Summary: The Council acknowledges Mrs X received poor care and treatment by the commissioned care provider. Mrs X suffered severe dehydration, often expressed pain which was not acted on and was not treated with dignity. The Council will now offer a sum in recognition of the harm caused to Mrs X and distress caused to her family. It has already taken steps to improve the quality of the care at the home.

The complaint

1. Ms A complains about the care and treatment of Mrs X (her stepmother) in a care home commissioned by the Council. She complains Mrs X was admitted to hospital with severe dehydration and pressure sores and says the care provider delayed in obtaining medical attention. There was an incident when Mrs X was able to scald herself with a hot drink. She says Mrs X’s condition deteriorated significantly while in the care home.

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The Ombudsman’s role and powers

2. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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 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

5. I considered all the information provided by Ms A and the Council. Both parties had the opportunity to comment on a draft statement before I reached this final decision.
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.

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What I found

Relevant law and guidance

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
8. Regulation 10 says care providers must treat all service users with dignity and respect.
9. Regulation 13 says service users must be safeguarded from abuse and improper treatment, including neglect.
10. Regulation 14 says the nutritional and hydration needs of service users must be met.
11. Regulation 17 says records relating to the care and treatment of each person using the service ‘must be kept and be fit for purpose. Fit for purpose means they must: Be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.’

What happened

12. Mrs X (who has dementia) went into the care home in February 2021 for a planned three-week respite stay. Ms A says her stepmother was still able to walk then. The intention was to put in place a home care package on Mrs X’s return. Her care plan said Mrs X needed full support with ensuring she had a proper diet: ‘Whilst in receipt of respite carers will ensure that she receives regular meals and drinks throughout the day.’ The care plan said she should be treated with dignity at all times during personal care. Her nutrition and hydration risk assessment assessed her at medium risk.
13. Mrs X returned home at the end of her planned respite on 8 March, but the home care package quickly broke down and she was readmitted to the care home on 9 March.
14. The Council’s initial review of the permanent placement on 13 April says, “Conversation has taken place with (stepdaughter) and (husband) and they advise that on the whole they are happy with the level of care (Mrs X) is receiving at Chamberlain Court…. Her family shared that (Mrs X) regularly complains of stomach pain and staff say they are monitoring this. I have requested that the GP is informed as in the past (Mrs X) has experienced water retention and had to have her bladder drained.” The reviewer went on to add there were some (unspecified) issues which needed resolving but she had advised the home accordingly and the care provider undertook to resolve the matters quickly.
15. On 17 April there was an unwitnessed incident when Mrs X suffered a scald to her left hip. The incident report recorded that a carer had taken Mrs X a cup of tea at 10.30. Mr X was present. At 11.45 Mr X had approached the carer and said Mrs X had spilled a hot a drink down herself. Mr X said he had made Mrs X a hot cup of tea. Staff members went to check Mrs X and applied cold wipes to her chest to cool the area. The incident report notes that when care staff had carried out personal care later, they noticed a red and blistered area on Mrs X’s left hip. Mr X was reminded the refreshments area was out of bounds to visitors.
16. The daily care notes show a deterioration in Mrs X’s health. There are increasing references to her unwillingness to eat and/or drink. On 14 April Mrs X was admitted to hospital. Ms A says a “DNAR” notice was recorded and the hospital initially wanted to discharge Mrs X back to the care home for end-of-life care. Notes for 15 April record Mrs X would be moving into a nursing care placement and would not return to the care home.
17. Ms A says Mrs X received IV antibiotics and fluids for the next five weeks. She says she had treatment from the tissue viability nurse for her pressure sores.

The complaint

18. Ms A complained to the Council and the care provider that Mrs X was admitted to hospital with severe dehydration and two pressure sores. She complained that staff had ignored Mrs X’s cries of pain and delayed in seeking medical attention; that Mrs X was dehydrated and had suffered a scald to her hip; and that Mr X had been kept waiting a long time when he went to collect belongings from the home.
19. The Council’s complaints manager replied in February 2022. She said she had spoken to Mrs X and to the care home’s manager. She upheld or partially upheld all Ms A’s complaints.
20. In respect of the complaint about expressions of pain, the complaints manager said although the care provider had called a GP it appeared it had taken some weeks for it to do so. She said staff should have recognized Mrs X could only communicate her pain through her ‘screams’ because of her dementia. She added, ‘I have also had a conversation with the RM on how staff speak to relatives and residents and that these need to be addressed asap, she accepts on occasions that staff haven’t shown little empathy and she will address this by running a “dignity in care course”.
21. The complaints manager said the care home’s notes did not give sufficient detail about how much Mrs X was drinking. She said because of her dementia Mrs X should been assessed as at high risk of dehydration.
22. In respect of the scald to Mrs X’s hip, the care home manager had said this happened after Mr X went into the refreshment room and made Mrs X a hot cup of tea, as the tea provided by staff on the drinks round was not hot enough for Mrs X. The complaints manager commented, ‘I feel this was an unfortunate incident and the home have recognised that this will not happen again as the door will be kept always locked. Therefore, I partially uphold this part of the complaint.’
23. The complaints manager upheld the complaint that Mr X had been kept waiting while staff sorted out Mrs X’s belongings after she left the home. She said care home staff could have arranged a time with Mr X beforehand, so he was not kept waiting.
24. The complaints manager apologized on behalf of the Council for the distress which the care provider’s failings had caused.
25. Ms A complained to the Ombudsman. She said the care provider had let Mrs X down. She said Mr X was still very upset about her treatment in the care home.
26. The Council says the home has now agreed to a voluntary placement stop and is working with the Council’s Quality Assurance Team to make improvements to its service: it says this followed the involvement of the Quality Assurance Team over some months in work to secure changes via visits, issuing service improvement plans, reviewing progress and referral to the Service Escalation Panel.

Analysis

27. There were failures (and potential breaches of the regulations) on the part of the care provider in respect of treating Mrs X with dignity, meeting her hydration and nutritional needs, safeguarding her from neglect and maintaining a proper and accurate record of her care.
28. Those failings caused Mrs X actual harm, in terms of suffering with dehydration, and waiting too long for medical attention, and considerable distress to Mr X. As the Council commissioned the care provision for Mrs X, it remains its responsibility to remedy the consequent injustice.

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Agreed action

29. The Council is taking continuing action to secure improvements at the home and so I do not have further recommendations there;
30. There remains the personal injustice suffered by Mr and Mrs X. Within 6 weeks of my final decision the Council will offer a payment of £1000 for the benefit of Mrs X, and a payment of £500 to Mr X in recognition of the distress caused to him.

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Final decision

31. I have completed this investigation on the basis there was fault on the part of the Council’s commissioned care provider which caused injustice to Mr and Mrs X. The completion of the recommendations at paragraphs 29 and 30 will remedy that injustice.

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Investigator's decision on behalf of the Ombudsman