Summary: The Council was at fault for the way it handled Mr X’s concerns about communication difficulties he faced when trying to contact Mrs Y at her care home. This caused injustice as Mr X was not able to speak to Mrs Y as often as he wanted in the final months of her life. The Council has agreed to apologise, make a payment to Mr X and have the care home review its communication facilities.

The complaint

1. Mr X complains about the difficulties he experienced in communicating with his mother, Mrs Y, at her care home.
2. He also complains about the level of service he and Mrs Y received from the care home, namely that:
• He was not able to communicate with her for two weeks while she was in her room and when a telephone call was arranged Mrs Y was too weak to speak.
• The care home delayed in contacting him when Mrs Y’s condition deteriorated.
• The care home did not contact a doctor after Mrs Y fell out of bed.
• The care home did not notify him Mrs Y’s medication had been stopped.
3. Mr X says he missed the opportunity to have a final conversation with Mrs Y before she passed away. He also experienced difficulties talking to her prior to her final weeks as the telephone line would cut out.

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The Ombudsman’s role and powers

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. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
6. 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, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. As part of this investigation I considered the complaint made by Mr X and the Council’s responses. I considered the information provided by Mr X. I made enquires with the Council and considered the response received. I sent a draft of this decision to Mr X and the Council and considered comments received in response.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

9. Safeguarding means protecting an adult’s right to live in safety, free from abuse and neglect. (Department of Health and Social Care, care and support statutory guidance)
10. The Council’s safeguarding duties apply to adults who:
• have needs for care and support;
• are experiencing, or at risk of, abuse or neglect; and
• because of those care and support needs cannot protect themselves from either the risk of, or the experience of abuse or neglect.
11. The care and support statutory guidance tells Council’s how to respond to safeguarding concerns. A Council must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should find out whether any action needs to be taken to prevent or stop abuse or neglect and if so, by who. The Council should involve any relevant partners (for example, the Police or NHS) or other persons relevant to the case.
12. Once the Council has completed its enquiries, it should decide what, if any, further action is necessary and acceptable.
13. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which is assesses against ‘fundamental standards of care’. These standards are set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Registered providers of care services are expected to achieve those standards.
14. Included in the fundamental standards are that service users must be treated with dignity and respect. This includes supporting people to maintain relationships that are important to them while they are receiving care and treatment.

What happened

Mr X’s complaint in June 2020 about difficulties communicating with Mrs Y

15. Mr X lives abroad. His mother Mrs Y lived in a care home.
16. In May 2020 Mr X contacted Mrs Y’s care home to say the phone used to talk to Mrs Y is not suitable as it only works in one location and is very noisy. Mr X explained Mrs Y was hard of hearing and cannot hear him. In addition, Mr X said the phone cuts out. He asked the care home to look at getting a telephone suitable for people who are hard of hearing.
17. On 27 May 2020 the care home told Mr X it could bring Mrs Y up to the manager’s office and she could use the phone there. Mr X and the care home continued to correspond about this issue. The care home acknowledged there were signal issues in the building and said it contacted a company about getting hearing devices, but they did not cover the area the care home was located in. The care home also suggested using video calls via Zoom or Skype. Mr X did not wish to use video calls as Mrs Y’s paid carer and representative both had already tried this with Mrs Y, and it did not work.
18. On 30 June 2020 the care home responded to Mr X. The care home said it had discussed the phone issues with its directors but no one else had complained about this. The care home said it would try to take residents to quiet places to speak on the cordless telephone. The care home said it could continue to facilitate phone contact in the manager’s office.
19. On 1 July 2020 Mr X contacted the Council to complain about the care home. Mr X said the care home only had one place where residents and family could talk, and this was on a normal phone not one suitable for someone hard of hearing.
20. Throughout July 2020, the Council made enquiries with the care home about the communication issues Mr X raised. The Council decided that the care home should address this issue and had already made other options available to Mr X. The Council also suggested to the care home it could purchase an amplifying phone as Mrs Y was hard of hearing and contact an occupational therapist to assess this. The Council also suggested the care home could refer Mrs Y to a GP for an audio assessment and to check what devices she could use.
21. The Council responded to Mr X’s complaint on 23 September 2020. The Council said the care home discussed other options with Mr X.
22. In November 2020 the Council reviewed its handling of this complaint. The Council told Mr X:
• It should have advised him to approach the Ombudsman if he remained unhappy when it wrote to him on 23 September 2020 and would remind its complaints team to do this in future.
• It did not keep him informed of the progress of the complaint.
• It significantly delayed in providing Mr X with a response to his complaint.
• It would review how it monitors and updates complainants.
• It had not found anything about the care home from this complaint which required further investigation.

Mr X’s complaint about the level of service he and Mrs Y received from the care home

23. In October 2020 Mrs Y’s health began to deteriorate and she started to receive end of life care.
24. On 14 October 2020 the care home emailed Mr X about Mrs Y and to say she was feeling better than in previous days. The care home said it tried to contact Mr X by telephone but could not get through to him.
25. Mr X responded on 15 October 2020 and was unhappy the care home had only emailed him since the previous weekend about Mrs Y’s health. He was unhappy the care home did not inform him immediately about the deterioration in Mrs Y’s health. Mr X asked the care home to send him full details of Mrs Y’s care going forward. The care home confirmed it would update Mr X and recorded a note for staff to update Mr X with a general update about Mrs Y.
26. The care home provided Mr X with updates about Mrs Y by email over the coming days. This included on 17 October 2020 when the care home told Mr X, staff found Mrs Y on the floor at 10:45am. The care home explained staff checked her and she was alright.
27. On the 22 October 2020 the care home told Mr X, Mrs Y was visited by a GP who decided to stop her medication.
28. On 23 October 2020, Mrs Y’s social worker contacted the care home and said Mr X could not telephone Mrs Y. The care home responded to Mrs Y’s social worker and said it had tried to telephone Mr X over 15 times but could not get through to him. The social worker passed this information onto Mr X via email.
29. The care home decided to purchase a mobile phone for Mrs Y’s room and did so on 23 October 2020. Mrs Y’s social worker contacted him and told him Mrs Y had a mobile phone and gave him the number to call.
30. On 24 October 2020 Mr X spoke to Mrs Y over the telephone, but was only able to briefly speak with her due to Mrs Y’s health. On 26 October 2020 Mrs Y passed away.
31. Mr X made a complaint to the care home. Mr X said he could not communicate with Mrs Y for two weeks before her death as she was in her room and could not move. The care home delayed in telling him about Mrs Y’s deteriorating health and he had to contact the care home on 23 October 2020 to arrange a call with Mrs Y. Mr X said the care home did not call a doctor after staff found Mrs Y on the floor.
32. Mr X did not receive a response and the complaint was not passed onto the Council. As a result Mr X contacted the Ombudsman with his complaint and we passed the complaint onto the Council.
33. In December 2020 the Council received a referral from the Care Quality Commission as an anonymous caller raised concerns about the care home. These concerns related to Covid 19, how service users were transferred and how service users were toileted. One concern related to how care home staff lifted Mrs Y.
34. The Council opened a safeguarding investigation. The Council told Mr X it would put his complaint on hold until the safeguarding investigation was completed.
35. The Council made enquiries with the care home about the allegations it received. The care home responded and provided the Council with its view and supporting evidence. In relation to the concern about Mrs Y, the care home provided the risk assessment for Mrs Y, fall assessment for Mrs Y and its log for falls at the care home over the past year.
36. After it considered the evidence, the Council decided to close the safeguarding investigation as there was no evidence to substantiate the allegations made. The Council concluded a risk management was in place for Mrs Y, handling guidelines in place for staff and Mrs Y was assessed before being transferred. The Council found the care home had a falls policy and staff were first aid trained. The Council also spoke with Mrs Y’s carer about her views of the care home.
37. Following the conclusion of the safeguarding investigation the Council provided Mr X with a response to his complaint. The Council said:
• It was satisfied with the care home’s response that it could not contact Mr X on 14 October 2020 by telephone.
• The care home contacted Mr X after staff found his mother on the floor. The Council said Mrs Y’s bed was lowered to the floor and a crash mat placed at the side of the bed minimise any injury should she roll off. The Council said staff assessed Mrs Y for injuries after this and the care home contacted Mr X to inform him. The Council said the safeguarding investigation found staff at the care home were first aid trained and there were falls policies.
• When the GP stopped Mrs Y’s medication, the care home said the GP told them it would contact Mr X. The Council found the care home followed the advice of the GP.

Analysis

Telephone communication issues at the care home

38. Mr X complains the care home did not put in place adequate facilities for him to communicate with Mrs Y. When Mr X initially raised this with the care home in May 2020, the care home did explore other options for Mrs Y and Mr X to communicate.
39. However, given the particular circumstances namely, Mr X lived abroad, and Mrs Y was hard of hearing, I consider the care home could have done more to try to address the communication issues between Mrs Y and Mr X. This is fault.
40. Mr X was asking for assistance not just because of the signal issues in the care home but because Mrs Y was hard of hearing so found the normal phone difficult to use. I recognise the care home did suggest Zoom and Skype calls, however Mr X said these had not worked previously. I note the Council suggested the care home consider purchasing an amplifier and referring Mrs Y to her GP to assess what devices were suitable for her to use, however the care home did not do this.
41. While the care home offered Mr X the option of Mrs Y having telephone calls in the manager’s office, it may not have been possible for her to do this when her condition deteriorated. As a result Mr X said he could not speak to Mrs Y. I cannot see what other options the care home considered at this stage to assist Mrs Y and Mr X to speak on the telephone, until 23 October 2020, a few days before Mrs Y passed away. This is fault.
42. The injustice Mr X suffered was that he was unable to have the communication with Mrs Y he perhaps wanted in the months before she passed away. Had the care home put in place a mobile telephone in Mrs Y’s room earlier this may have helped to address some of the communication issues between Mr X and Mrs Y.
43. There was also fault in the way the Council considered Mr X’s complaint about communication issues, namely a lack of signposting to the Ombudsman and delays. The Council has rightly recognised this and put in place actions to learn from this. I consider this appropriate to remedy any injustice from the Council’s complaint handling

The care home delayed in contacting Mr X when Mrs Y’s condition deteriorated.

44. The care home’s position is it could not contact Mr X by telephone on 14 October 2020. However Mr X suggests Mrs Y’s condition deteriorated the weekend before this. I have not seen evidence to suggest the care home attempted to contact Mr X at the time Mrs Y’s condition deteriorated.
45. I acknowledge there were issues with telephoning Mr X and the care home has provided evidence of this, namely on 23 October 2020, when it tried to telephone Mr X but could not get through. However the care home could have contacted Mr X by email as it had been corresponding with him via email. This is fault.
46. As a result Mr X was not aware Mrs Y’s condition had worsened until a later date.

The care home did not contact a doctor after Mrs Y fell out of bed.

47. When Mrs Y was discovered on the floor the records show she was checked by staff and assisted. Following this while the care home did not telephone Mr X it did inform him what had happened by email on the same day. I cannot see that Mr X asked for a doctor to check Mrs Y and the care home’s view was she did not have any injuries. I have not seen evidence since to show Mrs Y was injured.
48. The care home had a risk assessment in place for Mrs Y and a falls assessment. These detailed how staff should assist Mrs Y. I have not seen evidence to suggest that these were not followed by the care home.

The care home did not notify Mr X when the GP stopped Mrs Y’s medication

49. The records show the care home emailed Mr X on 22 October 2020 and told him a GP had stopped Mrs Y’s medication. While Mr X may have wanted to be consulted as part of this decision, the decision to stop Mrs Y’s medication was made by a GP not the care home.
50. If Mr X is unhappy with this decision he would need to complain about the GP to the National Health Service.

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Agreed action

51. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care provider, I have made recommendations to the Council.
52. Within one month of my final decision the Council agreed to out the following and provide evidence to the Ombudsman it has done so:
• Apologise to Mr X for the faults identified.
• Pay Mr X £200 to recognise the distress experienced because of the Council’s faults.
• Remind staff at the care home to notify appropriate family members promptly when a service user’s health has deteriorated.
• Request the care home review its communication facilities to see what it can do to improve this for residents. Following this the care home should advise the Council what actions it intends to take.

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Final decision

53. I have completed my investigation and found there was fault by the Council which caused injustice to Mr X. The Council has agreed to the above actions to remedy the injustice caused.

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Parts of the complaint that I did not investigate

54. Mr X also raised issues about a GP’s decision to stop Mrs Y’s medication. I have not investigated this as we cannot consider the GP’s decision or actions and Mr X would need to complain to the National Health Service about this. We can only consider the actions of the Council or care home acting on its behalf.
55. I have not investigated Mr X’s reports about Mrs Y’s advocate from 2019. We cannot consider complaints over 12 months unless there are good reasons. I see no reason why Mr X could not have complained about this sooner, or at the time.

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Investigator's decision on behalf of the Ombudsman