Summary: Mr P has complained on behalf of Mr R about the care he received by the Care Provider. The Ombudsman has identified various failings by the Care Provider about the level and adequacy of care provided to Mr R. This resulted in an injustice to Mr P and his family and so the Ombudsman has recommended a remedy.

The complaint

1. The complainant, who I refer to as Mr P, is making a complaint for his late father, who I refer to as Mr R. Mr P complains about the adequacy of care provided by the Care Provider to Mr R during his time in residential care. Specifically, Mr P says that Mr R did not receive the correct medication from the Care Provider during his time in care and was neglected by carers.
2. Mr P wants the Care Provider to pay compensation for distress. Further, he wants the Care Provider to pay compensation for the pain suffered by Mr R as a result of the Care Provider’s actions and oversights.

Back to top

The Ombudsman’s role and powers

3. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
4. 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).
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

6. I have reviewed Mr P’s complaint to the Ombudsman and Care Provider. I have also had regard to the response of the Care Provider and its findings following an internal investigation. Both Mr R and the Care Provider were given an opportunity to comment on a draft of my decision before reaching a final decision.

Back to top

What I found

Background

7. The CQC Fundamental Standards is guidance for care providers which interprets the regulations and shows what outcomes people who use services should experience when those regulations are properly met. It covers all aspects of care delivery, providing prompts for providers to consider, to ensure their service delivery arrangements are compliant with essential standards. Where the LGSCO finds fault which has wider implications, he shares his decisions with the CQC. The relevant regulations applicable to the complaint are contained in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations). The relevant regulations are as follows:

1. Regulation 9: The care and treatment of service users must be appropriate, meet their needs and reflect their preferences.
2. Regulation 10: Service users must be treated with dignity and respect.
3. Regulation 12: Care and treatment must be provided in a safe way for service users. This includes that medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe.
4. Regulation 14: Service users have adequate nutrition and hydration to continue life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment.

Chronology of events

8. In February 2020, Mr R entered residential care for a two-week respite stay with the Care Provider. Mr P says that on the day Mr R entered residential care, the family brought in pharmacy bought pain medication for him. Mr P said the family gave the medication to a nurse and was under the impression Mr R was receiving pain relief. However, the Carer Provider later told Mr P it could not give Mr R medication without a prescription. Mr P says this meant Mr R had been two days without any pain relief.
9. One week later, Mr P says his children visited Mr R in residential care. Mr P says his children were asked by the nurse to secure a urine sample from Mr R which they felt embarrassed to have been asked to do. Further, Mr P says his children were asked to make sure Mr R drank. Mr P says such tasks were the responsibility of the Care Provider and not his children.
10. Later, Mr P said Mr R’s health began to worsen though it was not until some days later the nurse called for a paramedic to attend. Mr R was taken to hospital and diagnosed with pneumonia. Mr P says the Care Provider neglected Mr R and his health problems could and should have been picked up earlier by carers.
11. In March 2020, Mr R passed away and Mr P complained to the Care Provider. The Care Provider completed an investigation and made the following findings:
1. That its policies were not followed and the nurse admitting Mr R did not tell Mr P of the medication procedure. The Care Provider said it does not allow over the counter medication to be administered and it should have told Mr P about this immediately. The Care Provider accepted fault that Mr R was not given enough pain relief medication and has set up new measures to avoid a repeat of this matter going forward.
2. That Mr P’s children being asked to take a urine sample from Mr R was not common practice and below the expected standards of its carers. Further, the Care Provider said that as Mr R’s health worsened, its carers should have checked his temperature, pulse, blood pressure and oxygen saturation, to identify any underlying health problems. However, it said there is no record to evidence that this was done. The Care Provider admitted fault in this regard has said it has carried out training to carers to avoid a repeat of the matter.
3. Its records showed that Mr R had forgotten to eat and began to have a small appetite, though this was not raised with the nursing team. The Care Provider said Mr R’s food and fluid intake was therefore not monitored which could have supported identifying his health decline. Further, the Care Provider found no evidence that team members prompted Mr R with his meals and offered food alternatives. The Care Provider accepted fault in this regard and that its actions possibly led to the worsening of Mr R’s health. Moreover, the Care Provider has said new monitoring and supervision policies are now in effect to ensure its resident’s nutritional needs are met.
4. That abnormalities to Mr R’s body had not been recorded on the provided body map documentation by carers. It said this contributed to a delay in diagnostic, possible treatment and advanced care planning for Mr R. The Care Provider has said it is now undertaking regular body mapping and this is being monitored by the management team of the home.
5. That concerns relayed to Mr R’s doctor were not detailed enough to identify the severity in the decline in his health. Also, it said the view of the paramedics attending Mr R was that he was unwell, and his condition should have been picked up earlier by its care staff. The Care Provider has said thorough measures are now in effect to record and support its care staff and to ensure the well-being of its residents.
12. In recognition of its faults and shortfalls, the Care Provider gave a full refund of Mr R’s care fees. Still dissatisfied, Mr P brought his complaint to the Ombudsman.

My findings

13. In this case, fault is not in dispute by the Care Provider and it has provided a full refund of Mr R’s care fees in recognition of this. Following a review of the findings by the Care Provider, it has accepted fault for not providing care and treatment suitable for Mr R’s needs. Further, the care and treatment provided was not safe. In addition, it is clear the Care Provider did not meet Mr R’s nutritional needs. I also do not consider the Care Provider treated Mr R with dignity and respect while in care as the identified faults prevented a degree of autonomy for Mr R live independently. Therefore, the Care Provider was at fault and fell below the standard of care normally expected, as set out in Regulations 9, 10, 12 and 14 of the 2014 Regulations.
14. In my view, the events and failures identified would have justifiability led to a high level of distress for Mr P and his family over a moderate period. I do therefore consider Mr P has suffered a personal and significant injustice by reason of the Care Provider’s faults. I am therefore recommending a moderate financial remedy be paid to Mr P, as set out below.
15. Separately, I recognise that Mr P wants the Care Provider to pay compensation for his father’s pain and suffering for the time he was in care. Where there is clear tangible evidence of financial loss (such as care fees), we would normally recommend a financial payment to the deceased persons estate. However, where the loss is less tangible (such as harm to the person), we will not normally recommend a financial remedy in a way we might had the person still been living. On this basis, I am exercising my discretion not to provide a remedy on the basis Mr P has since passed away.

Back to top

Recommended action

16. Our remedies are not meant to be punitive and we do not award compensation in the way that a court might. Our financial recommendations are more of a symbolic payment which serves as an acknowledgement of the distress or difficulties a person has been put through.
17. In reaching a recommended action, I have considered the various faults by the Care Provider, the number of people affected, the severity of distress and duration of that distress. On this basis, I am recommending the Care Provider pay Mr P £300 in acknowledgment of the distress he and his family suffered by reason of the faults. Further, the Care Provider should pay £100 to Mr P for the time and trouble he has spent in bringing the complaint. The Care Provider should pay Mr P the above amounts by 15 February 2021.
18. The Care Provider has accepted failings which it identified through its own internal investigation. Further, it has signposted Mr R to new measures and strategies put in place to ensure a high quality of care for residents going forward. On this basis, I am satisfied that no service improvement recommendations are necessary.

Back to top

Final decision

19. The Care Provider was at fault for providing inadequate care to Mr R. I believe the faults reasonably led Mr P and his family justifiably suffering an injustice. I have therefore recommended an action to remedy the injustice. However, I cannot make an award for pain and suffering for the reasons given.

Back to top

Investigator's decision on behalf of the Ombudsman