MACC Care Limited (20 004 133)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 25 Mar 2021

The Ombudsman's final decision:

Summary: We have discontinued our investigation into Miss X’s complaint about the poor quality of care her mother received during the three months she spent at Wulfrun Rose Nursing Home. The care home has agreed to waive the outstanding care fees which remedies any injustice caused.

The complaint

  1. Miss X complained that Wulfrun Rose Nursing Home (the care home) provided poor care to her late mother Mrs A during the three months she stayed there in 2019. She particularly referred to the times she found her mother in wet clothes and the time her mother suffered an injury and had to be taken to hospital.
  2. She said the care home’s poor communication caused her uncertainty and stress. Miss X is seeking an apology and a refund of fees for the period her mother spent in the home.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we are satisfied with the actions a council has taken or proposes to take. (Local Government Act 1974, section 24A(7), as amended)
  2. 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)

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How I considered this complaint

  1. I considered the documents provided by Miss X.
  2. I considered the care home’s response to my enquiries.
  3. Miss X and the care home had an opportunity to comment on my draft decision. I considered comments received before making a final decision.

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What I found

What happened

  1. In September 2019 Mrs A went into the care home. Before Mrs A’s arrival, Miss X spoke to two care home workers about the provisions the care home had in place to ensure her mothers safety. She said the workers assured her that all beds had pressure pads and the staff would watch her mother closely.
  2. Miss X visited Mrs A every day, with an exception of one weekend. She had concerns about the quality of care the home provided to Mrs A after she found her mother wet and distressed on two occasions.
  3. In October, Miss X visited her mother and discovered bruising on her face and her arm. She was upset the care home did not tell her of an incident that led to her mother’s injuries. When she approached the duty nurse Miss X said she was abrupt and did not provide her with the information she wanted.
  4. The care home said that it had no evidence that her mother suffered a fall, but the home manager said that she would investigate and tell the family the result.
  5. Within 24 hours, Mrs A’s condition started to decline and following a consultation with a GP, the care home kept Mrs A under close observation for the next 48 hours. Care home staff recorded wellbeing checks, fluid and food assistance, incontinence support, personal care and repositioning checks.
  6. As Mrs A did not show improvement the care home rang an ambulance and the hospital admitted Mrs A.
  7. Once admitted the hospital diagnosed Mrs A with dehydration and a cracked bone in her neck. The care home said the hospital confirmed this was a pre-existing injury that Mrs A could have aggravated by knocking into something.
  8. In November the care home ended Mrs A’s placement. The same month the care home sent a final response to Miss X about the internal investigation into the incident.
  9. The hospital discharged Mrs A to a different care home.
  10. In early December Mrs A passed away. Miss X complained to Care Quality Commission (CQC). The CQC contacted the Council’s safeguarding team. The safeguarding team asked the care home for more information and the provided evidence was enough for the safeguarding team to close its investigation. It did however recommend the care home should contact the local authorities’ Care Commission Group (CCG) quality team for a review.
  11. In January 2020 Miss X wrote a letter of complaint to MACC Care Group Limited who managed Wulfrun Rose Nursing Home. She said she never received a reply.
  12. The care home contacted CCG and outlined what happened. In July 2020 CCG responded with its findings and provided the care home with an action plan it had to follow and complete.
  13. In August 2020, Miss X complained to the Ombudsman.
  14. In reply to my enquiries the MACC Care Group director said it did not receive the complaint letter Miss X had sent. Since the complaint to the Ombudsman, the director has contacted Miss X to pass on his condolences and apologised for the lack of response to her complaint. The Group director has also offered to refund the care fees for the period Mrs A spent in the care home.


  1. There is nothing more we can achieve by investigating this complaint further as the MACC Care Group has:
    • apologised to Miss X for the lack of response to her complaint;
    • agreed to refund the full care fees,
    • investigated and terminated a contract with the duty nurse involved in the incident,
    • agreed and implemented the service improvements suggested by CCG.
  2. The MACC Care Group Limited has also confirmed it will apply the improvements to all the care homes the Group manages.
  3. I consider the above action to be satisfactory therefore, I discontinued my investigation.

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Final decision

  1. I have decided to discontinue my investigation as the care home has offered a suitable remedy to Miss X.

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Investigator's decision on behalf of the Ombudsman

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