Summary: We will not investigate Ms B’s complaint about the actions of her late father’s, Mr C’s, care provider. This is because further investigation could not add to the care provider’s response or make a finding of the kind Ms B wants.

The complaint

1. Ms B complained her late father’s, Mr C’s, care provider, neglected his personal care and hygiene and did not provide appropriate care to meet his needs. Ms B says the care provider alleged Mr C’s family did not mention he had suffered falls prior to accepting him in the care home for a period of respite, failed to complete a care needs assessment when he was accepted as a permanent resident and had numerous unwitnessed falls in the home. Ms B says the care provider gave Mr C Notice to Quit during the Covid-19 crisis and said it found her threatening when she was upset about the lack of care given to Mr C.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we could add to any previous investigation by the care provider, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, sections 34B(8) and (9))

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How I considered this complaint

3. I considered the information and documentation Ms B provided. I sent Ms B a copy of my draft decision and considered her comments on it.

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What I found

4. Mr C suffered from advanced Alzheimer’s disease, was unable to care for himself, had numerous falls and was cared for at home by his family. Mr C was assessed by the care provider in February, and it agreed for him to move into the home for a period of respite so Mrs C could have a break from her caring role.
5. Ms B says prior to agreeing to the respite, the family met with the Manager and clearly explained Mr C’s care needs, the amount of falls he had and the times he was active during the night. Ms B says the care provider alleged Mr C’s family did not tell them this.
6. Ms B says Mr C went into the placement for a period of respite on 2 March. On 8 March Mr C had an unwitnessed fall in the bathroom, Ms B asked that he be supervised when attending the bathroom.
7. Ms B says Mr C appeared settled and the family asked about making the placement permanent. Ms B is concerned this was agreed without the care provider completing an updated care needs assessment.
8. Ms B became concerned when Mr C had further unwitnessed falls, on average one a week. The care provider advised it could not provide 1:1 care for Mr C. Ms B says when she visited on 20 March Mr C appeared unkept, agitated, had not been showered, and was wearing dirty clothes. Ms B says she tried to calm Mr C and called Mrs C who attended and was told Mr C should not have been accepted into the home. Ms B says she became upset when the care provider took Mr C for a shower saying it was not her job and he should have been showered by the night staff. Mrs C received a call later that day advising of the lockdown situation due to the Covid-19 pandemic.
9. Mrs C complained about the care Mr C received from his care provider the following day. Ms B complained to the Care Quality Commission (CQC) and the care provider on 27 March as Mrs C had not received a response. Ms B says she spoke to the Manager of the home on 30 March and was told she could either take Mr C home, leave him there or find another care home. Ms B says she became very upset and said the care provider had a duty of care to Mr C. Ms B says the care provider later told her brother Ms B was threatening and included this as a reason for giving Mr C notice.
10. The care provider gave Mr C ‘Notice to Quit’ on 7 April. Ms B says the care provider only gave 7 days to find another care home, and although it had given the family contact details of other homes, no one was accepting residents because of the pandemic.
11. Mr C was admitted to hospital with a broken hip following a further witnessed fall on 11 April and discharged to another care home on 25 April. Sadly, Mr C passed away on 11 July 2020.
12. The care provider responded to Ms B’s complaint in November 2020. It said it agreed to accept Mr C for a period of respite and completed a pre-admission assessment form. Following a satisfactory period of respite, it agreed to accept Mr C on a permanent basis. However, it says Mr C’s mental health and the frequency of falls he was having rapidly deteriorated.
13. The care provider says it sought advice from a range of professionals and collaborated with the Community Mental Health, Physiotherapy and GP services, the Falls Team, the Local Authority Safeguarding Team, the Alzheimer’s Society and the CQC but could not keep Mr C safe or prevent him from falling. All services agreed Mr C needed a suitable placement with nursing care. It said Mr C remained active and fit which increased his risk of falls.
14. The care provider says it advised Mrs C it did not provide 1:1 care which could be purchased at an additional cost and also considered whether Mr C’s son could provide Mr C with additional support, however, given Covid restrictions, visitors were not allowed to enter the premises.
15. The care provider says it considered other possibilities but could not manage Mr C’s presenting needs so served him with a Notice to Quit. The care provider says it would have continued to provide Mr C with care until a suitable placement could be found but sadly his health deteriorated, he had another fall and was admitted to hospital.
16. The care provider apologised that it had not met the families expectations and found the admission process confusing.
17. Ms B remains unhappy with the care provider’s response and has asked the Ombudsman to investigate. She says she is concerned other residents and families may suffer as they have and is concerned the care provider is not being honest in its account of what happened, alleging family members did not give an accurate account of Mr C’s needs when it initially agreed to take him into the home.
18. We could not make a finding on what was said in conversations when we were not present or say the lack of re-assessment when Mr C was admitted as a permanent resident caused him any injustice. Neither could we say the care provider should not have given notice during a pandemic when it could no longer meet Mr C’s care needs. The care provider has explained what it did to try to make Mr C safe but says it could not manage his ongoing needs. The care provider’s response to Ms B refers to email exchanges and telephone conversations with her and Mrs C and says while it is clear they were unhappy with the care being provided to Mr C it could not keep him safe. We could not add to this or make a different finding even if we investigated.
19. Ms B says it took the care provider over three months to return monies it owed Mr C, and when it did it sent a cheque addressed to Mr C. When asked to resend it to Mrs C it took a further three weeks. Mr C’s estate has now been reimbursed with the monies owed. There is nothing for the Ombudsman to investigate regarding this point.
20. Ms B says the care provider has distorted the truth on social media. The Ombudsman cannot investigate this.

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Final decision

21. We will not investigate this complaint. This is because further investigation could not add to the care provider’s response or make a finding of the kind Ms B wants.

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Investigator's decision on behalf of the Ombudsman