Suffolk County Council (21 002 496)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 26 Apr 2022

The Ombudsman's final decision:

Summary: Miss X complained about the poor standard of care provided to her late mother while resident in a care home, arranged and commissioned by the Council. We have found there was fault with some aspects of care and recording practices and the Council has agreed to apologise and make a payment to Miss X for the injustice caused.

The complaint

  1. Miss X complains about the poor standard of care her provided to her late mother, Mrs C, while resident at Prince George House Care Home (operated by Care UK).
  2. Miss X says this caused Mrs C and her family significant avoidable distress and harm. She also says poor care contributed to her mother’s death.

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The Ombudsman’s role and powers

  1. 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)
  2. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
  3. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
  4. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
  5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
  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

  1. I considered:
  • Miss X’s complaint,
  • the Care Home’s response to the complaint, and
  • the Council’s response to my enquiries, including details of its own safeguarding enquiry into the matters complained about.
  1. Miss X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making this final decision.

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What I found

The fundamental standards

  1. 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 fundamental standards include minimum standards for:
  • Person-centred care
  • Meeting nutritional needs
  • Receiving safe care and treatment
  • Maintaining accurate and complete records
  • Safeguarding from abuse
  1. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
  2. When investigating complaints about the standards of care in a care home, the Ombudsman considers if the 2014 regulations and the fundamental standards have been met. If they have not, we consider whether any identified faults have resulted in injustice.

Adult safeguarding procedures

  1. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect him or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (Section 42, Care Act 2014).

What happened

  1. I have set out below a summary of the key events. But it is not meant to show everything that happened.
  2. In September 2019, Mrs C moved to Prince George House Care Home (“the Care Home”). She had a number of mostly age-related medical conditions, including diabetes, osteoarthritis, stroke, retinal detachment and heart disease. She also had bi-polar affective disorder. In June 2020, she moved to the nursing unit following a deterioration in her health.
  3. Miss X says the care provided to Mrs C was poor, particularly after she moved into the nursing unit. This had a detrimental effect on her health and well-being, including immediately prior to her death.
  4. Mrs C’s family raised concerns on numerous occasions, but they say the Care Home failed to take their concerns seriously and respond appropriately.
  5. In late January 2021, as a result of an infection and a general decline in her health, Mrs C was admitted to hospital and passed away soon afterwards. Miss X says the Care Home failed to realise the seriousness of the infection and had action been taken sooner, the outcome could have been different.

The safeguarding investigation

  1. Following her death, Mrs C’s family raised their concerns about the Care Home with the CQC who in turn alerted the Council. The Council carried out a safeguarding investigation where 48 specific incidents were looked into. As part of this investigation, the Council’s investigating officer asked the Care Home to respond to each allegation. She also scrutinised Mrs C’s care records, incident sheets, hospital records, staff statements and consulted with other agencies including the Coroner’s office and the police.
  2. The 48 incidents related the following main themes:
  • Failure to provide personal care on time, including continence care.
  • Incorrect diabetes care.
  • Failure to address the deterioration in medical condition prior to Mrs C’s death.
  • Meals were not culturally appropriate.
  • Poor medical care including treatment relating to leg ulcers, eyes, skin and infections.
  • Removal of personal items from Mrs C’s room without permission.
  • Lack of communication with family.
  1. The outcome of this safeguarding enquiry was that the allegations were “partially substantiated”. It identified four areas of concern that required action by the Care Home:
  • Removal of personal belongings had been removed from Mrs C’s room without consent.
  • Refusal of personal care had not been properly recorded.
  • There were occasions when diabetes care had not been administered correctly.
  • Quality and accuracy of Mrs C’s care plan.
  1. The enquiry concluded that it was not possible to ascertain what actually happened on many of the incidents complained about because it was essentially the family’s version of events against that of the Care Home. However, there were several incidents where the records were unable to confirm what the Care Home had said about Mrs C refusing personal care.
  2. The Council has carried out monitoring of the Care Home to ensure remedial action had taken place.

The complaint to the Care Home

  1. The family also complained to the Care Home directly and reported a staff member to the relevant regulatory body.
  2. The Care Home carried out its own investigation and provided a detailed response to the complaint and addressed the individual incidents of concern raised by the family. Some areas of complaint were upheld:
  • Some aspects around communications with Mrs C’s family.
  • Incorrect diabetes care
  1. The Care Home apologised and took corrective action including staff training.
  2. Miss X was dissatisfied with this outcome and so brought her complaint to the Ombudsman.

Analysis

  1. The records from the Council’s safeguarding investigation demonstrate the Council carried out a full and detailed safeguarding investigation into the concerns raised by Mrs C’s family. All relevant records were carefully scrutinised by a Council officer and some areas of complaint were upheld and several areas of service improvement were identified. I can see the Care Home co-operated fully with this process.
  2. The Care Home has also provided comprehensive and detailed responses to the family’s complaints. Some parts of the complaint were upheld and an apology given.
  3. The Ombudsman does not reinvestigate matters that have already been subject to proper external scrutiny, as was the case here. Mrs C’s family complained to both the Council and the CQC about the concerns they had about the Care Home.
  4. For this reason, my investigation has mainly focussed aspects of the complaint that were not considered by the safeguarding enquiry. I have also considered, where the Council did identify areas of poor practice, whether there is any outstanding injustice that requires a remedy.

Poor management of diabetes and other health conditions

  1. The Council’s safeguarding enquiry identified two incidents when Mrs C’s diabetes had not been managed correctly. This included adding sugar to orange juice that was contrary to the diabetes plan in place for Mrs C and medical advice should have been sought when it was not.
  2. The Council recommended all staff should have updated diabetes training. The Care Home accepted incorrect procedures had not been followed and training has now taken place. The Care Home has also taken specific action in respect of one staff member.
  3. I am satisfied the Council’s safeguarding review was thorough and reached the correct conclusion regarding this aspect of the complaint.
  4. While the action taken by the Care Home will seek to improve diabetic care standards going forwards, I must consider whether there is any outstanding personal injustice.
  5. I did not find evidence that Mrs C’s health was adversely affected as a result of the diabetic care given to her. However, it is clear that these incidents affected the trust and confidence Mrs C and her family had on the competence of the Care Home to manage her diabetes properly. This injustice requires a remedy.
  6. While it is not possible to remedy this injustice to Mrs C, I have made recommendations below to acknowledge the distress to Miss X.
  7. The safeguarding enquiry did not identify any other areas of inadequate nursing care and the evidence I have seen supports this conclusion.

Inadequate response to a deterioration in Mrs C’s health at the end of her life

  1. The Council’s Safeguarding investigation concluded that Mrs C was provided with appropriate care in the days prior to her final hospital admission. I agree with this assessment. The records I have seen confirm Mrs C was monitored closely and an ambulance was called when her condition deteriorated. There was no fault here.

Poor quality personal care

  1. The Council’s safeguarding investigation was unable to establish that Mrs C was neglected in this area. Mrs C’s family reported many times when Mrs C had not received any personal care until late morning or afternoon.
  2. The Care Home explained that Mrs C on these occasions, Mrs C had refused care that was offered. This was usually because her preferred member of staff was unavailable at that time. This is supported by both the care records I have seen and the statements provided by carers. Mrs C had capacity to make this decision and the Care Home was not able carry out personal care without her permission.
  3. I cannot add anything further to the Council’s investigation.

Inadequate, inaccurate and misleading recording practices

  1. There were however occasions when Mrs C’s refusal of care was not recorded and should have been. This was highlighted by the Council’s safeguarding enquiry and the Care Home was instructed to take action to address this in future.
  2. The fact it was not possible to reach a robust decision about what happened is a concern in itself. This has left uncertainty about whether care was provided on a number of occasions.
  3. Both the Care Home’s complaint response and the Council’s safeguarding enquiry identified some other inadequate recording practices. This understandably led her family to have concerns that the care plan was not person-centred and did not reflect her needs and preferences.
  4. The fundamental standards include the need to keep accurate, complete, and up to date records. The Care Home’s failure to meet this fundamental standard is fault.

Attitude and conduct of staff, both to Mrs C and her family

  1. Many areas of this complaint relate to interactions between Care Home staff and Mrs C and her family. As part of its own investigation and in response to complaints made to regulatory bodies, the Care Home obtained written statements from staff who witness the incidents of concern. I have read these statements and there is a clear conflict with the family’s view as to what happened.
  2. The Care Home accepted there were some incidents, particularly with the family, that could have been handled better and has already apologised. This is an appropriate remedy for the distress caused and the Ombudsman cannot add anything further here.
  3. The evidence I have seen, also shows that Mrs C often posed a challenge to many staff members, causing them to become upset and distressed. This was recorded in her care plan under the heading “Behaviour of concern”. Staff were advised to document all interactions with Mrs C. The records show this happened.
  4. The Ombudsman makes decisions on the balance of probabilities. In this aspect of the complaint, the issues essentially relate to the family’s word against that of the Care Home. There are no independent witnesses. As I am unable to prefer one account over another, I have not found fault with the Care Home’s general approach to Mrs C and her family.

Lack of cultural awareness

  1. Miss X says the Care Home was ill equipped to provide care that was appropriate to Mrs C’s cultural needs, particularly her dietary preferences.
  2. The records show there was an ongoing dialogue with the Care Home and the family to ensure Mrs C’s dietary preferences were met. I am satisfied the Care Home responded appropriately here.
  3. I found no evidence to support Miss X’s claim that the Care Home’s care of Mrs C was affected by racism.

Failure to properly address and respond to complaints raised

  1. From the records I have seen I am satisfied the Care Home fully investigated several complaints made by different family members. While the outcome from these was not to their satisfaction, other than some minor delay, there was no fault with the complaint handling in this case.

Injustice and remedy

  1. Since its safeguarding investigation, the Council has acted appropriately by instructing the Care Home to improve its standards in certain areas. I am satisfied the actions taken by the Council and the Care Home are appropriate and the Council has worked with the Care Home to monitor and improve the standard of care provided and to learn from the faults identified. I do not consider any further service improvement recommendations are necessary.
  2. The Ombudsman does not recommend compensation payments or punitive damages. But whenever we find fault causing injustice, we look to remedy the injustice caused. Sometimes this is not easy, and we recommend token payments in recognition of avoidable distress and uncertainty. While it is no longer possible to remedy the personal injustice caused to Mrs C, I consider it is appropriate for the Council to make such a payment to Miss X to acknowledge the failure by the Care Home to provide proper diabetes care and the fault with its recording practices.

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Agreed action

  1. 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 Care Home, I have made recommendations to the Council.
  2. The Council has agreed to take the following action within four weeks from the date of my final decision:
      1. Apologise to Miss X.
      2. Pay Miss X £500 as a symbolic payment to acknowledge her distress caused by the faults that were identified in the Council’s safeguarding investigation and this decision.

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Final decision

  1. I have found some areas of fault and the Council has agreed to apologise and make a payment to Miss X.

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Investigator's decision on behalf of the Ombudsman

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