HC-One Oval Limited (21 000 236)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 25 Oct 2021

The Ombudsman's final decision:

Summary: Mrs C complains on behalf of her mother, Mrs J, that the Care Provider did not share her mother’s care plans between 2019 and 2021. She also says the lift at the Care Home was out of order meaning Mrs J missed a number of appointments about her hearing and she was unable to access social spaces and activities. We find fault with the Care Provider’s poor recording of Mrs J’s care plan reviews which caused her and Mrs C uncertainty. The lack of a working lift was service failure which caused Mrs J an injustice.

The complaint

  1. The complainant whom I shall refer to as Mrs C, complains on behalf of her Mother Mrs J. Mrs C says;
  • The Care Provider did not share Mrs J’s care plans with Mrs C between 2019 and 2021, despite repeated requests, which caused uncertainty as to whether the care plans were being managed properly,
  • The Care Provider did not properly look after Mrs J’s hearing aids, and one was lost, meaning a new one will have to be purchased, and
  • The lift at the Care Home was regularly out of order, meaning for periods of time Mrs J was unable to access the main social spaces in the Care Home. She also missed five hearing related appointments because of the issue with the lift.

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The Ombudsman’s role and powers

  1. The Ombudsman investigates complaints about adult social care providers. She decides whether their actions have had an adverse impact on the person making the complaint. In this statement I refer to this as injustice. (Local Government Act 1974, sections 34B and 34C)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
  3. We normally name care homes and other care 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 read the complaint, spoke with Mrs C on the telephone and made enquiries of the Care Provider.
  2. I invited Mrs C and the Care Provider to comment on the draft decision and considered any comments made in response.

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What I found

  1. Mrs J became a resident of Grosvenor Park Care Home, HC-ONE Limited (the Care Home), in September 2019. Before this she had been a resident at another care home.
  2. Mrs C said that when Mrs J moved to the Care Home, she understood she would be involved in the care plans from the beginning and would be able to view them. She confirmed she had been involved in telephone reviews but had not been able to view the care plans despite making requests to do so.
  3. The Care Provider’s Care Planning Procedure policy says that care reviews take place every three to six months dependant upon risk factors. It says the review is to be completed by a Nurse, Nursing Assistant, Senior Carer or Carer.
  4. When Covid-19 restrictions eased in early 2021, Mrs C said she was able to view the care plans and have face to face reviews with the staff at the Care Home. She said she found the Care Home had obtained information about Mrs J’s care from the previous care home she had stayed at. Mrs C was satisfied with the overall level of care provided.
  5. In response to my enquiries, the Care Provider said it recognises the importance of engaging with residents and relatives when planning care. It said it looks to involve residents’ families as much as possible, particularly with care reviews held every three to six months, dependant on risk factors. It also explained that due to the Covid-19 pandemic, some of these reviews with families had to be conducted over the telephone but once restrictions eased it was able to arrange face to face reviews.
  6. The Ombudsman was provided with care plans completed by the Care Home for Mrs J. The documents were requested to cover the time period from when Mrs J moved to the Care Home in September 2019 until the date of my enquiries in August 2021.
  7. In September 2019, nine care plans were completed for Mrs J. Each of these listed Mrs J as the only person consulted when creating the plan. The plans said that they should be reviewed as a minimum monthly or as care needs arise. Some of the plans also had the frequency of review section left blank.
  8. Of the nine plans listed above, five of the plans had a handwritten note on them that they were reviewed in April 2021. One was reviewed in May 2020 and the remaining three did not have any detail of a review having taken place.
  9. In November 2019, two more care plans were completed for Mrs J. These were regarding safe environments and oral health. These were not covered in the plans completed in September 2019. The safe environments plan has a note that it was reviewed in April 2021 whereas the oral health plan listed July 2021 as the date it was reviewed.
  10. Since the reviews in April and May 2021, most of the care plans have been reviewed once, around three months after the last review.
  11. There are no entries on any of the care plans or relative communication documents that Mrs C was consulted when developing or reviewing the care plans.

Hearing aids

  1. Mrs C says one of Mrs J’s hearing aids was lost at the Care Home and has not been recovered. She feels the staff should have done more to look after the hearing aids. Mrs C said Mrs J has taken out her hearing aids herself on occasions and this can lead to them being misplaced.
  2. In response to my enquiries, the Care Provider said it did not regularly check whether Mrs J’s hearing aids were in place during the day as it would be an invasion of her privacy. It said staff discovered one of Mrs J’s hearing aids was missing when they went to put them on charge for her at night. Staff searched for the hearing aid, but it could not be found.
  3. The Care Provider’s residency agreement covers residents’ personal belongings. It says “whilst we make every effort to provide a secure environment, we are not responsible for loss or damage to your belongings unless we have failed to take reasonable precautions to look after them”.

Issues with the lift

  1. Mrs C said the lift at the Care Home has been out of order on many occasions. She said this means Mrs J has missed five appointments relating to her hearing and has not been able to use the downstairs social space and dining room, as she cannot get to the ground floor without the lift. Mrs C said the staff said they could not move Mrs J into the stairlift to access the ground floor.
  2. Mrs C said she spoke with the activities coordinator and whilst some activities were being conducted on residents’ floors, the majority were still taking place on the ground floor. She said Mrs C’s social interaction was also limited as she had only been able to go and see another resident in her room on a few occasions.
  3. In a letter to relatives in January 2021, the Care Provider said the lift had been upgraded in January 2020 and this took place at a cost of £29,651. It said for six months the lift was generally reliable. From July 2020, the Care Provider said the lift began to have issues again and it was difficult to obtain the necessary repairs due to parts from Europe taking longer than usual to arrive and the required engineers being on furlough due to the Covid-19 pandemic.
  4. The Care Provider said in September 2021 that the lift had been working without issue for the last four weeks. It said 27 breakdowns had been logged during the time since the upgrade to the lift. It also said it had taken measures to accommodate residents such as turning empty bedrooms into social space and having extra floor-based activities.
  5. The Care Provider said its records only showed one occasion where Mrs J had missed an appointment due to the lift being out of order.


Care Plans

  1. Some of the individual care plan documents show they should be reviewed as a minimum every month whilst others had the review date left blank. The Care Providers statement in response to my enquiries said it looks to do reviews every three to six months, which is the review period detailed in its policy. No reviews within these timescales were documented in the care plans. In most of the plans, the first documented review is a handwritten note 19 months after the care plan was created.
  2. Mrs C has said that the overall standard of care provided to Mrs J has been good from what she has seen. Mrs C said she has been involved in telephone reviews which would be suitable during the Covid-19 pandemic. However, Mrs J moved into the Care Home six months before the pandemic, so the Care Provider could have involved her in a face-to-face meeting for the creation of the care plans between September 2019 and March 2020.
  3. Mrs C said she asked to view the care plans regularly but was not provided with a copy. There is no record of a request being made and the Care Provider did not comment on it in response to my enquiries, only that it involved Mrs C in reviews. However, none of the care plans list Mrs C as having been consulted in the care plan or any reviews, only Mrs J is listed.
  4. There was fault by not documenting the reviews of Mrs J’s care plans. The Care Provider’s policy does not say relatives have to be involved although it has said it looks to involve them where possible. If they are involved, the Care Provider should record any contacts.
  5. This caused Mrs J and Mrs C uncertainty as to whether the care plans were being managed effectively as reviews were not documented.
  6. Mrs C is happy with the overall standard of care provided to Mrs J, so there is no further injustice.

Hearing aids

  1. Mrs J was known to remove her hearing aids and this could lead to them being lost. When staff realised one was missing, they tried to find it but were unable to. The residency agreement says it is not responsible for loss of such an item unless it has failed to take reasonable precautions to look after them. On the information available I do not find fault with the Care Provider for how it has handled this incident.

Issues with the lift

  1. An upgrade to the lift caused the ongoing issues with the lift being out of order on 27 occasions between January 2020 and September 2021. The Care Provider made good efforts to resolve the issue and also used considerable funds to do so. It kept relatives updated of the situation through letters. It also made extra social areas available to residents who could not leave their floor.
  2. Mrs C says Mrs J missed five appointments about her hearing due to the lift whereas the Care Provider says only one missed appointment is recorded. The care plans section above raises concerns about the Care Home’s recording of information, so I cannot decide exactly how many appointments were missed. It is agreed that at least one appointment was missed.
  3. Whilst the Care Provider did convert other areas on residents’ floors to social space, Mrs J was unable to use the core social space and engage in the expected activities.
  4. Whilst the lift not working was not the fault of the Care Provider and it did what it could to resolve the issue, the lack of a working lift was a service failure that caused a significant injustice to Mrs J.

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Agreed action

  1. To remedy the injustice identified, the Care Provider has agreed to take the following action, within one month of this final decision;
  • Apologise to Mrs J and Mrs C for the faults we have identified in this investigation,
  • Ensure Mrs J’s care plans are now all up to date with reviews,
  • Pay Mrs J £100 for her uncertainty by failing to document reviews of her care plans in line with policy,
  • Pay Mrs J £300 for the injustice caused by the lift being out of order, and
  • Pay Mrs C £50 for the time, trouble and uncertainty caused to her by the Care Provider not involving her in a face-to-face meeting when the care plans were created prior to the Covid-19 pandemic, and not recording her involvement and contributions to the care plans when she took part in telephone reviews.
  1. The Care Provider has agreed to look at lessons that can be learnt from this case. Within three months of a final decision, the Care provider will;
  • Review its policy and documentation to ensure it adequately details when care plan reviews should be carried out, ensuring there is consistency across its documentation, and
  • Conduct training with its staff to ensure they recognise when care plan reviews should be conducted and to record the outcome of reviews, including any relative involvement and contributions.
  1. Evidence of completing the above remedies should be provided to the Ombudsman.

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Final decision

  1. I uphold a finding of fault against the Care Provider for the reasons detailed in this statement. The Care Provider has agreed to my recommendations to remedy the injustice caused to Mrs J and Mrs C.
  2. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman

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