Summary: Mrs X complained, on behalf of her mother Mrs Y, about the poor standard of care provided to Mrs Y by a Care Home. We found the Council at fault. We recommended it apologise to Mrs X and Mrs Y, pay Mrs X £500 for distress, pay Mrs Y £700 for distress, and act to prevent recurrence.

The complaint

1. Mrs X complains on behalf of her mother Mrs Y, about the care Mrs Y received in Francis Court Care Home, West Sussex (operated by Care UK) which the Council arranged and commissioned.
2. Mrs X complained the Care Home:
• Failed to regularly feed, give medication, personal care or continence care to Mrs Y between October 2020 and 18 November 2020. Mrs X said this caused Mrs Y distress and loss of dignity. Mrs X said it also caused her stress and upset as she stepped in as an unpaid carer to look after her mother’s needs and find a new care home.
• Failed to adequately monitor or provide care to Mrs Y on 18 November 2020, resulting in Mrs X calling an ambulance after finding Mrs Y unresponsive in a soiled pad and clothing. Mrs X said this caused distress and upset.
• Harassed her for calling an ambulance on 18 November 2020, which Mrs X said caused her upset and frustration during a difficult time.

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The Ombudsman’s role and powers

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. 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. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with 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

7. I spoke to Mrs X and I reviewed documents provided by Mrs X and the Council.
8. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. When investigating complaints about council-funded care placements, the Ombudsman considers the 2014 Regulations when determining complaints about poor standards of care.
10. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
11. Regulation 10 says that all service users should be treated with dignity and respect.
12. Regulation 12(i) says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
13. Regulation 13 says that Care or treatment for service users must not be provided in a way that is degrading for the service user, or significantly disregards the needs of the service user for care or treatment.
14. Regulation 13(1) requires care providers to have effective systems to prevent abuse of service users. Guidance explains staff must prevent, identify and report abuse when providing care and treatment. This includes referral to other agencies.
15. Regulation 14 says the nutritional and hydration needs of service users must be met.
16. Regulation 17 requires care providers to keep accurate, complete and contemporaneous records of care and treatment.

Adult safeguarding procedures

17. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)

What happened

18. Mrs Y has dementia. Mrs X is Mrs Y’s attorney for financial and health and welfare matters. This means she has legal power to make decisions about Mrs Y’s finances and health on her behalf because she does not have mental capacity to do so.
19. Mrs X says the Care Home provided good care to Mrs Y for the ‘first few years’ but this changed in 2020. She says the Care Home did not regularly feed, medicate, or provide personal and continence care to Mrs Y, despite saying it was a dementia care home and able to do this.

October 2020 to November 2020

20. On 9 October 2020 the Care Home contacted Mrs X to discuss Mrs Y’s care as she was refusing personal care and continence care. A Best Interest meeting took place on the telephone and the Care Home explained, due to the risk of skin deterioration, it needed to ensure the care was carried out for Mrs Y. Mrs X agreed Mrs Y did not have capacity in this area. The notes provided of the meeting do not show finding another placement for Mrs Y was discussed or agreed with Mrs X at this time.
21. Daily care records seen covering the period from 9 October to 16 October show Mrs Y ate and drank well, however there were times she declined personal and continence care and so was left in dirty clothing and soiled pads. This was despite the Care Home agreeing Mrs Y had no capacity in this area and it needed to ensure the care was carried out.
22. On 16 October Mrs Y became unwell and admitted to hospital. She returned to the Care Home two days later. Daily care records show the Care Home struggled to meet Mrs Y’s continence and personal care needs when she returned, managing only three continence pad changes in two days. It spoke with Mrs X on 19 October and advised it had contacted the Community Psychiatric Nurse (CPN) due to Mrs Y’s refusal to eat, drink or accept assistance with care.
23. Records show the Care Home spoke with the CPN again on 20 October for advice regarding Mrs Y’s refusal to accept care. It advised the situation could not continue and it needed the crisis team. It is not clear from the records what the outcome of this request for the crisis team was. However, on 22 October the Care Home spoke with Mrs X and agreed that as Mrs Y responded well to care from Mrs X, she could visit the Care Home and provide care for Mrs Y. Mrs X told me she wanted to help with her mother’s care as the home said they could not cope with her.
24. Mrs X visited Mrs Y, three times a day, between her shifts at work from 22 October to 18 November. During this time, Mrs X says she gave Mrs Y her meals and drinks, washed her, dressed her, brushed her teeth, changed her continence pads, and gave her medication. Mrs X said she often found Mrs Y in the mornings sitting in soiled, leaking continence pads and she had developed sores in her groin from this. She brought this to the attention of the home but was told Mrs Y was refusing the care they tried to give.
25. Daily care records from the Care Home say it contacted the CPN on 12 November explaining it was finding it difficult to meet Mrs Y’s needs even with regular visits from Mrs X. Records say the CPN planned to speak with the GP and would get back to the Care Home.
26. Daily care records from 16 November show the CPN contacted the Care Home to tell it they planned to review Mrs Y’s medication with the GP. The records also say the CPN raised concerns about photographs and claims of neglect they had received from Mrs X about Mrs Y.
27. The same day, the Care Home met with Mrs X. It said it could no longer meet Mrs Y’s care needs and gave notice on her placement. Mrs X then began the process of finding a new home. She says she became exhausted from looking after her mother, working full time and finding a new care home.
28. In the early morning of 18 November, Care Home staff noticed Mrs Y’s legs were swollen and hot to touch. Staff booked a telephone consultation with the GP for later that day.
29. Mrs X visited Mrs Y the same day later in the morning. She found Mrs Y unresponsive, sitting in a chair in the lounge, in a soiled pad and wet nightdress, in full view of other residents. Mrs X says she looked for a nurse on two floors of the Care Home but could not find one. She decided to call an ambulance as she could not wake Mrs Y, and then told the receptionist.
30. When ambulance staff arrived, they asked for Mrs Y’s care records. The Care Home provided Mrs Y’s care plan profile and care needs summary but did not provide the care plan folder as it contained confidential information. Ambulance staff then asked for recent notes and GP consultations. The home explained it dd not have printed notes and told ambulance staff they could view Mrs Y’s records on the computer if they wanted to.
31. Mrs X said while ambulance staff tended to Mrs Y, the deputy manager at the home harassed her about calling an ambulance, until ambulance staff told them to move elsewhere.
32. The ambulance took Mrs Y to hospital with a suspected condition and raised a safeguarding referral. Mrs Y did not return to the home when she left hospital as it said it could no longer meet her needs.
33. Mrs X complained to the Care Home about its lack of care for Mrs Y, resulting in her hospital admission on 18 November.
34. The Care Home explained it was unable to provide a response to Mrs X’s complaint, until the Council’s safeguarding investigation was complete.

The safeguarding investigation

35. The Council carried out a safeguarding investigation and looked into six points of enquiry. As part of this investigation, the Council’s investigating officer asked the Care Home to respond to each point of enquiry and inspected Mrs Y’s care records.
36. The six points of enquiry related to:
• Whether the home sought assistance from professionals.
• What happened on 18 November.
• The expectations placed on Mrs X to meet the care needs of Mrs Y.
• The conduct of Care Home staff on 18 November.
• Available documentation regarding observations and checks on 18 November.

The safeguarding investigation found:

• The Care Home sought appropriately requested support from professionals prior to letting Mrs X know it could no longer meet Mrs Y’s care needs. However, it did not document the information in Mrs Y’s care plan or review, to reflect the support asked for or given.
• The Care Home did not update care plans and reviews regularly to reflect Mrs Y’s care needs and statements within were not dated.
• Mrs X’s psychological need care plan was outdated and needed review and update, with strategies and techniques to support Mrs Y. The Care Home made medication changes for Mrs X but did not document this in the care plan or review.
• The Care Home had a GP appointment booked for later in the day on 18 November. However, it should have escalated Mrs Y’s condition, because of the hourly checks, to ensure Mrs Y received medical attention in a timely manner. Also, further/ in depth documentation needed to ensure accurate recording of Mrs Y's condition.
• Daily care records for Mrs Y lacked detailed information. It asked the home to add further information to the daily record sheets and hourly check sheets to ensure it is documenting accurately.
• Documentation needs to be readily available to paramedics in their preferred format, regardless of who calls the ambulance.
• The Care Home told the Dementia and Older People’s Mental Health Service (DOMPHS) that it was struggling to meet the needs of Mrs Y. It also told DOMPHS Mrs X was assisting with Mrs Y’s care, although this should have been reviewed by the Care Home.
• The Care Home appropriately asked for support from DOMPHS and as a result medication changes were made but not documented in the care plan or review.
• On 17 November Mrs Y had only had her continence pad changed once from 8am to 4.50pm. On another occasion Mrs Y was seen sitting in soiled continence pads in an armchair in the lounge, documented by the DOMPHS.
6. The safeguarding investigation report recommended the Care Home raised concerns with appropriate professionals and speak with family members about levels of support in the future. If the Care Home cannot meet a resident’s needs without further intervention of family, it should consider reviewing and increasing the care provision.
7. In response to the recommendation in the safeguarding report the Care Home said:
• Allowing relatives to care for residents will not happen again. When Mrs Y was transferred back to the home on the 18 October, it should have raised a safeguarding referral and informed the CQC that it could no longer meet Mrs Y’s increased care needs.
8. Other information the home provided to inform the investigation included:
• When ambulance staff attended the home on 18 November, they commented that Mrs Y was soaking wet. Staff explained that it had been struggling to meet Mrs Y’s personal hygiene and continence needs and that Mrs X had been supporting it regularly to help meet her needs.

Mrs X’s complaint

40. The Care Home sent its initial complaint response to Mrs X on the 14 October. It said in summary:
• Mrs Y’s mental health was deteriorating while at the Care Home and at the Best Interest meeting it was agreed a smaller specialist placement needed to be found.
• Staff constantly tried to provide personal care and give food and fluids to Mrs Y. This was successful on some days but often not.
• It did not find Mrs Y was neglected, but it should have made a safeguarding referral when Mrs Y returned from hospital in October for potential self-neglect and refusal of treatment. This may have resulted in Mrs Y receiving more specialist care at an earlier stage.
• It would ensure, in future, it made safeguarding referrals at an earlier stage as soon as it recognised a risk of self-neglect, due to residents’ non-compliance.
• There was no expectation that Mrs X would assist with Mrs Y’s care. If she had mentioned she did not think it was appropriate her decision would have been supported.
• Managers at the home were upset that Mrs X called an ambulance without speaking to staff who could have explained Mrs Y had a GP appointment booked. It said it was sorry if Mrs X had perceived questions from them as harassment as it did not intend them to be.
• On 18 November the Care Home Manager and Deputy Manager, both registered nurses, were in the building. It understood Mrs X was concerned for Mrs Y however it may have been appropriate to stay with Mrs Y and press the emergency buzzer to alert staff.
• It concluded it could not find the Care Home at fault regarding the care Mrs Y received, but it agreed with the recommendations made by the safeguarding investigation.
41. Mrs X was unhappy with the complaint response and asked the Care Home to review it.
42. The Care Home responded with its final complaint response on the 15 November. It explained:
• The outcome of the S42 enquiry was clear and quoted “It was found that the Care Home acted appropriately with regard to seeking professional support and advice prior to meeting with family when they were informed that it could no longer meet Mrs Y needs, however documentation requires improvement in this area.
• It had reflected on where the documentation and recording needed improving to ensure that it was capturing the changes of Mrs X’s condition more frequently. However, the safeguarding investigation found it took all the necessary action.
• It had highlighted it was struggling to support Mrs Y due to mental health needs from June 2020 and was in regular contact with the DOPMHS where several strategies and medication reviews had taken place before advising Mrs X on 16 November it could no longer meet Mrs Y’s needs.
43. Mrs X was unhappy with the Care Home’s response as it did not accept that it had failed to provide adequate care for Mrs Y and brought her complaint to the Ombudsman.
44. In its response to my enquiries the Care Home summarised what it had said to Mrs X in its initial complaint response. It also said it had fully investigated Mrs X’s complaint and shared the lessons learnt with the team.

Analysis

Care to Mrs Y between October and November 2020.

45. The Care Home accepts it was unable to meet all of Mrs Y’s care needs due to her mental health.
46. From 9 October to 22 October I have seen evidence the Care Home failed to act in the best interest of Mrs Y and often provided her with little or no personal and continence care. This is fault causing distress to Mrs Y and Mrs X. This is injustice.
47. From 22 October to 18 November Mrs X assisted the Care Home in Mrs Y’s care, ensuring all her care needs were met during the times she was there. However, when Mrs Y was not there, evidence I have seen shows the Care Home failed to meet the personal and continence care needs of Mrs Y. This is fault causing distress to Mrs Y and Mrs X. This is injustice.
48. I am satisfied on balance Mrs Y did not receive care as she should have done from 9 October to 18 November. The Care Home should have either reviewed and increased Mrs Y’s provision or given notice because it could no longer meet her needs. The fact the Care Home took neither action at that time is fault.
49. Mrs X also had to step in as an unpaid carer to feed, medicate, provide continence care and personal care to Mrs X as the Care Home were unable to manage this. This was on top of Mrs X’s own work commitments, causing undue distress. This is injustice.
50. The Care Home told the Council this would not occur again and would ensure it sought further support should they be unable to meet a resident’s needs. However, I have not seen evidence of any change in process or policy to ensure this. I will therefore make a service improvement recommendation.
51. Although the safeguarding investigation found the Care Home had consulted other professionals, the Care Home did not make a safeguarding referral or notify the CQC when it knew it could not meet Mrs Y’s care needs. It is at fault for not doing this.
52. The Care Home told the Council this would not occur again and would ensure safeguarding concerns are raised immediately but I have not seen evidence of any change in process or policy to ensure this. I will therefore make a service improvement recommendation.

Care to Mrs Y on the 18 November 2020.

53. The safeguarding investigation found that on 18 November, although the Care Home did have an appointment booked for Mrs Y the same day, it should have escalated Mrs Y’s condition as a result of its hourly checks. The Care Home did not escalate Mrs Y’s condition. This is fault.
54. Mrs Y was caused undue distress by the Care Home not escalating her condition. Mrs X also believed Mrs Y was neglected and felt she needed to act urgently herself, this caused her distress and anxiety about Mrs Y’s well-being. This is injustice.
55. I have not seen evidence of any recommendation regarding this in the safeguarding investigation. Neither have I seen any evidence of change in the Care Homes procedure or policy to ensure this fault does not happen again. I will therefore make a service improvement recommendation.

Care Home staff actions on 18 November 2020

56. While I recognise Mrs X is unhappy with the way Care Home staff spoke to her on the 18 November, without other evidence of what took place in those conversations, I am unable to find the Care Home at fault.

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Agreed action

57. To remedy the injustice set out above I recommended the Council carry out the following actions:
58. Within one month of the date of my final decision:
• Issue an apology to Mrs X and Mrs Y.
• Pay Mrs X £500 for distress;
• Pay Mrs Y £700 for distress;
59. Within three months of the date of my final decision provide evidence to the Ombudsman of the following:
• Check the Care Home has a process in place to ensure it acts quickly and appropriately when a resident refuses support including, considering an increase in provision or giving notice, notifying the CQC and raising a safeguarding alert.
• Provide training or issue guidance to Care Home staff to ensure they escalate concerns about resident’s health appropriately.
60. The Council has accepted my recommendations.

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Final decision

61. I have found fault by the Council. This fault caused Mrs X and Mrs Y injustice and the Council has agreed to my recommendations, therefore I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman