentation. Mr W passed away at the end of May 2019. A social worker visited the home in June 2019 to complete the safeguarding enquiry, which the Council subsequently discussed with the family in August 2019.
46. The care provider promised in October 2019 that it would write to the family following its own internal enquiry and root cause analysis. However, the family was unhappy with the home’s internal enquiry and asked for a safeguarding meeting to discuss this.
47. Mrs W complains the Council failed to ensure it had verified with the care home that relevant staff members would be able to attend, before it agreed to go ahead with the safeguarding meeting of 18 November 2019. As such, the care home representatives present were unable to answer her questions about the incidents she had complained of.
48. The Council says that, at the safeguarding meeting in November 2019:
• The manager and other staff members had changed, so those who were responsible at the time of the incidents were no longer available to come to the meeting and answer certain questions. The care provider was represented by the new home manager, the regional director and the director of quality and governance. This was sufficient representation from the care provider.
• At the meeting, it was agreed to make a referral for a SAR (safeguarding adults review). By this time, the care home had a new manager who apologised for the experience, explained lessons learned and shared a document about learning with the family.
49. It subsequently took until August 2020 before the case was discussed at the SAR panel. The Council accepts there was an unreasonable delay but says this was partly because of a restructuring of the Adults Safeguarding Board at the time and the impact of the Covid-19 Pandemic.
50. The Council told me the SAR panel decided the case did not warrant any further action under the SAR process. However, this is not entirely correct. The Panel decided the Safeguarding Investigation should continue because: It appears that family have raised further questions in the safeguarding meeting. These should be explored through the safeguarding process and further enquiries should be completed before consideration for a SAR review. It is not clear what the family wanted from these further concerns or whether any advice was given how they could complain or register their concerns with agencies.
51. The Council says it did not view the CCTV footage because it was not considered to be of any value for council officers to view this. It says the police had already viewed it and decided not to proceed criminally. It took this decision because the impact on Mr W had not been severe enough to meet the criminal threshold. Furthermore, the care provider had already admitted failings and produced action plans for improvement.
52. Mrs W complains the Council failed to consider / provide a financial remedy for the distress she suffered as a result of the above, at the time and since then.
53. However, the Council says Mrs W never made an official complaint to the Council, or said she believed the Council should provide a financial remedy. As such, it was never in a position to consider this.

Analysis

54. The SAR panel concluded the safeguarding investigation into the (new) issues raised by the family should continue. However, this did not happen, which is fault. As a result, valuable time was lost, and important care records (such as MAR sheets and maintenance records), which the Council could have obtained and looked into, are no longer available to provide more information about what happened. This is because the ownership of the home changed in the interim (February 2020) and the manager of the home changed as well.

Agreed action

55. When a council commissions a care home to provide services on its behalf, it remains responsible for those services and for the actions of the care home providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council.
56. As such, I recommended that the Council should, within four weeks of my decision,
• Provide an apology for the faults identified above.
• It should also pay Mrs W £500 for the distress she suffered at the time, and since then, knowing it failed to provide the support her husband needed in several areas. This includes the £60 for the missing clothes.
57. The Council has told me it has accepted my recommendations.

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Final decision

58. For reasons explained above, I have upheld the complaint.
59. I am satisfied with the actions the Council will carry out to remedy this and have therefore decided to complete my investigation and close the case.

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Investigator's decision on behalf of the Ombudsman