Summary: Miss X complained on behalf of her mother, Mrs Y, about the service she received at Lakelands Lodge over four weeks. She said Mrs Y was unrecognisable after her stay. We found the care fell significantly below that to which she was entitled, and the Care Provider caused Mrs Y actual harm and distress. It also caused significant stress to Miss X. We recommended the Care Provider apologise and refund the full amount of Mrs Y’s stay. The Care Provider agreed to this and had already recognised the problems and made improvements to avoid similar problems in future.

The complaint

1. Miss X complained that her mother, Mrs Y, was neglected during her short stay at Lakelands Lodge, run by Athena Healthcare (Fleetwood) Limited (the Care Provider). Miss X said the Care Provider:
• Placed Mrs Y in the dementia unit without proper consultation;
• Failed to recognise and treat signs of constipation throughout her stay which caused long term bowel problems;
• Released Mrs Y to a stranger without ID when she left the home;
• Made errors with medication;
• Did not provide promised activities to provide mental stimulation;
• Did not adequately protect Mrs Y’s personal belongings;
• Generally lacked in care and stimulation; and
• Did not respond adequately to her complaint about this.
2. Miss X says Mrs Y was unrecognisable after her stay with the Care Provider. She went from living independently to being unable to hold a conversation and was no longer continent. She said the experience caused Mrs Y’s dementia to worsen.
3. Miss X says she does not expect compensation but does not want Mrs Y to have paid for anything to do with Lakelands Lodge so she would like a full refund.

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The Ombudsman’s role and powers

4. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
5. 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)
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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How I considered this complaint

7. I considered information from both Miss X and the Care Provider.
8. Miss X and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Background

Fundamental Standards of Care

9. 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.

CQC

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
11. Regulation 9 is about 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”.
12. Regulation 12 is about safe care and treatment. CQC’s guidance says: “Providers must do all that is reasonably practicable to mitigate risks. They should follow good practice guidance and must adopt control measures to make sure the risk is as low as is reasonably possible. They should review methods and measures and amended them to address changing practice.”.
13. Regulation 17 is about good governance. 17(2)(c) says care providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.

Safeguarding

14. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

15. Mrs Y had dementia and lived at home independently with help around medication and with showering. She had some occasional, minor continence issues. She was admitted to Lakelands Lodge for four weeks following a fall in which she injured her arm; she could not push herself up and kept taking off her splint. Mrs Y’s GP would not cover her at Lakelands Lodge as it was outside of their area. The Care Provider delayed arranging a transfer to another GP.
16. Mrs Y was placed in the home’s dementia unit where Miss X said people were “screaming and all sorts”. Miss X was unhappy about this and said it confused and distressed Mrs Y. Miss X found medication at the back of Mrs Y’s wardrobe.
17. Mrs Y had been at Lakelands Lodge for four weeks when the local authority arranged for her to move to another home due to safeguarding concerns. I understand CQC was involved in the safeguarding enquiry and was alerted to the events at the time, but I will send a copy of my final decision to CQC anyway.
18. When someone arrived from the new home to take Mrs Y, she was not ready. The staff did not know she was moving to another home and let Mrs Y go with someone they did not know and did not identify. Mrs Y had net knickers on but no pad.
19. Miss X said she discovered Mrs Y had been constipated and that staff did not take appropriate action. She says this caused a significant haemorrhoid and Mrs Y now must take laxatives permanently and is no longer continent. Miss X also found out that Mrs Y had a skin tear to her leg and had antibiotics, neither of which she had previously known about. Mrs X also said staff would remove Mrs Y’s walking frame to prevent her walking around.
20. While Mrs Y was at Lakelands Lodge, some personal items went missing. These included a gold coloured locket, which is listed on the inventory.
21. Miss X complained early in July 2022. The Care Provider responded towards the end of September that year. It apologised and acknowledged that it should have dealt with Miss X’s concerns sooner. It said it “breached our own timescales”. It agreed Mrs Y may have found it more beneficial to be in the main community where she would have had more stimulation. It said staff could have managed any disorientation there. It did not deal with all the complaint in this response and issued a further response in October 2022.
22. The Care Provider said Mrs X had moved about the home and records showed this. It said staff would not have moved the frame to stop her walking about but may have moved it to the side when she was sat down, which had a similar effect. The Care Provider said it had spoken to all staff about this and had increased observation of staff practice. It subsequently implemented a system which ensures the same staff work on each unit or floor for consistency. It also said it did not know how the medication got into the wardrobe but should have noticed this during Mrs Y's stay. It said there were also inconsistent entries on the medication charts though nothing to suggest medication was not administered as prescribed. It had regional clinical development nurses in Lakelands Lodge overseeing medication and retraining staff. The Care Provider acknowledged that it should have advised Miss X about the skin tear on Mrs Y’s leg and the antibiotics.
23. The Care Provider accepted there had been various failures around communication with Miss X. Also, with the GP around transferring Mrs Y, and the community nursing team around constipation. It said staff should have alerted the community nurses that Mrs Y was not opening her bowels as expected and that it was clear she had constipation. It said it was retraining staff in managing continence. It also apologised for Mrs Y being unprepared for the move and said the manager had not told anyone that she was moving. It apologised and said the safety issue was being addressed with staff.
24. The Care Provider offered to reimburse Mrs Y with £2,130 for the lost personal items and their experience.
25. The care that Mrs Y received fell significantly below that which she was entitled to expect. This was fault which caused her injustice. Rather than receive the care to which she was entitled and which should have limited the risks to her, she was put at an increased risk of harm. This relates to releasing Mrs Y to an unidentified person, inconsistencies with medication recording, and lack of appropriate action around constipation. We cannot say that her long term difficulties were the result of the poor care, or that her dementia worsened as a result. However, on the balance of probability, the impact of the Care Provider’s failure to deal with her constipation appropriately, caused actual harm and significant, undue distress. These faults were potentially breaches of regulations 9, 12 and 17, so I will send a copy of my final decision to CQC.
26. The Care Provider’s actions also caused Miss X significant undue distress. I have noted Miss X’s wishes in relation to the outcome of this complaint and agree that Mrs Y should not pay for the service she received. I will recommend therefore, that the Care Provider make a further reimbursement so that Mrs Y is fully reimbursed for her stay at Lakelands Lodge.
27. I should also note that the Care Provider accepted responsibility for its actions and implemented appropriate actions to avoid similar problems in future. It will have been supported in this by CQC, and the local authority, under the safeguarding procedures which I have not investigated. I will therefore not make further recommendations around this.

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Agreed action

28. To remedy the injustice identified above, I recommended the Care Provider:
• Make a further apology to Miss X, ensuring this covers all the issues identified in this decision.
• Reimburse Mrs Y with a further amount to ensure she is fully reimbursed with the cost of her stay at Lakelands Lodge.
29. The Care Provider agreed to these actions and should do this within one month of our final decision. It should provide us with evidence it has complied with the above actions.

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Final decision

30. I have completed my investigation and uphold Miss X’s complaint.

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Investigator's decision on behalf of the Ombudsman