Summary: Ms D complained about the standard of care given to her mother, Ms X, by the care provider while Ms X lived in Field House Residential Care Home. She also complained that Ms X’s belongings went missing. She said that as a result Ms X will have suffered distress and will have not had the quality of life she should. There was fault and to remedy the injustice caused the care provider should make a payment to Ms D.

The complaint

1. I refer to the complainant as Ms X. She is represented in bringing the complaint by her daughter Ms D. Ms D complained about the standard of care given to her mother, Ms X, by the care provider while Ms X lived in Field House Residential Care Home. She also complained that Ms X’s belongings went missing. She said that as a result Ms X will have suffered distress and will have not had the quality of life she should.

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The Ombudsman’s role and powers

2. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
3. 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)
4. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)
5. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely further investigation will lead to a different outcome, or
• there is another body better placed to consider this complaint.

(Local Government Act 1974, sections 34B(8) and (9))

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How I considered this complaint

6. I considered the complaint and documents provided by Ms D and spoke to her I asked the care provider to comment on the complaint and provide information. I sent a draft of this statement to Ms D and the Care provider and considered their comments.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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What I found

8. Ms X moved into the home in May 2019 and left in February 2021. When she left Ms D was concerned about how she was dressed which was unsuitable for the cold weather. She said it also became apparent that some of Ms X’s clothing and possessions were missing. Particularly significant was that she was not wearing glasses. When Ms D asked the staff that were present none of them were aware that Ms X wore glasses.
9. Ms D had correspondence with the home although that was mainly about the fees that had been charged. In May she made a formal complaint about the care provided and the missing items. The home responded in early June. Ms D wrote further explaining why she was not satisfied at the end of July but did not receive a reply.

Analysis

Missing possessions

10. This concerned Ms X’s glasses, her clothing including a coat, underwear and shoes and a chair. The chair was located when this was raised by the family. The care home manager said she was unaware of a coat and that Ms X’s shoes had worn out as she did a lot of walking around the home and they had started to rub her feet and cause blisters.
11. This meant that when she left the home she was wearing slippers, no coat and no tights. The care plan recorded that Ms X’s preference was to wear pop socks. In responding to Ms D’s complaint the home said that Ms X had started to become distressed if staff tried to put them on so they had decided it was in her best interest they were not put on. The manager said she had not seen a coat while she had been at the home. Ms D had asked for a copy of the inventory of Ms X’s possessions which was not provided. The home said they were not able to locate an inventory as that pre-dated when the current management took over.
12. If Ms D wanted to pursue a claim for missing possessions then the appropriate way to do that would to make a claim in the courts. We will not, therefore, consider this point further.

How Ms X was dressed

13. On the point about Ms X wearing slippers the home said she did not need shoes and that slippers were comfortable for her. It is recorded that Ms X walked a lot around the home so I consider there has to be a question whether slippers would be appropriate. But, in any event, there should have been a proper record of what had happened to her shoes and the basis for deciding that she did not need replacements. This should have been discussed with the family.
14. Nor is there a record of the decision making around Ms X not wearing pop socks. It is recorded that Ms X feels the cold so it would have been important to show how she was going to be kept warm.

Personal care

15. Ms D also questioned why Ms X left without a toothbrush in her possession. The home said it had been providing toiletries during the pandemic and would have provided a toothbrush. The care plan showed that Ms X needed assistance with personal care including with teeth brushing. There is not enough evidence to enable me to come to a conclusion that there was any fault by the care provider on this point.

Glasses

16. In responding to Ms D the home said Ms X did not have any glasses and had not worn any for over a year. Ms X’s care plan records she wears glasses all the time but she will sometimes hide them.
17. It is particularly concerning that the manager was unaware of the contents of the care plan and that for over a year Ms X was without the glasses she needed. And that none of the staff caring for her were aware of this.

Complaint response

18. The home said it was an oversight that it did not send a response to Ms D’s correspondence.

Conclusion

19. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences. They inspected the home in May 2021 and found it to be inadequate.
20. The CQC is best placed to consider and address wider concerns about the standards of care provided at the home but this complaint has highlighted shortcomings in the care provided to Ms X. The failure to ensure she was wearing her glasses and the lack of provision of adequately warm clothing will have impacted on her quality of life. It is not possible to provide any meaningful remedy to Ms X but a payment should be made to Ms D to recognise the distress caused to the family.

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Agreed action

21. The care provider will apologise to Ms D and pay her £500 to recognise the distress caused. It should do this within one month of the final decision.

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Final decision

22. There was fault which caused injustice.

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Investigator's decision on behalf of the Ombudsman