Summary: Mrs R complains that Halcyon Care Homes provided inadequate care for her mother, Mrs C. Halcyon has accepted it was at fault. It caused injustice to Mrs C who received substandard care and whose health was affected. It also caused injustice to Mrs R and her family who were distressed at their mother’s ill-health. We have recommended a remedy.

The complaint

1. Mrs R complains on behalf of her deceased mother, Mrs C. She says Halcyon Care Homes Ltd was at fault for various failures in the way it provided care for Mrs C. In particular, she says the Care Provider:
1. Failed to administer medication according to instructions,
2. Failed to keep hearing aids operational,
3. Failed to keep Mrs C well dressed and presented,
4. Failed to communicate adequately with family members, and
5. Failed to keep Mrs C safe and well.
2. Mrs R says this caused injustice to Mrs C as she was unable to communicate with her family during lockdown, her health was affected and she became distressed.

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The Ombudsman’s role and powers

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. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
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. 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.
7. 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

8. I spoke to Mrs R. I wrote a letter to the Care Provider asking for further information. I considered the evidence and wrote a draft decision.
9. Mrs R and the Care Provider had an opportunity to comment on the draft decision and we considered their comments before issuing the final decision.

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What I found

What should happen

10. We can investigate complaints about actions by adult social care providers that can be regulated by the Care Quality Commission. Such activities include giving personal care or other practical support in the place where the person lives. This might include complaints about residential accommodation and personal care provided as a condition of treatment for substance misuse, but we cannot investigate complaints about the treatment or therapy itself. Non-regulated activities include day centre services. We cannot investigate complaints about those services if they have been privately arranged.
11. The law defines ‘personal care and other practical support’ as ‘physical assistance (or prompting and assistance) given to a person in connection with:

• eating or drinking (including giving nutrition other than by mouth or alimentary canal),
• toileting,
• washing or bathing,
• dressing,
• oral care, and
• the care of skin, hair and nails (except for nail care provided by a chiropodist or podiatrist)’.

12. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2010)

What happened

13. In early 2021, Mrs C had dementia which posed a risk to her safety. She had very poor sight and hearing. She also had a range of age-related illnesses. She was unable to live alone. In January 2021, she moved into a care home run by the the Care Provider (‘the Home’).
14. Mrs R says that, before Mrs C moved in, Mrs R’s sister, Mrs S, filled in a comprehensive form detailing all Mrs C’s conditions and setting out the timings and quantities of medications she should receive.
15. Mrs R says that the care Mrs C received was inadequate from the start. She says that staff never administered medication in accordance with the form completed by Mrs S. For example, one such medication was lorazepam, a treatment for insomnia and anxiety which Mrs C was meant to take only occasionally when required. Mrs R says that, within days, the home was administering lorazepam to Mrs C every night against her wishes which left her “semi-conscious and unable to do anything for herself”.
16. Mrs R says Mrs C was “very dependent on her hearing aids” which required fresh batteries daily. She says that, despite numerous calls and letters to the Home, the batteries were never changed and the hearing aids were seldom worn.
17. This, she says, was particularly important because it was at the time of national lockdowns caused by COVID-19. The phone was the only way that Mrs C could communicate with her family and, because of her hearing problems, without hearing aids, even that was impossible.
18. Mrs R says she and Mrs S frequently phoned the Home about their concerns throughout 2021. She says the phone was seldom answered and, when it was, staff would agree to carry out certain actions and then fail to do so. For example, Mrs R says she frequently asked staff to replace the batteries in Mrs C’s hearing aids every day. She says staff frequently agreed to do so but, instead, Mrs C rarely even wore them and they were left in a drawer in her room.
19. Mrs R says this was distressing to the family. The home was very expensive, she says, costing X per week. It was “likened to a five-star hotel” on the Care Provider’s website but “the care did not live up to the descriptions”.
20. Mrs R says she complained “several times” about Mrs C’s dirty clothes, lack of hearing aids. She says that this carried on throughout 2021.
21. In early October, Mrs R and Mrs S took Mrs C out for the day. They say she was “confused, sleepy and very unsteady on her feet”. On returning Mrs C to the Home, they told staff they feared Mrs C might have a urinary tract infection (UTI). She says staff said they would carry out a urine test. She was not aware that this was ever done.
22. Later in October, on Mrs C’s birthday, her family gathered with one family member coming from abroad. The family were expecting Mrs C to be well-turned-out. Instead, Mrs R said, she was still unwell. In addition, she was dressed in dirty trousers and a dirty pyjama top, odd socks and someone else’s shoes. She was unwashed with dirty hair and nails. Her incontinence pants had not been changed for some time.
23. That night, Mrs C was taken into hospital extremely unwell. Doctors told Mrs R that Mrs C was severely dehydrated and might not survive.
24. A few days later, when Mrs C had recovered, Mrs R wrote to the Home to complain formally. She complained about:
• The events of Mrs C’s birthday
• Failure to follow up on concerns about UTI in early October
• Poor hygiene, clothing and grooming of Mrs C
• Failure to maintain hearing aids and ensure Mrs C wore them
• Failure of the Home’s laundry service/loss of Mrs C’s clothes
• Rudeness of a receptionist
• Understaffing leading to poor service
• Mrs R also said that many members of staff had cared well for Mrs C and made her feel happy and safe.
25. The Care Provider’s managing director responded in December 2021. He said:
• The events of Mrs C’s birthday: Mrs C had not been properly presented on her birthday. Complaint upheld.
• Failure to maintain hearing aids and ensure Mrs C wore them: Mrs C had dementia and often refused her hearing aids but staff failed to go back and try again later. Complaint upheld.
• Failure to follow up concerns about UTI in early October: There had been no test carried out in early October. Complaint upheld.
• Failure of the Home’s laundry service/loss of Mrs C’s clothes: There had been failures. Complaint upheld.
• Rudeness of a receptionist: The receptionist was rude and had since left the Care Provider. Complaint upheld.
26. Mrs R’s other points went unanswered but the managing director said he was now based at the Home and would give Mrs C’s case his full attention. He apologised and said there would be a care plan review in the near future.
27. Mrs R says that, in fact, matters did not improve after the managing director’s intervention. There was a care plan review in January. Mrs R says despite frequently asking the Home did not share the care plan and when it eventually did it contained incorrect details and the family had no part in its compilation.
28. Mrs C wrote to the managing director again in January 2022. She said Mrs C’s clothing was still dirty on four of six occasions they visited. In addition, Mrs C had not had working hearing aids, her fingernails were cracked and dirty and her hair was long and unkempt. However, care over UTIs had improved.
29. Mrs C died in early 2022.
30. Mrs R came to the Ombudsman.

Was there fault?

31. Mrs C stayed at Home 1 for approximately one year. Mrs R has given me a list of falls and other incidents during her stay. It is clear from this that Mrs C was unwell with many health and perception problems. She fell from time to time. She was prone to UTIs. None of this is, in itself, evidence of fault by the Home.
32. The Care Provider accepts there were failures. It says the Home “was experiencing some recent challenges particularly in relation to recruitment” during the time when these events took place. It was using agency staff more than usual. It says that this caused poor service.
33. The Care Provider says it took various steps to improve its service after receiving Mrs R’s complaint. It says it:
• Increased the number of visits from senior management to the Home with a regional support manager being present four or five days a week,
• Prioritised fulltime recruitment for the Home,
• Delayed new admissions to the Home for 12 weeks,
• Audited all care plans,
• Provided additional training to staff,
• Put an action plan in place to institute these changes.
34. The Care Provider says these changes have had the effect of improving care at the Home. I do not, therefore, intend to recommend further service improvements.

Failure to maintain care plans/administer medication according to plan

35. The Care Provider has though provided evidence that it did maintain Mrs C’s care plans. I accept this.
36. Nonetheless, I accept Mrs R’s evidence that Lorazepam was administered more frequently than specified. This claim is consistent with the other evidence. Mrs C should have had it only as a last resort. In fact, she seems to have had it daily. This was fault as Mrs C became confused and lethargic, while Mrs R and her family became increasingly concerned about the care Mrs C received.

Failed to keep hearing aids operational

37. The Home has admitted to failure to ensure Mrs C had her hearing aids in. However, the records do show that she would refuse them. Staff could not force her to wear them. Nonetheless, the admitted failure to come back and offer them again was fault, as Mrs C and her family were unable to communicate particularly during the lockdown periods.

Failed to keep Mrs C well dressed and presented

38. The managing director has admitted that, on the day of her birthday in mid-October 2021, Mrs C was not dressed and presented as she should have been. Mrs R and Mrs S say this was not an isolated incident.
39. Mrs R says the Home’s manager told her this was because there were insufficient staff at the Home during the relevant time. The Care Provider broadly accepts this. It says there were more agency staff at the Home than was desirable and this affected the assistance Mrs C received in dressing and grooming.

Failure to communicate adequately with family members

40. There is evidence of failures of communication. There is also evidence of good practice. Mrs S has provided a table of events including calls from the Home about occasions when Mrs C was, for one reason or another, causing concern.
41. However, the communication was sufficiently poor to diminish the family’s faith in the service Mrs C was receiving.

Failed to keep Mrs C safe and well

42. As stated above, Mrs C was frail and in failing health. Falls and illness are a sad reality in these circumstances so instances of falls, illness and hospitalisation are not, in themselves, evidence of fault.
43. It is clear that, particularly after October 2021, Mrs C’s condition was very variable and that she suffered bouts of illness and restlessness that caused concern.
44. However, in this case, there is clear evidence that the Home’s failures led to a worsening of Mrs C’s condition on at least one occasion. In early October 2021, Mrs R told staff that she thought Mrs C might have a UTI. The staff took no action for over a week by which time Mrs C was very ill and had to go to hospital.
45. This was fault. Mrs C became gravely ill and her family became distressed that their mother was hospitalised, and nearly died, on her birthday.

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Recommended action

46. Within four weeks of the date of this decision, the Care Provider should:
1. write to Mrs R and her family to apologise for the fault found in this decision. It should pay Mrs R £500 in recognition of the distress suffered by her and her siblings.
2. It should also offer them a 25% reduction in the fees payable by Mrs C.
47. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

48. I have completed my investigation and uphold Mrs R’s complaint. Mrs R has been caused an injustice by the actions of the service provider and I have recommended it take action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman