Summary: Mrs D complained about the quality of care her late mother, Mrs E, received from the Care Provider. She also complained it failed to address her complaints. We find the Care Provider caused injustice when it failed to keep accurate records, failed to adequately care for Mrs E, failed to follow Mrs E’s care plan and failed to communicate effectively with Mrs D. The Care Provider also failed to deal with Mrs D’s complaints according to its complaints policy. The Care Provider has agreed to our recommendations to address the injustice caused.

The complaint

1. Mrs D complained about the quality of care her late mother, Mrs E, received from the Care Provider. Mrs D says there were four incidents, over a nine-month period, where Mrs E sustained serious injuries. She asserts Mrs E suffered unnecessary injury, pain and distress.
2. Mrs D also complained the Care Provider failed to address her complaints about these incidents and provided an unsatisfactory response. Mrs D says it has caused her enormous distress.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)

6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
7. If we are satisfied with a care provider’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)
8. 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

9. I considered the information Mrs D submitted with her complaint. I made written enquiries of the Care Provider and considered the information it provided in response. I have also considered a safeguarding report produced by the local council when it investigated some of Mrs D’s concerns.
10. Mrs D and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

11. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers, inspects care services to assess if they meet the fundamental standards of care and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
12. 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 below which care must never fall.
13. Regulation 10 says service users must be treated with dignity and respect.
14. Regulation 12 says care and treatment must be provided in a safe way for service users.
15. Regulation 17 care providers should maintain an accurate, complete, and contemporaneous record in respect of each service user.
16. Regulation 18 says care providers should notify the CQC of incidents causing serious injury to residents.

What happened

17. Mrs E was a resident at the Care Provider’s care home for nearly two and half years. Mrs E sadly died in October 2019.

Incident one

18. The Care Provider’s records show Mrs E had a fall on 31 July 2018. Staff called 999 and Mrs E went to hospital. Mrs E fractured her hip and so she had an operation. Mrs E’s care plan before her fall said she was mobilising independently.
19. The Care Provider updated its incident log on 1 August 2018. The member of staff who witnessed the fall said Mrs E was walking down the corridor and stumbled backwards.
20. The Care Provider updated Mrs E’s care plan when she came out of hospital. The updated care plan said Mrs E had limited mobility and would need a walking frame and help from carers to get around.

Incident two

21. Mrs E’s room was locked all night on 21 September 2018.
22. When two care assistants went to check on Mrs E in the morning of 22 September 2018, they realised she had been locked in her room all night. They found her lying in a puddle of her own urine. The pressure mat to alert staff if Mrs E had left her bed was turned off. Her catheter bag was full. Mrs E was upset and distressed.
23. Mrs E’s care plan from August 2018 said she had reduced mobility and required two carers to transfer her in and out of bed. Her sleep and rest care plan from June 2018 said that she liked to lock her door at night but that she would need to be checked on every two hours because of her diabetes.
24. The daily care records for 22 September 2018 do not refer to the issues the previous night. The two hourly night checks show Mrs E was recorded as being asleep.
25. The Care Provider referred the matter to the CQC on 27 September 2018. It also referred the matter as a safeguarding concern to the Adult Social Care department at the council. It did this because it was concerned about the neglect Mrs E had suffered.
26. The Care Provider met with Mrs D at the end of September 2018. It expressed its sincere apologies and confirmed it would investigate the matter.
27. The Care Provider ended its investigation in November 2018. An agency employed the staff involved in the incident. It asked the agency to remove the members of staff from the site and any future placements.

Incident three

28. Mrs E was found on her front on the floor on 17 March 2019. Staff called for an ambulance. Mrs E went to hospital and a doctor diagnosed her with a chipped bone to her wrist. The doctor also said she probably had a broken nose, although this was not investigated fully. She left hospital the following day and was provided with a wrist support.
29. The incident sheet from 18 March 2019 shows the Care Provider employed extra staff for a 12-hour period to record if Mrs E became distressed. It updated Mrs E’s care plan and said staff should manage pain relief and help her with exercises for her recovery. It also said Mrs E should wear a wrist support until she recovered.

Incident four

30. Mrs D visited Mrs E on 5 April 2019. She noticed Mrs E’s wrist support was missing. Carers could not find Mrs E’s wrist support and they called for an ambulance. The paramedics arrived and they assessed Mrs E. They were happy she could grip but provided her with a bandage for extra support.
31. Mrs E went to hospital the following day. She had her wrist x-rayed. The x-ray revealed there was a second fracture. Mrs E was given a cast for her wrist.
32. The Care Provider investigated the matter after Mrs D complained about it. It found staff had not checked Mrs E’s care plan and they were unaware of the exercises she needed to complete. Care staff had no knowledge of why Mrs E was not wearing her wrist support. There was no written documentation to say that Mrs E had been lifting cups, but staff said this was the case.
33. The Care Provider introduced hourly observation sheets after its investigation. It also referred the matter to the CQC.

Complaints handling

34. Mrs D emailed the Care Provider on 3 March 2019 and said she had serious concerns about the care Mrs E was receiving. Mrs D had previously raised numerous concerns about Mrs E’s care.
35. She emailed the Care Provider again on 24 March 2019 after incident three. She said she believed another resident pushed Mrs E violently. She asked to speak to a manager as a matter of urgency. The Care Provider logged it as a formal complaint on 26 March 2019 and confirmed it would investigate the matter.
36. The Care Provider issued its stage one response to Mrs E’s complaint on 17 May 2019. It said:

• Incident one – There was no evidence to suggest Mrs E’s fall could have been prevented or that a member of staff was using a trolley without due care and attention. Mrs E received appropriate care immediately, during and after the incident.
• Incident two – Mrs E’s care plan reflected she could mobilise independently. An agency worker had not supported Mrs E as instructed. It offered its sincere apologies again for the standard of care Mrs E received.
• Incident three – The fall was not witnessed and there was no evidence to suggest another resident was involved. Staff followed correct procedures and quickly sought medical help.

37. Mrs D attended a meeting with the Care Provider and the council on 16 September 2019. The council carried out its own safeguarding investigation after Mrs D had raised concerns about the care Mrs E was receiving with the police. The council concluded the allegations of neglect had been partially substantiated. This was based on the fact there was poor record keeping, poor care planning and poor communication.
38. Mrs D emailed the Care Provider on 20 September 2019. She said she wanted to continue with her complaint because the council had partially substantiated her allegations. She also complained about the length of time it took the Care Provider took to respond to her concerns.
39. The council wrote to the Care Provider at the beginning of October 2019. It identified several learning points for the Care Provider to action from the safeguarding investigation. This included:

• Adequate and timely recording to be completed by care staff.
• Effective care planning.
• Care staff to be offered training on completing risk assessments.
• Care staff to be in regular communication with Mrs D.

40. Mrs D emailed the Care Provider on 12 October 2019. She said she was raising a further formal complaint and wanted a response to her previous emails. The Care Provider responded on 14 October 2019 and confirmed it would deal her complaint in line within its complaints policy. Mrs D chased for a response on 17 October 2019.
41. The Care Provider issued its stage two complaint response to Mrs D on 29 October 2019. It said it had already responded to majority of Mrs D’s points in previous correspondence. It referred Mrs D to the Ombudsman if she was not happy with its response.
42. Mrs D remained unhappy with the Care Provider’s response and referred her complaint to the Ombudsman.

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Analysis

43. The Ombudsman cannot investigate late complaints unless there are good reasons to do so. A late complaint is when someone takes 12 months to complain to us about something a care provider has done. Mrs D was aware of incidents one and two in July and September 2018. She did not refer her complaint to the Ombudsman until March 2020. I will exercise discretion to investigate incidents one and two because it was not until the council had completed its safeguarding investigation in September 2019 that she realised the full extent of the injustice Mrs E suffered.
44. Mrs D says Mrs E was knocked over by a trolley and this is what led to incident one. The daily records do not suggest this was the case. However, I note the incident log was updated on 1 August 2018, one day after the event. Therefore, the Care Provider failed to provide a timely record of the incident. This is fault.
45. The Care Provider has recognised it failed to support Mrs E in relation to incident two. I welcome that the Care Provider has apologised to Mrs D, and that it took the correct steps in referring the incident to the CQC. I also note agency workers involved in the incident no longer work for the Care Provider. However, carers neglected Mrs E all night. It would have been distressing for Mrs D when she found out what happened. The records from the night are inaccurate and do not reflect what happened. This leaves Mrs D with further uncertainty as to whether other incidents took place that were not properly recorded. The Care Provider also failed to record the events of 21 September 2018 in the daily care records on 22 September 2018.
46. Mrs D says Mrs E with involved in an altercation with another resident that resulted in incident three. The Care Provider says there is no evidence to suggest another resident was involved. I have not seen any evidence to suggest another resident was involved. The Care Provider acted quickly and sought medical help. It also acted properly in employing extra care staff to monitor Mrs E.
47. Mrs E’s care plan from March 2019 said she should wear a wrist support and complete exercises for her recovery. Despite this, Mrs E did not have her wrist support on when Mrs D visited on 5 April 2019. The Care Provider has accepted its staff failed to follow Mrs E’s care plan. There is no evidence to suggest carers helped Mrs E with her exercises. I welcome that the Care Provider referred the matter to the CQC and introduced hourly observation sheets. However, it understandable why Mrs D says a second fracture would have been avoided if Mrs E had been wearing her wrist support and had been completing the exercises according to her care plan.
48. The Care Provider also failed to keep thorough and accurate records because there was confusion among staff about whether Mrs E had been lifting cups or not. There was also nothing in the daily records to say when Mrs E had stopped wearing her wrist support.
49. I also consider the Care Provider did not effectively communicate with Mrs D after each incident. I have not seen any evidence to suggest that the Care Provider wrote to Mrs D and explained what it had investigated and what measures it had put in place to prevent the same thing happening again. This caused Mrs D unnecessary worry and understandably led her to question the quality of care provided.
50. The Care Provider’s complaints policy says it will provide a full response to a complaint within 10 calendar days. If a customer is not happy with the first response, they can ask for it to be escalated. They will receive a further response within 10 calendar days. The Care Provider took just under two months, rather than 10 calendar days, to respond to Mrs D’s first complaint. The Care Provider responded to Mrs D’s email on 20 September 2019 when she asked to continue with her complaint. Finally, the Care Provider took 17 calendar days to respond to Mrs D’s email on 12 October 2019. Mrs D had to wait longer than she should have done for a response to her concerns which caused avoidable upset and frustration.
51. I am also concerned about the quality of the Care Provider’s final response to Mrs D’s complaint. The Care Provider said it had already responded to the substantive points Mrs D raised in its stage one response. However, the Care Provider did not explain what procedures it would be implementing after it had received the council’s recommendations and learning points from the safeguarding investigation. This leaves Mrs D with further uncertainty that the Care Provider has not taken steps to improve its service after many of her concerns were upheld.

Agreed action

52. To remedy the injustice caused, by 13 April 2021 the Care Provider has agreed to:

• Apologise to Mrs D for the uncertainty, distress, and frustration it has caused her.
• Pay Mrs D £500.

53. By 11 May 2021:

• Provide evidence:

1. Of the action plan it has set up to ensure staff are aware of:

1. The importance of recording accurate, complete, and timely records.
2. The importance of adhering to care plans.

2. It has discussed the serious implications of falsifying records with its staff at the next general meeting.
3. It has shared its new communication standard with relevant staff so they are aware of the importance of sharing investigation outcomes with relatives after an incident has taken place.
4. Staff who deal with complaints are aware of the importance of adhering to the timescales set out in its complaints policy.

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Final decision

54. I have completed my investigation and find the Care Provider’s actions have caused an injustice. It has agreed to my recommendations and so I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman