Summary: Ms X complains about the care her mother received when the Council arranged for her to stay at Lennox House for respite care. The Council accepts there were failings over her mother’s placement and has apologised. There are no grounds to ask the Council to do more than that.

The complaint

1. The complainant, whom I shall refer to as Ms X, complains about the care her mother received when the Council arranged for her to stay at Lennox House for respite care.

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The Ombudsman’s role and powers

2. 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)
3. 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, sections 30(1B) and 34H(i), 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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Ms X;
• discussed the complaint with Ms X;
• considered the comments and documents the Council has provided; and
• shared a draft of this statement with Ms X and the Council, and invited comments for me to consider before making my final decision.

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What I found

What happened

6. The Council arranged for Ms X’s mother, Mrs Y, to stay at Lennox House for a respite break.
7. Lennox House completed a pre-admission assessment at Mrs Y’s home on 26 July 2019 with a carer. This says Mrs Y:
• lacks capacity to make informed decisions due to dementia;
• had no history of refusing medication but was on “crushed meds (covert)”;
• likes to have her medication crushed and given with a pot of yoghurt;
• needs help with mobility and uses a walking frame and a manual wheelchair;
• needs help from two people with bed and other transfers;
• needs help from one person with sitting/standing, general movement, using the toilet and bathing.
8. After the assessment Ms X wrote to the Council asking if it needed any more information before her mother went to stay at Lennox House. The Council told her the respite stay was setup, approved and there was no need for it to be delayed.
9. Mrs Y stayed at Lennox House from 5 to 15 August 2019.
10. Ms X complained about her mother’s care after she returned home but the Council did not uphold her complaint. She complained again and when the Council replied in December it said:
• it accepted they had not been invited to view Lennox House before Mrs Y went to stay there and apologised. It said it had raised this with the managers of Lennox House as an area for improving its service for residents and relatives;
• some rosary beads had been located at Lennox House (having been put in a safe) and would be posted to them if they confirmed they belonged to Mrs Y;
• Lennox House had provided inaccurate information about a member of staff on duty the day Ms X collected her mother;
• there had been a misunderstanding about the date Mrs Y left Lennox House;
• it apologised for Lennox House saying Mrs Y had taken sleeping tablets when none had been prescribed for or given to her;
• Ms X should request an earlier review of Mrs Y’s needs if her mental and physical health had declined following her stay at Lennox House.
11. The Council tells me Mrs Y’s family asked for a review of her needs in February 2020. It says it did a needs assessment in July and an Occupational Therapy assessment in August.
12. Ms X and her daughter responded to the Council’s letter, raising further concerns. When the Council replied it said they could take their original concerns to the Ombudsman, if they were not satisfied with its response. It said it would return the rosary beads by post and would follow up on a missing purse. It said it would treat concerns over the discrepancy around administering pills in crushed form with food and Mrs Y’s weight being recorded as “5.5” as a new complaint.
13. Ms X complained to the Ombudsman in March 2020. She said:
• Lennox House did not get her mother to walk while she was there, which meant it was difficult to get her to stand, let alone walk when she came home;
• when she went to pick her mother up staff kept her waiting too long, tried to give her mother the wrong pills and then tried to stop her from leaving with her mother;
• they were still trying to get some of her mother’s belongings back;
• she wanted the home to be held to account;
• she wanted financial redress or more support for Mrs Y to give her a break.
14. In April the Council did not uphold Ms X’s new complaint. Ms X asked for a review in May 2020. When the Council replied in July 2020 it said:
• the information Lennox House gathered at the pre-admission assessment about crushing pills and adding them to yoghurt was not conveyed properly and apologised. But it said no issues with medication were recorded during Mrs Y’s stay [the medication administration records say Mrs Y took all her prescribed medication];
• it had been a mistake to record Mrs Y’s weight as “5.5” at the preassessment stage and Lennox House apologised. It said Mrs Y’s weight was recorded elsewhere as 72.8 kg.

Is there evidence of fault by the Council which caused injustice?

15. There is no dispute over the fact that there were faults with Mrs Y’s placement at Lennox House:
• the request to crush tablets and give them with yoghurt was not implemented;
• Ms X was not invited to view Lennox House before her mother stayed there;
• it did not discuss her mother’s needs with Ms X (it could have done this over the telephone);
• it did not send Mrs Y home with all her possessions;
• it incorrectly recorded Mrs Y’s weight on the pre-admission assessment;
• it gave inaccurate information about who was on duty when Ms X went to pick her mother up and about her taking sleeping tablets.
16. The Council has apologised for these failings and raised them with Lennox House so it can address them. The issue for me to consider is whether there is any outstanding injustice which warrants more than an apology. The failure to crush Mrs Y’s tablets could have caused he actual harm, but Lennox House records show she received all her medication so that was not the case. I cannot say the other problems caused any significant harm to Mrs Y.
17. I note that the complaint process has been protracted, but this reflects the fact that Ms X has raised new issues at each stage of the process. She raised a new concern when complaining to the Ombudsman; the failure to encourage Mrs Y to walk while she was there, resulting in reduced mobility when she returned home. Given Mrs Y’s circumstances when she went to Lennox House (e.g. age, dementia, and reduced mobility) I cannot say there is a causal link between her stay there and any further reduction in her mobility.
18. Ms X would like more support from the Council, so she has more respite. It is not for me to say what care the Council should put in place. I note the Council has reviewed Mrs Y’s needs fairly recently. If Ms X is not happy with the outcome of that review, it would be open to her to make a complaint about it.

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Final decision

19. I have completed my investigation as the Council has already apologised for the problems Mrs Y experienced at Lennox House and there are no grounds to ask it to do more than that.
20. Under the terms of our Memorandum of Understanding and our information sharing protocol with the Care Quality Commission, I will send a copy of my final decision statement.

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Investigator's decision on behalf of the Ombudsman