Summary: Ms X complained about poor care provided to her mother, Mrs Y, whilst at two Council-commissioned care homes between March and May 2022. She says the poor care caused her and her mother distress and contributed to her mother’s death. There was fault in one care home’s record keeping and in how the Council handled Ms X’s complaint. The Council has agreed to apologise to Ms X for the frustration and uncertainty caused and act to improve its services.

The complaint

1. Ms X complained about poor care provided to her mother, Mrs Y, whilst at two Council-commissioned care homes between March and May 2022. She says the poor care caused her and her mother distress and contributed to her mother’s death. She wants the Council to accept there was poor care, apologise to her for this and take action to ensure the care homes improve their service.

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The Ombudsman’s role and powers

2. 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)
3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), 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)
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. I read Ms X’s complaint and spoke with her about it on the phone.
7. I made enquiries of the Council and considered the information received.
8. Ms X and the Council had the opportunity to comment on the draft decision. I considered comments received before making a final decision.

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What I found

Background information

Standards in care

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.
10. The fundamental standards say:
• the care and treatment of service users must be appropriate, meet the person’s needs and reflect their preferences. The care provider must assess the person’s needs and preferences and provide appropriate care and treatment to meet these needs;
• care providers must keep accurate, complete and current records for each person in their care, including a record of the care and treatment provided and decisions about care and treatment; and
• any care and treatment provided must be safe. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe.
11. When investigating complaints about the standards of care in a care home, the Ombudsman considers if the 2014 regulations and the fundamental standards have been met. If they have not, we consider whether any identified faults have resulted in injustice.

Complaint handling

12. The Council has a policy to ensure the effective handling of complaints about its adult social care services. This policy says that where it decides to investigate a complaint, this will normally include the following elements:
• Interviews with case officers and other relevant staff;
• Review of files;
• Review of relevant national and local policies, procedures and practices;
• Summary of the issues and a conclusion;
• If any part of the complaint has merit, consideration of a suitable remedy.

What happened

13. Following a hospital admission in April 2022, Mrs Y was discharged to a Council-commissioned care home, care home A, for a period of assessment and rehabilitation. Mrs Y’s discharge medications did not include any pain relief.
14. Care home A assessed Mrs Y on admission and put in place several care plans to meet Mrs Y’s needs. The care plans stated Mrs Y had full mental capacity to make decisions and was able to verbalise her care needs and state her wishes. She also had two pressure sores and leg ulcers, which were to be dressed regularly and monitored by the district nursing team. To help maintain Mrs Y’s skin integrity and promote wound healing, her care plans included positional changes every two hours and bed rest each afternoon.
15. On 11 April 2022, Mrs Y was assessed by the community physiotherapist. The physiotherapist gave Mrs Y a programme of lower leg exercises and mobility practice. They asked staff to complete the programme with Mrs Y twice a day.
16. On 14 April 2022 Mrs Y’s family asked for her to be prescribed some pain relief, as they felt Mrs Y was in pain but was not telling staff this. Care staff contacted the GP who prescribed paracetamol.
17. The care records for April 2022 show:
• Mrs Y was assisted with her personal care each day;
• Mrs Y was offered regular food and drink and her daily nutritional intake was recorded;
• staff completed positional changes with Mrs Y every two hours, where she agreed to this. The record also stated Mrs Y “refuses to follow advice to have bed rest during the day”;
• staff administered Mrs Y’s medications as prescribed apart from two doses of pain relief which were missed on one day at the end of April 2022. The records state this was due to a lack of supply and a dispute between GP surgeries about who was responsible for prescribing these; and
• staff did sometimes mobilise with Mrs Y but mobility practice was not regularly documented, nor do the notes show that Mrs Y was offered mobility practice twice a day but declined this. There are no records of Mrs Y being offered or completing daily lower leg exercises.
18. At the end of April 2022, care home A were concerned that Mrs Y choice to decline afternoon bedrest was impacting on her skin integrity and wound healing. It asked Mrs Y to sign a statement confirming she understood and accepted the risks associated with her decision to decline this part of her care. Mrs Y signed the statement as requested.
19. In May 2022, the records show care home A continued to provide Mrs Y’s care in line with her care plans including offering positional changes every two hours and administering medications as prescribed, including regular pain relief. She was assisted daily with her personal care and records show her weight had increased.
20. There is evidence that Mrs Y declined exercise on intermittent occasions and continued to decline afternoon bedrest. However, there is no consistent record of Mrs Y being offered or completing the seated exercise programme as implemented by the physio or being regularly offered mobility practice.
21. On 14 May 2022, Mrs Y moved to a different Council-commissioned care home, care home B. Care home B put care plans in place to meet Mrs Y’s needs. District nurses visited to manage and re-dress Mrs Y’s pressure sores and leg ulcers.
22. Two days after admission, the records show staff noted Mrs Y had developed a chesty cough. Care home B requested a GP review.
23. The GP visited the following day and prescribed a course of oral antibiotics.
24. Ms X collected the antibiotics from the pharmacy the next day.
25. The following day, Mrs Y’s health deteriorated and care home B called an ambulance. Care home B informed Ms X, who arrived as the paramedics were assessing Mrs Y. Mrs Y was admitted to hospital, where she later died.
26. In July 2022, Ms X complained to the Council. She complained about poor care at care home A including that:
• following Mrs Y’s admission, care home A did not provide her with any pain relief for a week;
• staff did not help her to mobilise each day, against physiotherapy advice;
• staff did not appropriately support Mrs Y with her personal care;
• Mrs Y constantly needed to ask staff for her medication and health drinks; and
• Mrs Y was not re-positioned regularly, so her pressure sores deteriorated. The home then asked her to sign a waiver so it would not be responsible for them getting worse.
27. She also said care home B had let Mrs Y down as it should have realised Mrs Y was unwell sooner and delay obtaining the antibiotics from the pharmacy had contributed to the deterioration in her health.
28. The Council responded to her complaint in September 2022. It apologised for the delayed response. The response consisted of information gathered from the managers at care home A and care home B. In summary, care home A said:
• Mrs Y was prescribed “as required” pain relief and accepted there was one day where two doses were not available. It said this was due to a dispute between GP surgeries which the care home escalated to NHS management and which was quickly resolved; and
• Mrs Y often declined to mobilise or complete chair exercises. She also often chose not to go to bed in the afternoons and would at times refuse positional changes. It said Mrs Y had capacity to make her own decisions and would refuse this care, despite being aware of the risks.
29. The investigating officer said they had requested risk assessments and charts from care home A and once they had reviewed these, they would write to Ms X again with their findings.
30. Care home B said the pharmacy would have delivered the antibiotics, had Ms X not collected them. It said it would never ask a family to collect a prescription but sometimes family would offer to do this.
31. The response directed Ms X to us if she remained dissatisfied. Ms X brought the complaint to us in October 2022.
32. In response to our enquiries, the Council said the investigating officer had not obtained the care home records from care home A or written to Ms X again with further findings, as stated in the complaint response.
33. It said its commissioning service was due to visit care home A and care home B in the near future as part of its quality assurance framework.
34. Care home A said although staff had been mobilising regularly with Mrs Y and completing the prescribed exercises, it accepted this was not consistently recorded. It said it had now introduced a new form where staff could record compliance with therapy care plans.

Analysis

35. When a council commissions another organisation to provide services on its behalf, it remains responsible for those services and for the actions of the organisation providing them. So, although I will discuss the actions of care homes A and B, I will make findings against the Council.

Care home A

36. There is no evidence that care home A carried out the physiotherapist recommendations to offer a daily seated exercise programme and mobilise with Mrs Y twice a day. Although there are some references to Mrs Y declining to mobilise, the records do not show she was consistently offered mobility practice twice daily or daily seated leg exercises. Although care home A say she would often decline these, this was not documented, so I cannot know whether this care was offered or not. This was poor record keeping and was fault. The lack of documentation causes uncertainty for Ms X as to whether care home A were appropriately completing this aspect of Mrs Y’s care.
37. Care home A’s records show that other aspects of Mrs Y’s care were carried out in accordance with the care plans. She was regularly assisted with personal care. Care staff assisted Mrs Y to change position every 2 hours to help maintain skin integrity. She was offered regular meals, snacks and drinks and her nutritional intake was closely monitored.
38. Although Mrs Y did not have pain relief in her first week at care home A, this was because the hospital medical team had not prescribed it prior to her discharge. Once the GP prescribed paracetamol a week later, staff offered this to Mrs Y in line with the prescription, apart from one day late April where it was not available for two out of the four doses. The lack of availability of this medication was due to a dispute between GP surgeries and was not the care home’s fault. In any case, I do not consider these two missed doses caused Mrs Y a significant injustice. Care home A worked as we would expect to quickly resolve the matter.

Care home B

39. When care staff noted Mrs Y becoming unwell, they appropriately requested a GP review. The GP reviewed Mrs Y and considered she was well enough to remain at care home B but needed a course of oral antibiotics. Care home B was not at fault for relying on the GP’s assessment and decision-making.
40. Ms X says the pharmacy delayed delivering the antibiotics which meant she had to go and collect them. This would be a complaint against the pharmacy involved and I cannot say any delay experienced was Council fault. Ms X offered to go and collect the antibiotics and it was not fault for care home B to accept this offer.
41. Two days later when Mrs Y’s health deteriorated and staff became concerned, they called an ambulance. This is what we would expect. This is a professional judgement and there is no evidence in the records that this need was identified earlier. This was not fault.

Complaint handling

42. The Council’s response to Ms X’s complaint was poor. Although the officer appropriately gathered comments from the care home managers, they should have also completed their own investigation including examining the records, rather than relying on these comments as the only source of evidence. There was no independent analysis of Ms X’s complaint as the officer did not view the care records, contact the Council’s commissioning service for further information, or seek any other evidence before providing Ms X with a response.
43. Furthermore, the investigating officer said they would obtain records from care home A and then provide a further response for Ms X, but did not do this. This was poor complaints handling and was fault. This caused Ms X frustration and uncertainty as to whether the Council had appropriately investigated her concerns.

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Agreed action

44. Within one month of the final decision, the Council will write to Ms X to apologise for the frustration and uncertainty caused by the poor record keeping and its poor handling of her complaint.
45. Within three months of the final decision, the Council will:
• share the findings from this complaint with its commissioning service. It should review care home A’s record keeping as part of its next planned visit, to assure itself that care home A is keeping accurate and complete records for residents in their care.
• Review its adult social care complaint handling procedures to ensure officers responding to complaints are appropriately trained to investigate complaints and provide comprehensive responses in line with its policy.
46. It should provide us with evidence it has completed the above actions.

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Final decision

47. I have completed my investigation. I have found fault and the Council has agreed action to remedy the injustice caused and improve Council services.

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Investigator's decision on behalf of the Ombudsman