Summary: Mrs X complains the Council’s care provider, Elm House Residential Care Home (Elm House), failed to look after her late mother, Mrs Y, properly. Elm House failed to take Mrs Y’s temperature for five hours on the day she fell ill. It also failed to record what possessions she had with her when she went to hospital and failed to deal properly with Mrs X when she raised her concerns. The care provider has apologised for these failings. The Council now needs to pay financial redress for the distress they have caused.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care provider, Elm House Residential Care Home (which is run by Croftwood Care UK Limited), failed to look after her late mother, Mrs Y, properly.

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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. 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, sections 30(1B) and 34H(i), as amended)
4. 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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the Ombudsman’s guidance on remedies; and
• invited comments on a draft of this statement from Mrs X and the Council, for me to consider before making my final decision.

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What I found

What happened

6. Mrs X’s mother, Mrs Y, was in and out of hospital in 2021. The Council arranged for her to stay at Elm House for respite care from 20 December. Mrs X visited her mother every day. Elm House said Mrs Y could spend Christmas day with her at her home. However, when Mrs X visited on 24 December, Mrs Y was slumped in her bed and did not feel well. Her temperature was 41.4C when taken five hours later. Mrs Y died in hospital 18 days later, having had a pacemaker fitted on 31 December.
7. When Mrs X collected her mother’s possessions from Elm House, a gold amethyst necklace and £40 were missing. Mrs X says her mother always wore the necklace, but the hospital did not include it in its inventory of her belongings. The necklace had great sentimental value, as it was the last gift Mrs Y received from her husband. Mrs X tried contacting Elm House but it took two weeks for it to get back to her, only to tell her the room had been checked and none of the staff would have taken the necklace or the money.
8. Mrs X raised further concerns about her mother’s care with Elm House.
9. Elm House responded to Mrs X’s concerns on 24 March 2022. It gave an account of her stay there and said she had eaten normally until 24 December. For that day, it said:
• Mrs Y only ate a little breakfast but seemed OK during the morning;
• she felt unwell at lunchtime;
• at 14.00 staff took observation as she remained unwell (blood pressure was 149/57, oxygen level 93% and pulse 101);
• at 17.20 her blood pressure was 144/69, pulse 111 and 113, and oxygen level 95%. She said she felt the same and wanted to sleep. She drank a little juice;
• at 18.45 her temperature was 41.4C, so staff called an ambulance which arrived at 19.15 and took her to hospital.
10. Mrs X complained to the care provider, Croftwood Care UK Limited, in August 2022.
11. When the care provider replied to Mrs X’s complaint, it said:
• it apologised for the delay in responding to Mrs Y’s call bell when Mrs X visited on 24 December 2021. Elm House’s new manager would check nurse call response times each day and record them;
• it accepted Mrs Y had to isolate in her room so had no choice but to take her meals there, and apologised for Elm House suggesting otherwise;
• on 24 December staff carried out observations (pulse, blood pressure and oxygen levels) but failed to take and record temperature checks until five hours later, and apologised. Elm House would learn from this mistake and make sure it did not happen again;
• it apologised for the lack of empathy shown by staff at Elm House after Mrs Y died;
• it apologised for the time taken to respond to Mrs X’s questions about the missing necklace and money, but said there was no way of knowing if Mrs Y had been wearing the necklace on 24 December 2021;
• Elm House needed to review its transfer to hospital procedures and include on the transfer form if a resident went to hospital with any jewellery, money or other personal belongings.
12. An inquest was held into Mrs Y’s death. It found she died of natural causes (infection of the heart). The coroner said there was nothing to suggest Elm House’s failure to take Mrs Y’s temperature had anything to do with her death.

Is there evidence of fault by the Council which caused injustice?

13. There is no dispute over the fact Elm House failed to take Mrs Y’s temperature for five hours on 24 December. While this had nothing to do with her death, it caused avoidable distress to Mrs X, including a lingering doubt over whether the outcome could have been different.
14. There is also no dispute over the fact Elm House failed to record what possessions Mrs Y had when she was transferred to hospital and failed to deal properly with Mrs X after her mother’s death. The care provider has apologised for these failings and accepted the need for Elm House to make improvements. However, these failings added further to Mrs X’s distress. She is particularly upset about the loss of the necklace, which had sentimental value. Unfortunately, there is no way of knowing what happened to the necklace, which is partly due to Elm House’s failings. The Council is accountable for these failings (see paragraph 4 above).

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Agreed action

15. 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 found fault with the actions of Elm House, I have made recommendations to the Council.
16. I recommended the Council within four weeks pays Mrs X £300 for the distress caused to her. The Council has agreed to do this and should provide us with evidence it has done so.
17. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

18. I have completed my investigation on the basis there has been fault causing injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman