Summary: Mrs C complained a care home, acting on behalf of the Council, failed to provide her with appropriate care, failed to treat her with dignity and compassion, failed to ensure she received suitable medical care, unreasonably restricted Mrs D’s access and influenced a second care home’s decision not to admit Mrs C. The home, acting on behalf of the Council, failed to cleanse Mrs C’s room as regularly as it should, failed to carry out a risk assessment on admission, interrupted telephone calls and wrongly refused to accept Mrs C back at the home. There is no fault in the remainder of the case. An apology and payment to Mrs D is satisfactory remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs C, is represented by her daughter, whom I will refer to as Mrs D. Mrs C complained the care home the Council placed her in:
• failed to promote her best interests and provide appropriate care;
• failed to treat her with dignity and compassion;
• failed to promote her well-being;
• failed to ensure she received suitable medical care;
• failed to respond to her representative’s telephone calls;
• influenced a second care home’s decision not to admit her.
2. Mrs D says fault by the Council caused her and Mrs C significant distress.

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The Ombudsman’s role and powers

3. 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)
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)
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.

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How I considered this complaint

6. As part of the investigation, I have:
• considered the complaint and Mrs D's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
7. Mrs D say and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What should have happened

8. The Care Act 2014 require councils to assess a person’s care needs and how identified needs should be met. If it is found a person needs residential care, councils have a duty to arrange for the care. A council may arrange residential care in private care homes, but it remains responsible for the care arrangement, and ensuring the persons needs are met.
9. 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 Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
10. Regulation 10 of those standards says people using the service are treated with respect and dignity while they are receiving care and treatment.
11. Regulation 12 of those standards says care providers must assess the risks to people's health and safety during any care or treatment and act to mitigate risks.
12. The care home has a Dealing with abusive and violent visitors policy. This provides the home with various options when an incident of violent or abusive behaviour has taken place. Those options include:
• a caution/counselling the individual about the conduct and the consequences of any repetition;
• visits allowed only in a designated area and with supervision;
• temporary exclusion for a limited period of time;
• visiting treated to dates and times determined by the home with a clear understanding this will be reviewed if the behaviour of the individual improves;
• permanent exclusion from the home which would be an option of last resort usually when other options have failed or in extreme circumstances;
• involvement of the police where criminality has occurred.

What happened

13. Mrs C was admitted to Springfield House Care Home (the care home) in Malvern from 23 July-20 August 2021 as a temporary measure following a period in hospital as she had been unable to cope at home with a care package. The care home identified provided support predominantly for residents living with dementia. Mrs C was admitted as having capacity and being alert and enjoying the social stimulation of friends and family. At the time though the availability of accommodation was limited and this placement was intended as respite only until a long-term plan could be agreed.
14. During Mrs C’s stay at the care home it reported some issues with Mrs D which resulted in the home stopping Mrs D from accessing the home. Those issues and concerns about whether the home was suitable for Mrs C eventually led to the care home telling the Council it could no longer provide accommodation for Mrs C. That information was initially given in a telephone message to the Council on 12 August 2021, which the Council says it did not receive. When Mrs C went to hospital for an appointment on 16 August the care home then refused to allow her back in when she returned and she was kept waiting in the ambulance outside for 25 minutes until the Council’s social worker negotiated a temporary return to enable a new placement to be found. A placement was identified but the home did not consider it was suitable for Mrs C and it therefore declined admission. Unfortunately Mrs C became unwell before she could move to a new placement. Mrs C was admitted to hospital on 20 August where she sadly later died.

Analysis

15. Mrs D says the care home, acting on behalf of the Council, failed to promote Mrs C’s best interests and provide her with appropriate care. Mrs D particularly referred to concerns about failing to provide Mrs C with appropriate personal hygiene, health and safety issues, inadequate cleaning of the room and failure to respond promptly when Mrs C had a fall.
16. Having considered the documentary records kept by the care home I am satisfied appropriate care, including support with personal hygiene, was provided to Mrs C throughout her stay. While the daily records are not always consistent in terms of the amount of information recorded, they do show daily care being provided to Mrs C. That included records of when Mrs C had a shower or took a bath. In addition to that, the records show regular visits from care home staff to Mrs C throughout the night to check on her or to respond when she rang the bell. Given those records I could not say the care home arranged by the Council failed to provide Mrs C with appropriate care.
17. I recognise though that in addition to personal hygiene issues Mrs D is also concerned about the standard of cleaning of the room. Mrs D has provided a photograph showing issues with cleaning. The documentary evidence I have seen also shows at the time in question the care home was understaffed. It is clear this meant the care home had to prioritise tasks. In those circumstances I consider it likely, on the balance of probability, the standard of cleaning of Mrs C’s room was not as it should have been. That is fault.
18. Mrs D has also raised concerns about health and safety issues due to trailing wires being left across the floor. Mrs D has provided photographic evidence of those trailing wires. In response, the care home says the wires in question were exposed only when family members moved furniture around in the room. That is something Mrs D disputes. I consider it likely, based on the photographs I have seen, the trailing wires in question were originally hidden by the bedside table and when that bedside table was moved the wires were exposed. As there is nothing in the documentary records to show when and how often furniture was moved or who moved the furniture I cannot reach a safe conclusion about whether the care home was at fault here or whether a third party moved the furniture.
19. Mrs D says the care home failed to explain to Mrs C how to use the medical assistance equipment. In its complaint investigation the Council decided there was evidence the door and alarm sensory activation systems had been explained to Mrs C and the care home had explained how to use the glide mat. I have seen evidence the care home discussed operation of the glide mat with Mrs C. I am also satisfied Mrs C knew how to use the call bell, given there is evidence of her using that during the night. However, I have seen no evidence of the care home discussing with Mrs C the operation of other medical equipment. Nor is there any evidence the home completed a manual handling risk assessment at the time of Mrs C’s admission. I am concerned about that given the care home knew Mrs C had a history of falls before she was admitted. Failure to complete a risk assessment on admission is fault.
20. There is one specific incident, which took place on 4 August 2021, where Mrs D has raised a specific concern. This relates to an incident where Mrs C fell when trying to get out of bed. Mrs D is concerned Mrs C could not contact any care home staff when she had the fall as the call bell had become disconnected. Mrs D is particularly concerned about what the impact on Mrs C would have been had she not had access to her mobile at the time. While I understand Mrs D’s concern, I am satisfied this was a one off incident. The care home’s investigation of the incident indicates that although the call bell was no longer connected at the time of the fall it was still operational. As the records also show care home staff were carrying out regular checks on Mrs C during the night and discovered her on the floor I do not consider this warrants a finding of fault.
21. Mrs D says the care home failed to treat Mrs C with dignity and compassion. In particular, Mrs D says the care home treated Mrs C as a nuisance rather than recognising she had a urinary tract infection on admission. Having considered the daily care records and notes kept by care staff at the home I have found no evidence to suggest the home treated Mrs C as a nuisance. While there are records showing the care home had concerns about the level of care Mrs C required given she would often ring the bell many times during the night for assistance there is no evidence this affected the way care staff treated the Mrs C.
22. Mrs D says the care home pressurised Mrs C to walk further than she was comfortable with. As part of the documentary evidence I have considered there is a mobility care plan. This records Mrs C can walk short distances but needs lots of encouragement. There are then some daily records of her walking with a frame. None of those records indicate Mrs C was pressurised into walking further than she felt confident to do, taking into account the fact the care plan indicates Mrs C needed encouragement to walk. As I have found no evidence of inappropriate pressure being placed on Mrs C I have no grounds to criticise the Council.
23. The Council accepts there was one occasion when the care home dressed Mrs C in somebody else’s clothing. This appears to have occurred because Mrs C was admitted to the care home in an emergency and therefore her clothing was not labelled as it should have been. Nevertheless, placing Mrs C in somebody else’s clothes is fault.
24. Mrs D raises concerns about the home’s decision to exclude her from the property. Mrs D raises concerns about the impact that had on Mrs C given she (Mrs D) was the main person visiting Mrs C. There is evidence in the documentary records of staff members at the home raising concerns about inappropriate behaviour from Mrs D which was causing significant distress. The Council has now provided evidence the home has a written policy on exclusion of family members/visitors. I refer to that policy in paragraph 12. That policy provides the home with the ability to restrict visiting from an individual, including exclusion from the home. I therefore cannot criticise it for doing so in Mrs D’s case, given the case recordings showing what the home considered to be inappropriate behaviour from Mrs D. While I would have expected the home to review its exclusion of Mrs D I note in this case Mrs C only stayed in the home for a short period and therefore any restriction was unlikely to have come up for review. I therefore do not intend to pursue the point further.
25. Mrs D says the care home failed to promote Mrs C’s well-being or ensure social interaction took place. I have carefully considered the documentary records. Those documentary records show both that care staff in the care home interacted socially and communicated with Mrs C and she had similar social interaction with some of the other residents. I recognise though the situation was complicated in this case by the fact the care home was arranged as an emergency and is normally occupied by people with dementia, which Mrs C did not have. It would not be surprising if that left Mrs C feeling out of place and isolated. Nevertheless, I am satisfied the care home did all it could to settle Mrs C in and communicate effectively with her.
26. In reaching that view I am aware Mrs D is concerned about the home’s decision to require two staff members to be present with Mrs C. Mrs D says the home introduced that because they considered Mrs C was a liar and could not be trusted. Mrs D has interpreted that as intimidation. The evidence I have seen satisfies me the care home introduced two members of staff to work with Mrs C because the relationship between the care home and Mrs C/Mrs D was breaking down and allegations were being made. I can understand why Mrs D would interpret that as suggesting Mrs C could not be trusted. However, I have seen no evidence to suggest staff members dealt with Mrs C in a way that was intimidating or that anybody suggested she did not tell the truth. It was for the care home to decide how to provide care to Mrs C and it is not my role to comment on the merits of decisions it made on behalf of the Council.
27. Mrs D says the care home failed to ensure Mrs C received suitable medical care. Having considered the records, which includes records of contact with the district nurse, GP and hospital, I have found no evidence to suggest the care home failed to ensure Mrs C received suitable medical care. There is evidence of regular contact with the GP and GP visits to the home. In addition, there is evidence of the home providing Mrs C with her medication and chasing the pharmacy for updated medication when it had run out. I have seen no evidence of any delays contacting the GP. I therefore have no grounds to criticise the Council.
28. In reaching that view, I note Mrs D says the care home told Mrs C it did not have paracetamol for pain. I have found no evidence to support that allegation. There is evidence on one occasion of care home staff refusing to provide Mrs C with paracetamol. However, I am satisfied on that occasion care staff refused to administer paracetamol because Mrs C had already had some and care staff were concerned about her overdosing. In those circumstances refusing to provide paracetamol is not fault. I also understand paracetamol was refused on other occasions when Mrs C had been drinking alcohol. Again, refusing to provide paracetamol in those circumstances is not fault.
29. Mrs D raises concerns about the care home delaying providing Mrs C with prescribed drugs on 20 August 2021 when she was due to go to hospital. Mrs D says those prescribed drugs were intended to make Mrs C more comfortable on her journey to the hospital and therefore they should have been provided earlier. The documentary records for what happened on 20 August are detailed. They show the prescribed drugs were delivered to the carer at 4pm, they were passed to another member of staff at 4:40pm and administered at 4:55pm. The documentary records also show the ambulance took Mrs C to hospital at 5:55pm. That was one hour after the drugs were administered. In those circumstances I do not consider the delay of 55 minutes administering the drugs warrants a finding of fault. That is because I am satisfied the drugs were administered in time for the journey to the hospital.
30. Mrs D says the Council social worker failed to respond to her telephone calls. I have considered the documentary records for this case. Those documentary records do not show any occasions when the Council failed to respond to Mrs D’s telephone calls. Nor is there any evidence Mrs D provided details of the dates on which she says her telephone calls had not been returned. I therefore have no grounds to criticise the Council.
31. Mrs D says the trainee care home manager spoke to the second care home and reported Mrs C as being demanding. Mrs D says this influenced the care home to refuse to admit Mrs C. Having considered the documentary records relating to this point I am satisfied the second care home declined to admit Mrs C because it did not consider it was suitable for her needs. The records show this was because the care home was concerned it had more dementia patients than the care home from which Mrs C was moving and this had been an issue with the existing care home. There is nothing in those records to suggest the existing care home described Mrs C as demanding or that this is what persuaded the second care home not to admit her. It is not, however, fault for the first care home to give the second care home factual information about Mrs C such as difficulties she had experienced with managing in an environment with dementia patients or the level of care she required. That is a normal part of the process and not something I could criticise the Council for.
32. In addition to the fault I have identified in this statement the Council has also accepted a member of the care home staff interrupted Mrs C’s telephone call with a family member and refused to accept her back from hospital on 16 August. I have not investigated those two points given the Council has already upheld a complaint about those issues. However, I have taken those matters into account when considering an appropriate remedy for the complaint. I am satisfied the faults identified in this statement plus the two areas upheld by the Council have caused Mrs D distress and led to her going to time and trouble to pursue her complaint. It is also likely there was distress caused to Mrs C. However, it is not possible for the Ombudsman to remedy that injustice given Mrs C has now sadly died. I therefore recommended as remedy for the complaint the Council apologise to Mrs D and pay her £250. The Council has agreed to my recommendation.

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Agreed action

33. Within one month of my decision the Council should apologise to Mrs D and pay her £250.

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Final decision

34. I have completed my investigation and found fault by the Council in part of the complaint which caused Mrs C and Mrs D an injustice. I am satisfied the action the Council will take is sufficient to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman