Summary: Ms X complained about the care her late mother, Mrs Y, received at the Council commissioned Care Home. The Care Provider was at fault. There were errors in how staff at its Care Home communicated information about Mrs Y’s care amongst each other and with other healthcare professionals and with how staff recorded information about her care. A safeguarding investigation identified faults by the Care Home. The Care Provider recognised the faults and put measures in place to improve its service. The Council has agreed it will apologise to Ms X and make a symbolic payment of £150 to acknowledge the distress and frustration the faults caused her. The Council will also provide evidence to show the Care Provider has actioned the lessons it learned.

The complaint

1. Ms X complained about the Council commissioned Care Home, Mountbatten Lodge, and the care it provided to her late mother, Mrs Y. Ms X said the care was poor which caused Mrs Y and her family distress and it affected Mrs Y’s mental health. She wants the Council to refund the full cost which was paid for her mother’s care.

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The Ombudsman’s role and powers

2. 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)
3. 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)
4. 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

5. I considered the information provided by Ms X and I spoke with Ms X on the telephone.
6. I considered the information provided by the Council and the safeguarding investigation conducted by Council B.
7. Ms X and the Council had the opportunity to comment on the draft version of this decision. I considered their comments before making the final decision.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Adult Social Care Safeguarding

9. 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 himself 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

10. Mrs Y had health problems which required her to have support with her daily needs. In July 2020, Mrs Y moved into the Care Home, Mountbatten Lodge. The Care Home was commissioned by the Council but was in another council area (Council B). She was a resident at the Care Home until October 2020 when she moved into a new care home. Mrs Y died in August 2021.
11. The Care Provider, Quantum Care, issued Mrs Y with a bill of £9481.09 for her stay at the Care Home. In November 2020, Mrs Y’s daughter, Ms X, complained to the Care Provider about the care her mother received whilst she resided at the Care Home. She said the Care Home did not provide her mother with safe care and it did not treat her mother with dignity and respect, it was not responsive to her mother’s needs and it did not properly communicate with her about her mother’s care. As a result, Ms X said her mother should not be charged £9481.09 for her stay at the Care Home. Ms X also raised a safeguarding alert with Council B. The Care Provider responded to Ms X and said it would revisit her complaint following the outcome of her safeguarding alert. It referred to an additional charge of £300 it had issued to Mrs Y. It said it was prepared to waive the additional charge, considering the circumstances.

The Council’s safeguarding investigation

12. Council B completed a safeguarding investigation and considered Mrs Y’s allegations of neglect and emotional and psychological abuse by staff members at the Care Home. As part of its investigation, it reviewed statements from care staff and reviewed information between the Care Home and other healthcare services. It also reviewed the action the Care Home took in response to the matters Ms X complained of. It identified areas of concern and investigated each one.

Injury and referral to the District Nurse Team

13. Mrs Y suffered an injury to her leg. Ms X said the injury happened when her mother’s foot fell off the foot plate of the wheelchair which caused her mother’s leg to drag whilst she was being pushed forward. The Care Home said the injury occurred whilst Mrs Y was being transferred using a moving and handling aid and she caught her leg on the wheelchair.
14. Care staff dressed Mrs Y’s leg and informed Ms X it had made a referral to the District Nurse Team on the day of the incident. Ms X said a few days after the incident, she was concerned as the District Nurse Team had still not visited her mother. Ms X said she spoke with the staff at the Care Home and it was unclear if a referral had been made. Ms X said she then spoke with the District Nurse Team herself and the Team informed her it had received a referral a few days after Mrs Y’s incident but not on the day of the incident. Ms X felt it should have been the Care Home’s responsibility to get an update from the District Nurse Team regarding the referral. The Care Home said generally the District Nurse Team does not send out confirmation once it receives a referral. It said it did send a referral on the day of the incident and had followed it up a few days later.

Pain management

15. Prior to Mrs Y’s stay at the Care Home, Ms X says Mrs Y routinely visited a pain management clinic for pain in her foot. This was arranged via her General Practitioner (GP). When Mrs Y moved into the Care Home, she registered with a new GP. Ms X said her mother had informed the new GP of the pain management treatment she routinely received via her previous GP. Ms X assumed at this point the GP had made a referral to a pain management clinic for continuous treatment. However, during a review meeting, Ms X found that the new GP was not able to access all of Mrs Y’s medical history including information about her pain management. Ms X said the Care Home was aware of this issue weeks before the review meeting and it failed to investigate it further and inform her of it. Ms X said it was neglectful and unacceptable the Care Home had not taken further action upon knowing Mrs Y’s GP did not have access to the necessary information. The Care Home said it was not aware Mrs Y received pain management treatment for pain in her foot. It said Mrs Y’s previous care plan and medical summary did not provide this information and it only became aware of it through Ms X.

Contact with the GP

16. Ms X said her mother was suffering with constipation and had symptoms of a urinary tract infection. Ms X said her mother did not feel comfortable telling staff about her symptoms because she felt staff did not like her and did not treat her with respect. Mrs Y had planned to speak with her GP directly however staff had spoken with her GP instead. Ms X said her mother had capacity to speak with her GP directly and was not given the opportunity to do so. The Care Home said it acknowledged Mrs Y should have spoken to the GP herself. It said Ms X called later the same day to tell staff of Mrs Y’s symptoms. It then called the out of hours GP who prescribed antibiotics.

The outcome of the safeguarding investigation

17. Council B said the concern of neglect in relation to Mrs Y’s injury to her leg was inconclusive. It said it was Mrs Y’s word against the Care Home and there was no further evidence to prove how the injury occurred.
18. Council B continued and said, there was evidence the Care Home did refer Mrs Y to the District Nurse Team but there was a lack of evidence which showed the Care Home had followed up the referral. Council B said the concern of neglect in relation to the referral to the District Nurse Team was inconclusive but it believed there had been failings in staff communication and follow-up with professionals.
19. Council B said the outcome of its investigation into emotional and psychological abuse was unsubstantiated. It said there was no evidence of emotional abuse in its investigation. However, it considered there was organisational abuse.
20. Council B’s safeguarding investigation found fault with how the Care Home reported matters and recorded information. It found:
• there was no evidence which showed staff had chased up the referral with the District Nurse Team. The information Council B reviewed showed staff did not follow up the referral until after Ms X had raised her concern about her mother not being seen by the District Nurse Team.
• it had identified communication issues as the staff member Ms X spoke with was not aware if the Care Home had referred Mrs Y to the District Nurse Team.
• there had been failings regarding the Care Home’s record keeping and audit trails.
• the Care Home failed to follow up Mrs Y’s medical history. However, Council B acknowledged this could be partly due to the two GP surgeries not communicating about the matter.

The Care Provider’s complaint response

21. The Care Provider acknowledged its failings in some areas of care it delivered to Mrs Y. It said it put measures in place to improve its communication amongst the team and with other healthcare services and to improve its record keeping.
22. Following Council B’s safeguarding investigation, Ms X contacted the Care Provider in relation to her desired outcome of her complaint. She still wanted the Care Provider to reimburse her mother’s care fees. The Care Provider responded to Ms X and said although it recognised there were failings in relation to communication and record keeping, it did not consider they had a detrimental impact on her mother’s care. It said its previous offer of waiving the additional charge of £300 remained and it would not be offering further payment.
23. Ms X remained unhappy and complained to us.

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Findings

24. Council B properly investigated Mrs Y’s concerns. It set out the evidence in relation to the key areas it investigated but it could not reach a conclusion regarding neglect due to the different version of events. It did not find evidence of emotional and psychological abuse. It considered there was organisational abuse as it identified faults with the Care Home’s communication amongst staff and other healthcare services and with how it recorded information such as when it followed up the referral for Mrs Y.
25. The Care Provider acknowledged the faults identified and listed its lessons learned. I am satisfied the lessons learned addressed the faults which were identified. However, I have seen no evidence to show the Care Provider has made improvements and actioned the lessons learned.
26. The Care Provider’s response to Ms X’s complaint said it would offer to waive the additional cost of £300 of Mrs Y’s care fees. However, this was not a direct remedy for Ms X.
27. As Mrs Y has since died, I cannot provide a remedy for any injustice these faults caused to her. However, the faults left Ms X with a sense of uncertainty over whether Mrs Y was properly cared for and caused her distress and frustration.

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Agreed actions

28. 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/service of the Care Provider, I made recommendations to the Council.
29. Within one month of the final decision, the Council agreed it will:
• apologise to Ms X for the distress and frustration the matter caused her and;
• make a symbolic payment of £150 to Ms X to acknowledge the distress, uncertainty and frustration caused by the faults identified in relation to her mother’s care.
30. Within one month of the final decision, the Council will liaise with Council B and obtain evidence which shows the Care Provider has actioned the lessons it learned from the safeguarding investigation. The Council will provide the evidence to the Ombudsman. The actions include ensuring:
• staff at the Care Home will record conversations they have had with healthcare professionals in relation to a resident’s care.
• there is good communication amongst staff about the care of the residents and that they are aware of recent changes to their care such as referrals being made to other healthcare services.
• staff are aware when a follow-up is required with other healthcare services such as the District Nurse Teams and GP’s, they raise this with the management team and document the necessary information.
• information staff have recorded on the system is monitored and information in relation to skin tears and wounds is updated regularly.

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Final decision

31. I have now completed my investigation. There was evidence of fault causing injustice which the Council has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman