Summary: Ms X complained about the care home’s treatment of her friend, Mrs Y, when giving end of life care, which caused distress to both of them. The Care Provider was not at fault.

The complaint

1. Ms X complained that during a visit to Mrs Y she saw a carer move Mrs Y’s arm back and forth for the carer’s own amusement. At the time, Mrs Y was receiving end of life care. She said this caused distress to Mrs Y and to herself.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)
3. 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)

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How I considered this complaint

4. I considered the information provided by Ms X and the care provider.
5. Ms X and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

Fundamental Standards of Care

6. 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 Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below.
7. Relevant to this complaint, regulation 13 says care providers must have robust procedures and processes to prevent people using the service from being abused. Where abuse is suspected, or reported by a third party, the care provider must take appropriate action, including carrying out an investigation and/or referral to the appropriate body.

What happened

8. Ms X visited Mrs Y, who was receiving end of life care. During the visit she said two carers came into the room. She said one of them, carer 1, moved Mrs Y’s arm back and forth for her own amusement. She said the other carer, carer 2, told carer 1 to stop but she did not do so. Ms X said she also told carer 1 to stop but carer 1 did not stop until Mrs Y, who was semi-conscious, asked carer 1 to “leave me alone”. A few days later, after Mrs Y had died, Ms X made a formal complaint.
9. The same day the care provider received a complaint, it called Ms X to discuss the incident. It carried out an investigation, which included formally interviewing carer 1 and carer 2. Carers 1 and 2 provided a different account of the incident to Ms X so the care provider spoke to Mrs X again to clarify her account of what happened. The care provider also reported the matter to CQC.
10. After considering all the information, the care provider decided that, on balance, there was no evidence of abuse. It wrote to Ms X to explain it had investigated the complaint but was not able to share information about any action it may have taken as a result. Ms X was unhappy with the outcome and said she would refer the matter to CQC. At that point, the care provider sought advice from the local council’s safeguarding team, which said the matter did not amount to a safeguarding concern.

My findings

11. Since I was not present, I cannot say what happened when Ms X visited Mrs Y in June 2020.
12. When Ms X reported her concerns to the care provider, it took appropriate action to investigate the incident, including speaking to Ms X and interviewing the two carers, who were present when the incident occurred. There was no fault in the way it carried out its investigation.
13. It wrote to Ms X to inform her of the outcome but explained it could not provide details about what action, if any, it was taking with regard to carer 1. Although Ms X was unhappy with the outcome, I have not found fault with the care provider’s actions. It is a matter for the care provider to decide what disciplinary action, if any, should be taken.
14. The care provider did not refer the matter to the safeguarding team at the Council until Ms X said she was unhappy with the outcome. It should have considered doing so when it first received the complaint but I have not seen any record to show it did so. However, this does not amount to fault causing injustice because when it did make the referral the Council said it did not amount to a safeguarding concern.

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Final decision

15. I have completed my investigation. The care provider was not at fault.

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Investigator's decision on behalf of the Ombudsman