Summary: The Ombudsman finds fault with Rex Develop Ltd for delays responding to Mrs B calls for assistance. It also failed to accurately record the time of the calls and how long it took to respond. This caused Mrs B distress. Rex Develop Ltd agrees actions to remedy the injustice.

The complaint

1. Mr and Mrs B complain about the care Mrs B received during her stay in New Haven care home:
2. They complain that:
• Staff twice delayed responding to Mrs B's request for assistance going to the toilet. This resulted in Mrs B urinating in her bed and having to wait to be changed. Mrs B was very distressed at the loss of dignity.
• A staff member made an insensitive comment to Mr B which caused him distress.

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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 normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
5. 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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How I considered this complaint

6. I considered all the information Mr and Mrs B provided with their complaint. I made enquiries with the care provider and considered its response along with relevant law and guidance.
7. Mr and Mrs B and the care provider had the opportunity to comment on my draft decision. I carefully considered all the comments I received.

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What I found

Law and guidance

8. The Care Quality Commission (CQC) has published guidance on meeting the fundamental standards expected of care providers. Care and treatment must reflect the needs and preferences of residents, who must be treated with dignity and respect. Care providers must meet resident’s nutritional and hygienic needs and protect them from abuse. We consider this guidance when deciding complaints about poor standards of care.

What happened

9. In early 2020 Mrs B spent 13 days in New Haven care home. The care home is owned by the care provider Rex Develop Ltd.
10. Mr and Mrs B complained to the care home about delays responding to Mrs B’s calls for assistance and a staff members comments to Mr B.
11. The care home responded to their complaint, but they were unhappy with its response and complained to the Ombudsman.
12. I have summarised the complaints and my findings under the two complaint headings.

Delays responding to Mrs B's requests for assistance

13. Mrs B says on two occasions during the night she used her call buzzer to request assistance when she needed to use the toilet. She says the staff did not come for some time and she had no alternative but to urinate in the bed. She then had to wait in soiled clothing and bedding until staff assisted her.
14. The care home investigated. It partially upheld this part of their complaint. In its complaint response it:
• apologised for the distress cause to Mrs B;
• explained the wait was due to the staff attending to other residents;
• assured Mr and Mrs B the care home work hard to ensure staffing levels reflect the needs of the residents; and
• reduced the fees by £107.26 (one night’s stay).
15. I asked the care home how long Mrs B had to wait on each occasion. It said she waited 25 minutes on the first and 10 minutes on the second. It was unable to provide evidence to support this. I reviewed the care records and found no reference to either incident.
16. I can not be sure how long Mrs B waited on either occasion. This is fault. The lack of record for either incident causes uncertainty about how long Mrs B waited to have her call answered.
17. I am also concerned how the care home monitors its response times to calls if it does not accurately record the waiting times in care records. This is fault. It could compromise the quality of care to residents and stop the care home from effectively monitoring its call response times.

Staff member’s comment

18. A staff member made a comment to Mr B about a football team. Mr B found the comment upsetting because he had a personal connection to a tragic event involving the team.
19. In its complaint response the care home apologised. It spoke to the member of staff involved.
20. The care home’s response to this part of the complaint is an appropriate remedy for the distress caused. I do not propose to pursue this part of the complaint further.

Agreed action

21. Within one month of my final decision the care provider agrees to:
• Pay Mrs B £250 for the distress it caused. The care home may deduct the £107.26 it has already paid from this amount.
22. Within three months of my final decision the care home agrees to:
• Review its policy and procedures for recording its call response and waiting times. It should ensure it is able to provide this information and monitor its times to identify any issues.
23. The care provider should provide the Ombudsman with evidence it has completed the agreed actions.

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Final decision

24. I find fault causing injustice. The care provider agrees actions to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman