Summary: Mrs X complains about the care provided to her mother (Mrs Y) at Sherwood Grange Care Home (the Home), in London, and the decision to end her contract. We find fault with the Home, causing Mrs X distress. We have suggested remedies for this injustice.

The complaint

1. Mrs X complains about the care provided to her mother (Mrs Y) at Sherwood Grange Care Home (the “Home”). Mrs X says the carers ignored manual handling advice, Mrs Y’s room was dirty, and there was medication in her room that she had not been prescribed.
2. Further Mrs X says the Home did not realise Mrs Y had a stroke, failed to get medical attention when she was in pain, and gave an incorrect medical history when Mrs Y went to hospital.
3. She says the manager of the Home was verbally abusive to her, then served notice for Mrs Y to leave the Home within 28 days with no prior warning, during the Covid pandemic.
4. Mrs X would like an apology.

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The Ombudsman’s role and powers

5. 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)
6. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
7. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. (section 26A or 34C, Local Government Act 1974)
8. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
9. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission.
11. 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

12. I spoke with Mrs X about her complaint and what she wanted to achieve. I asked the Home questions about the care provided. I considered -
• Mrs Y’s case records, care plans and risk assessments;
• Complaint correspondence;
• Relevant legislation and guidance.
13. Mrs X provided further evidence after the first draft decision.
14. Mrs X and the Home 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

Legislation and Guidance

Fundamental standards of care

15. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards those registered to provide care services must achieve.
16. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
17. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall. The relevant regulations here are:
18. Regulation 9 on personalised care. The CQC’s guidance on the regulations says:
• “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
19. Regulation 10 is about dignity and respect. “When people receive care and treatment, all staff must treat them with dignity and respect at all times. This includes staff treating them in a caring and compassionate way.”
20. Regulation 12 sets out the requirement for care and treatment to be provided in a safe way for service users. This says a registered person must, amongst other requirements, do the following:
• assess the risks to the health and safety of service users of receiving the care or treatment;
• do all that is reasonably practicable to mitigate any such risks;
• ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.

Record keeping

21. Care providers should keep records relating to the care of each person, including an accurate record of all decisions taken in relation to their care. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17)
22. When a complaint or allegation of abuse is made, all agencies should keep clear and accurate records of the issues and any action taken. In the case of providers registered with the CQC, these records should be available to the CQC so they can take any necessary action. (Care and Support Statutory Guidance, Section 14)

Complaints about care

23. There must be policies and procedures in place for anyone to raise concerns about their own care or the care of people they care for or represent. The policies and procedures must be in line with current legislation and guidance, and staff must follow them. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12)
24. Complainants must not be discriminated against or victimised. An individual’s care must not be affected if they make a complaint, or if somebody complains on their behalf. Providers must maintain a record of all complaints, outcomes and actions taken in response to complaints. Where no action is taken, the reasons for this should be recorded. (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 16)
25. The Care Provider’s complaints procedure sets out its process for handling complaints from residents or their representatives. This says there is a three stage complaint procedure. Once a complaint is submitted it will be acknowledged within three days, and a resolution sought within 20 working days. If the response is unsatisfactory it can go to stage two. A response from a complaints investigator will be given within 20 working days. After this complaints can be brought to the Ombudsman.

Mrs Y’s contract with the Home

26. The contact says normally the Home will try to resolve any problems before serving a termination notice.
27. The Home may end the contract by giving prior written notice taking effect after 28 days following a material breach.
28. The Home may end by giving written notice effective immediately, or any time frame stated, where circumstances of behaviour which they feel to be seriously detrimental to the Home or the welfare of the other residents and such circumstances or behaviour is continuing despite reasonable efforts to consult with you.
29. The notice to terminate may be appealed to the Regional Director within seven days of receiving the notice.

What happened

30. Mrs Y moved into the Home in September 2020. Within two months Mrs X was concerned about Mrs Y’s personal care and support in the Home.

Pain management

31. In November Mrs X worried the Home were not properly managing Mrs Y’s pain needs. She asked for a GP visit, but this did not happen so she called the GP who prescribed pain relief for Mrs Y.
32. Mrs X says the Home asked her to buy medication for pain relief for Mrs Y. She says any medication she bought for Mrs Y she handed in to staff – she could not enter Mrs Y’s room due to Covid.

Stroke

33. Mrs X visited Mrs Y in March 2021 and expressed her concerns she thought Mrs Y had had a stroke. The Home did nothing until the next routine GP visit the following week. There was a routine GP visit the week before, but the GP could not see Mrs Y as she was in the bathroom.
34. At the end of March Mrs Y went to hospital and the Home told the ambulance crew she had a urine infection. Mrs X says this was not the case and the staff gave a wrong medical history. The Hospital prescribed Mrs Y antibiotics.

Cleanliness

35. In May 2021 Mrs X took photos of Mrs Y’s room. It was untidy and dirty with unwiped surfaces and trays, and used wipes left on the chair. There were prescription medications there and ibuprofen which Mrs Y must not take.

Manual handling

36. Mrs X says the Home ignored manual handling advice. The Occupational Therapist (OT) made a referral to safeguarding about staff hoisting Mrs Y, as she thinks it was unnecessary and causing Mrs Y distress.
37. Mrs X says she had multiple conversations with staff at the Home about her concerns.

Notice to leave

38. On 19 May the manager asked Mrs X for a “catch up session”. The manager was rude and aggressive to Mrs X which left her upset and distressed.
39. Mrs X and the OT had gone to the Home to organise Mrs Y’s room and discovered it was unclean with out of date food and a broken lamp under the bed.
40. Mrs X says when they complained about this, the manager said Mrs Y would have to leave the Home.
41. Mrs X had no knowledge of the meeting or any prior warning that Mrs Y was going to get notice to leave.
42. Mrs X received a termination letter from the manager of the Home dated 21 June, giving her 28 days to find another suitable Home for Mrs Y.
43. Mrs X says this was incredibly stressful, made harder by the fact it was in the middle of the Covid-19 Pandemic.

Analysis

Pain management

44. In the first complaint response from the Home to Mrs X, the manager says the GP had stopped Mrs Y’s pain relief medication in November. There was no sign she was complaining of being in pain.
45. However, the GP did prescribe pain relief for Mrs Y after the call from Mrs X. I find fault with the Home as it should have contacted the GP if there was a report of pain which might need medication.
46. On 19 May the Team Leader recorded in the diary notes that Mrs X removed medications from Mrs Y’s room saying they were no longer useful. Mrs X refutes this. She says she told the team leader the medications should not have been in the room, not they were no longer useful.
47. The manager says the staff asked the family to stop buying pain relief tablets for Mrs Y. Again Mrs X refutes this saying she was encouraged to buy over the counter remedies and a cooling gel which were handed to staff to administer.
48. The Home should not have asked the family to provide medication as there is access to a GP for all residents, so this is fault.

Stroke

49. When Mrs X visited Mrs Y on 19 March she expressed her concern to the care staff and the manager that she thought Mrs Y was having a stroke.
50. Mrs Y missed her GP appointment on 16 March as she was in the bathroom. The Team Leader on duty told the GP Mrs Y appeared to be better.
51. Mrs Y attended hospital on 24 March and on 26 March the GP asked for a urine sample.
52. The OT was with the GP when she examined Mrs Y on the 24 March. She says Mrs Y had a clear facial palsy. The GP noted in the care plan “possible CVA in March. Had episode of right facial droop and reduced power in arm.”
53. The Consultant Geriatrician says in his letter to the Home after his visit on 30 April about Mrs Y “gradual cognitive decline – worse after recent stroke. Worsening mobility likely secondary to all of the above and loss of confidence.”
54. Care records from the Home show that Mrs Y presented as more confused than usual during this period. There is no mention of any stroke symptoms, or of Mrs X’s concerns.
55. On the balance of probabilities there is evidence of Mrs Y suffering from a stroke. The Home should have logged Mrs X’s concerns and at least called the GP. That care Home notes do not record this is fault as it put Mrs Y at risk of harm.

Cleanliness

56. The Home has apologised in the first complaint response to Mrs X for failing to keep Mrs Y’s room clean, saying standards fell below those expected.
57. In the second complaint response the Home says it was clear by the photographs provided the room was untidy. It goes on to say it was not like this when the regional director visited the Home himself.
58. Mrs X asked her MP to intervene after the second complaint response, as she felt her complaint had not been investigated properly. The response from the Home to the MP accepts Mrs Y’s room “was not maintained to the standards of cleanliness and tidiness during her stay. Sometimes the housekeepers were refused access to her room but there should have been a better process in place to ensure her room was kept clean.”
59. There is fault here by the Home which they have apologised for. I have recommended a service improvement to ensure this does not happen again.

Manual handling

60. The OT raised a safeguarding concern about hoisting Mrs Y.
61. Mrs Y uses a wheelchair for mobility and a “sara steady” with help from a carer for transfers.
62. The Council completed a safeguarding investigation and found the Home had made decisions about equipment in Mrs Y’s best interests as her mobility had declined. The investigation decided the Home should note the rationale for using the hoist rather than the sara steady each time it was used.
63. I find fault with the Home for not documenting properly the reasons for using the hoist, and for failing to carry out the risk assessment before using it.

Notice to leave

64. Mrs X had no notice of the meeting and the manager said it was an informal “catch up”. In the complaint response to Mrs X the Home apologises for any distress caused and says the manager was aware Mrs X found the meeting upsetting and distressing.
65. The Home accepted it should have given notice to Mrs X.
66. The Home’s response to the MP said it did not take the decision lightly to ask a resident to leave, especially during a pandemic. However they felt they could not meet the expectations of Mrs X and the OT.
67. The manager apologises for any distress caused but does not accept he was verbally aggressive to Mrs X.
68. The decision to give notice to Mrs Y was in response to complaints brought by Mrs X and the OT. We would not criticise a Home for ending a resident’s contract if it received complaints which were unfounded, or if it had faced repeated unreasonable behaviour from the person or their representative(s). However, I do not think this was the case for the following reasons.
69. There is no evidence to suggest Mrs X’s concerns were baseless. Mrs X was not aware the GP had taken Mrs Y off painkillers in November, as the Home had not told her. The OT saw Mrs Y in distress when having to use a hoist. Although I found no evidence of fault with the manual handling of Mrs Y, the Home did not properly explain why they used the hoist. The Action on the safeguarding report was for the Home to note the reasons. Further, the Home carried out the risk assessment after they had started to use the hoist, when it should have been carried out before.
70. There is no evidence Mrs X or Mrs Y behaved unreasonably. The Home did not follow the terms of its own contract as in paragraphs 23 – 25 above.
71. I find fault with the Home for failing to give any prior warning of the meeting to Mrs X, and the behaviour of the manager was unprofessional.
72. This caused Mrs X distress and upset, and the stress and inconvenience of having to find another Home for Mrs Y within a month, during the Covid pandemic.

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Recommended action

1. write a personal apology to Mrs X for the faults we have identified;
2. pay Mrs X £300 to recognize the avoidable distress and upset caused by its actions;
3. pay Mrs X £250 for the time and trouble caused by having to find another Home for Mrs Y and having to bring a complaint; and
4. pay Mrs Y £500 for distress due to not acting on Mrs X’s concerns about her stroke.

73. Within three months of my final decision the Care Provider should review its policies and procedures for the following:
1. cleaning the resident’s bedrooms. Issue reminders to relevant staff, to ensure they maintain cleanliness and tidiness throughout the residents stay;
2. medication and pain relief for residents. Ensure staff know not to ask family members or representatives to buy medication for residents;
3. note and record keeping. Ensure staff know to document any concerns from family members or representatives, and fully explain the reasons for using manual handling equipment.
4. contract termination. Issue reminders to staff, to ensure:
1. its procedures are compliant with, and relevant staff are aware of and follow, the relevant statutory guidance about ensuring an individual’s care is not affected if a complaint is made;
2. proper consideration is given to alternative options, and to the best interests of the resident, and this consideration is properly recorded; and
3. residents and/or their representative(s) are properly consulted if the Home is considering termination and this consultation is properly recorded.

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Final decision

74. I find fault with the Home with regards to medication, cleanliness, record keeping and the termination of Mrs Y’s contract. I have recommended it acts to remedy the injustice caused, and reviews the relevant policies and procedures.

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Investigator's decision on behalf of the Ombudsman