Summary: Mrs X complained about several aspects of poor care she received while resident at The Georgians Nursing Home. We have identified some areas of fault including poor record keeping, uncertainty about care provision and complaint handling. To remedy the injustice caused, the Care Home has agreed to apologise, make payments to Mrs X and her daughter, Miss P, and review its practices.

The complaint

1. Mrs X complains about the poor standard of care she received while a resident at The Georgians Nursing Home (the Care Home). In particular, she complains about the following matters:
1. Poor patient management regarding medical appointments.
2. Failure to properly facilitate social contact with her family.
3. Lack of care when managing her personal possessions.
4. Failure to properly manage her medication.
5. Poor handover arrangements when she moved to a new care home.
6. Poor communication with her family.
7. Poor complaint handling.
2. She says this caused considerable distress and frustration, impacting on her health and well-being. Loss of trust in the Care Home’s ability to provide good quality care led to her moving to a different care home.
3. Mrs X is represented by her daughter, Miss P in making this complaint.

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The Ombudsman’s role and powers

4. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
8. If we are satisfied with an organisation’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

9. During my investigation I discussed the complaint with Miss P and considered the information she submitted.
10. I made enquiries of the Care Home and considered its response. Only some information was available because some records were destroyed by a flood. This has impacted on my ability to investigate parts of this complaint.
11. I consulted the law and guidance relevant to this complaint, referenced where necessary in this statement.
12. I issued a draft decision statement and invited comments from Miss P and the Care Home. I considered all comments received before making a final decision.

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What I found

Relevant law and policy

Care home regulations and guidance

13. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers, inspects care services to assess if they meet the fundamental standards of care and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
14. 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 CQC has issued guidance on how to meet the fundamental standards below which care must never fall.

• Regulation 9 says care and treatment must be appropriate and meet service users’ needs.
• Regulation 10 says service users must be treated with dignity and respect.
• Regulation 12 says care and treatment must be provided in a safe way for service users.
• Regulation 17 says care providers should maintain an accurate, complete, and contemporaneous record in respect of each service user.

What happened

15. In early 2021, Mrs X moved to the Care Home because she was struggling to manage at home. She moved three months later because her family were unhappy about the standard of care provided. A formal complaint was made on her behalf by her family after she moved. This complaint referred to several incidents which had led to the decision to move Mrs X. I have summarised the main areas of concern below, followed by the Care Home’s response and my findings.

Poor patient management

• Failure to notify the family that Mrs X was not engaging with physiotherapy.
• Failure to facilitate three remote therapy appointments.
• Failure to keep a copy of the form setting out Mrs X’s emergency care and treatment wishes (the Respect Form). When it was temporarily mislaid by the hospital, Mrs X was verbally asked for this information, causing her distress and confusion.

16. The Care Home says it informed another family member that Mrs X was unwilling to perform physiotherapy exercises that had been set for her. The Care Home says it was not told about remote therapy appointments, and so staff were unaware assistance was required.
17. The Care Home has explained the Respect Form would never be copied because only the original would be valid. After it failed to return with Mrs X from hospital, in the event of an emergency situation occurring, it was necessary to discuss this with Mrs X as a matter of urgency.

My findings

18. In the absence of any records about whether a particular family member was told about Mrs X’s lack of engagement with her physiotherapy exercises, evidentially it becomes a matter of one person’s word/recollection against that of another. The only available record about this matter states that the exercises were given to her on 24 February 2021. However, there are no subsequent records of any assistance/prompting having been offered or refused afterwards. The Care Home has also been unable to provide a copy of Mrs X’s care/support plan, that should have included details about the expectation of staff to assist Mrs X.
19. It is reasonable to assume that, because Mrs X was admitted to the Care Home because of mobility issues, physiotherapy would be a central part of a rehabilitation plan to improve her quality of life. Any refusal should have been formally recorded in her case notes. Similarly, I would expect to see some evidence of prompting from care staff. While I do not have the evidence to say with enough certainty whether this did or did not happen, the Care Home’s inability to provide any evidence to substantiate its version of events is sufficient for me to make a finding that there was fault in respect of its oversight of her physiotherapy. I cannot say whether any intervention from staff would have assisted Mrs X to better engage with the physiotherapy, but this uncertainty about the matter requires a remedy set out below.
20. In the absence of any evidence to the contrary, I have accepted the Care Home’s explanation that it was not aware of specific online therapy appointments that had been made privately by her family.
21. I have accepted the Care Home’s explanation for why the Respect Form was not copied and why it was necessary to ascertain her wishes as matter of urgency. There is no indication that Mrs X did not have capacity to engage in this conversation.

Failure to facilitate social contact

• Failure to facilitate telephone/video call contact between Mrs X and her family. The complaint referred to several occasions when Mrs X’s phone and iPad were missing and uncharged.

22. The Care Home says it was unaware Mrs X’s iPad was not charging. It has also recalled that Mrs X often declined contact because she was tired.

My findings

23. It is understandable why Mrs X’s family were frustrated when they were unable to speak to her. Covid-19 restrictions on face-to-face contact were in force at the time. These restrictions, whilst challenging for all parties, nevertheless meant that establishing alternative methods of communication was fundamental to the wellbeing of residents. This was reflected by the Care Home’s policy. This confirmed that, “virtual communication will be promoted. Staff will ensure that residents are fully supported to use it”.
24. It is not possible for me to ascertain with enough certainty whether the Care Home failed to act in accordance with its policy. It has provided explanations for what happened regarding Mrs X’s iPad. I have read an email from the Care Home to Miss P’s sister explaining it was unaware of an instruction not to allow Mrs X to charge the iPad, and staff had not realised her phone was in the front pocket of her suitcase so it had not been available for her to use. The Care Home has offered an apology for this oversight. This is an appropriate remedy.
25. The Care Home has also said Mrs X sometimes refused contact and I cannot dispute this, based on the available evidence.
26. Overall, while I acknowledge there may have been occasions when Mrs X’s family were unable to contact her, I cannot say with enough certainty that this demonstrated a pattern of poor practice in this area. For this reason, I have not found the Care Home to be at fault.

Lack of care in respect of her personal possessions

• Mrs X’s clothes were not unpacked for 14 days when she first arrived at the Care Home.

27. The Care Home has accepted it did not realise Mrs X’s suitcase was in her wardrobe and therefore out of reach to Mrs X. The Care Home has apologised for this oversight.

My findings

28. The Care Home should have realised Mrs X did not have access to her personal possessions especially after two weeks. It is entirely understandable that her family felt this demonstrated a lack of care by the Care Home.
29. This was not in line with Regulation 10 (Dignity and respect). I am satisfied Mrs X suffered a personal injustice as a result of this fault because of the frustration and confusion caused by her inability to access her suitcase.

Failure to properly manage medication

• Medication for anxiety was out of stock and therefore not administered for nine days.
• Thyroid medication was reduced with no explanation.
• Pain relief was reduced, that was of particular concern due to the possible side effects of sudden withdrawal.

30. In response, the Care Home has confirmed stock levels were low at the local pharmacy. Any reductions in medication were made under direction given to the Care Home by the prescribing GP.

My findings

31. My ability to investigate this aspect of the complaint has been limited by the lack of care records, specifically a copy of the relevant medication charts or any information to support what the Care Home has provided by way of explanation. I fully understand Miss P’s concern about the changes that were made to Mrs X’s medication, particularly as Mrs X had experienced withdrawal symptoms in the past and relied on other medication to treat anxiety and long-standing thyroid issues.
32. The Care Home should have been able to provide some evidence in support of what it has said. Records should be stored securely. While I cannot say whether or not the relevant changes where GP led, the fact I am unable to do so leads to inevitable uncertainty about whether Mrs X’s medication was appropriately managed. This is fault. Again, while I am unable to say whether Mrs X suffered harm as a result, this uncertainty requires a remedy that I have recommended below.

Poor handover arrangements when she moved to a new care home

• The Care Home did not make the necessary arrangements for Mrs X to move to the new care home until late on the day of the intended move. As a result, it was extremely stressful and paperwork/continence supplies were not organised in time.
• Mrs X was put in a wheelchair belonging to another resident with a broken footplate, on the day of transfer.
• No pain medication was not administered on the transfer day.

33. The Care Home has explained there were some concerns about Mrs X moving to a new home that was a residential, as opposed to nursing setting. The accepted procedure was for the receiving care home to make contact with regard to the necessary handover arrangements, and this did not happen until the morning that Mrs X was due to move.
34. The Care Home apologised for the wrong wheelchair being used.

My findings

35. I have been provided with emails between the Care Home, Mrs X’s family and the new care home about the move. These confirm the Care Home was awaiting contact from the new home and there was concern about its ability to provide appropriate care for Mrs X. They also confirm the Care Home did not receive written confirmation from the new home that it was able to meet her need until the morning of the proposed move. The Care Home advised Mrs X’s family it was awaiting contact from the new home.
36. While I appreciate it was frustrating for Mrs X and her family that arrangements were seemingly not made in good time, I am satisfied with the explanation that has been provided by the Care Home for this delay as evidenced by the emails I have seen.
37. It is disappointing the wrong wheelchair was used on this occasion, particularly as it was damaged. It is entirely understandable why Mrs X’s family felt this demonstrated a lack of care. This should not have happened and was fault. However, there is no evidence Mrs X suffered any physical harm as a result and so I am satisfied the Care Home’s apology is an adequate remedy here.

Poor communication with Mrs X’s family

• An MRI appointment was accepted by the Care Home without any discussion with the family about whether it was convenient.
• Mrs X was moved to a larger room without mentioning it to her family first.

38. The Care Home has explained the MRI appointment was accepted as it was a decision that had to be made quickly. It was not considered necessary to consult with Mrs X’s family because staff would have been made available to transport her to the hospital in the event her family was unable to do so.
39. The Care Home says Mrs X was initially placed in a room that was accepted as too small and it was agreed with her family that she would be moved as soon as a larger room became available.
40. As a general observation the Care Home has explained it had a good relationship with one of Mrs X’s daughters, and there was no indication of the level of dissatisfaction until the complaint was made after Mrs X had moved to the new home.

My findings

41. As the Care Home has provided a reasonable explanation for its actions, I do not find fault with the Care Home’s communication with Mrs X’s family.

Poor complaint handling

42. A 12 page complaint detailing the various aspects of concern was submitted after Mrs X had left the home. The Care Home provided a six-line response simply saying an investigation has taken place and there was “no evidence of shortfalls”.
43. Miss P says this inadequate response in representative of the Care Home’s unprofessional and overly-relaxed approach to Mrs X’s care generally.

My findings

44. I have been provided with a copy of the Care Home’s complaints procedure, including template forms providing guidance on the structure of investigations and responses. This procedure was not followed in this case. The Care Home’s response was, in my view, inadequate and unhelpful. Had a proper investigation taken place, it is entirely probable that Mrs X’s family would have been reassured that some lessons had been learned and a complaint to the Ombudsman avoided. It also failed to signpost the complainant to the Ombudsman. This was fault.

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Agreed action

45. Within four weeks of my final decision, the Care Home has agreed to take the following action:

• Provide a written apology to Mrs X and Miss P for the faults identified above and any distress caused as a result.
• Pay Mrs X £500. This is a symbolic payment to reflect the distress and uncertainty caused by the areas of fault I have identified, particularly the inadequacies in the Care Home’s medication procedures and recording practices.
• Pay Miss P £100 to acknowledge the failure to follow its complaint procedure and her time and trouble spent making her complaint to the Ombudsman.
• Review its record keeping procedures, particularly in respect of their retention in a safe and secure manner. The Care Home should provide the Ombudsman with a short report, explaining what steps it has taken to ensure its compliance with Regulation 17.
• Remind all staff of the need to properly record any assistance with private health appointments where appropriate.
• Remind relevant staff of the requirement to properly investigate complaints in accordance with its policy.

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Final decision

46. I have identified some areas of fault and made recommendations to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman