Summary: The care provider has acknowledged that Mrs Y’s care was not always to the required standard. It promised to update training. I have also found that the care provider did not handle her son’s complaint to it properly. I have recommended it take further action to remedy the complaint.

The complaint

1. Mr B complains about the care provided by Care UK Community Partnerships Limited (the Provider) to his mother, Mrs Y while she lived in a residential home. He also complains about how the Provider handled his complaints and concerns.
2. In particular, Mr B complains that:
• The Provider did not respond properly to the family’s concerns that their mother, Mrs Y was treated roughly by a member of staff. It made a safeguarding referral, but did not give the family any explanation of what happened, was not clear what had been shared with the Police or how the family might access this, and did not give details of Care UK’s findings or what it would do to put things right.
• The Provider has not explained marks on Mrs Y’s body or what it did in response to this.
• Its staff left Mrs Y in excrement and dirty clothes and bedding. The Provider has not explained what happened and why.
• Following a fall, its care home staff left Mrs Y for over an hour before calling an ambulance, and when she was discharged back to the home, did not administer the prescribed pain medication. Again, the Provider has not explained what happened, why and what it has done to make sure the problem does not recur.
• Overall, the complaint handling is not effective. The Provider has not properly addressed the issues or explained what happened and why. On two issues it has referred to conversations it had with Mr B’s sister and maintained that this addressed the complaint.
3. Mr B says that as a result of the shortcomings, his mother was badly treated, left in pain and her dignity and hygiene was compromised. He has been distressed and frustrated by the Provider’s response, and to some extent has lost trust in the Provider’s ability to respond to problems.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
5. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
7. 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)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

9. I have deemed Mr B to be a suitable representative for his mother in this complaint, who cannot herself give written consent. I considered the information provided by Mr B and discussed the issues with him. I considered the information provided by the Provider including its file documents. I also considered the law and guidance set out below. Both parties had the opportunity to comment on a draft of this statement. I have considered their comments before making a final decision.

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What I found

The law and guidance

10. 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. The fundamental standards include:
• That service users must be treated with dignity and respect.
• Service users must be protected from abuse and improper treatment.
• Care and treatment must be provided in a safe way.
• The provider must operate an effective complaints system, investigate complaints received and take necessary and proportionate action in response to any failure identified.

What happened

11. Mrs Y has a progressive disease and dementia. She cannot mobilise and she is nursed in bed. Mrs B requires two carers to help her with all her daily care tasks. She lives in the Provider’s residential care home.

The Provider’s response to Mrs Y being treated roughly

12. In June 2022, the Provider was alerted to Mrs Y being treated roughly by a member of staff. I have seen the Provider’s documentation about this incident. The Provider learned that a member of staff had become increasingly annoyed when Mrs Y asked them to provide her care in a certain way, rolled their eyes at her, told her to shut up, and became rough when handling her.
13. It is clear that the Provider alerted the local authority, the CQC, the Police and the family. This triggered safeguarding and police investigations. The Provider carried out its own investigation. It suspended and later dismissed the member of staff. It made sure that the regular supervision of the remaining staff would now include a discussion about safeguarding, risk assessments especially in moving and handling, and whistleblowing.
14. The Provider told Mr B that a member of staff had handled his mother roughly and it was investigating the issue. It said it would keep him updated with the investigation. Mr B was understandably concerned. He asked for more details at various times, including contact details for the Police and what information had been passed to them.
15. In July, Mr B complained that the Provider had not given him any more details. On 23 September, the Provider told Mr B that the member of staff had been dismissed. It offered to meet with him to discuss this. Based on the information I have, it seems the Provider did not give Mr B the contact details of the Police until November.
16. The Provider responded properly to the alert. Its own investigation was robust and it reached a sound conclusion based on this. It also made sure that it put in place changes to supervision to strengthen safeguarding.
17. The Provider wrote to Mr B with details of the incident soon after it became aware. However, the Provider did not always communicate with Mr B properly on this issue. It did not offer to meet with him to give further details of its investigation until September, or give him contact information for the Police until November 2022. This caused Mr B distress and frustration at a very worrying time.

The Provider’s response to concerns about marks on Mrs Y

18. Mr B says that shortly after the safeguarding incident, his mother told hospital staff that she had sustained a scratch on her breast from a member of staff at the home. He asked the Provider to investigate whether this was part of the ‘rough treatment’. Mr B made this part of his formal complaint in July 2022.
19. The Provider responded in September. It said that having looked at all the records, the scratch could have been caused during the incident. In October however, the Provider told Mr B that it had reviewed the case notes and could not find any reference to that particular scratch, although there were records of Mrs Y scratching herself. The Provider also reviewed the medication records and found that the doctor had stopped Mrs Y’s antihistamine medication and this could have caused her to scratch herself.
20. Looking at all the records I have, I cannot say how the scratch was sustained. The Provider investigated the matter as thoroughly as possible but took too long to do so. The Provider says that it was difficult to draw conclusions because it was raised some weeks after it had happened. However, if detected, the scratch should have been noted on Mrs Y’s care records and it was not.
21. The lack of clarity over how Mrs Y sustained the injury caused Mr B distress and uncertainty.

The Provider’s response to concerns that Mrs Y was left in unhygienic conditions

22. In July 2022, Mr B visited Mrs Y at the home. He found a member of the care staff in her room, tidying. When she left the room, Mr B found that his mother had dried excrement on her legs, fingernails, clothing and bedding. Mr B immediately asked a staff member to help with this, but was told she had to weigh someone and so Mr B reported it to the duty nurse. He returned to the room and cleaned his mother. The Provider says he was supported by the nurse to do so. He complained to the Provider about what had happened.
23. The Provider says it discussed this with Mr B at the time, and it held a meeting of concern with the relevant member of staff. However, the Provider again did not respond to Mr B’s complaint until September. It said that it could see that staff had attended Mrs Y, but could not see that her clothing had been soiled. The Provider responded further in October. Here it set out the notes of Mrs Y’s care for that day. It assured him that weighing a resident does not take priority over personal care. It apologised that this had not been better explained to him. The Provider did not make any finding as to whether Mrs Y had been left in this condition or what had happened. It reassured Mr B that the manager is working with the nursing team to ensure the respect and dignity of residents is paramount, and will revisit this as part of staff supervisions. The Provider has also discussed with staff in supervision sessions, the need for accurate, contemporaneous and clear record keeping.
24. The Provider gave Mr B information but did not properly address his concerns. I have reviewed the care notes for this day and there is no mention that Mrs Y had to be cleaned of dried excrement. However, I have no reason to disbelieve Mr B. On balance, it is likely that the Provider did not treat Mrs B with dignity and respect, and it is likely that her care was not safe on that day, as required by the Fundamental Standards.

That the Provider did not call an ambulance in time and did not give Mrs Y the pain medication on time

25. Mrs Y’s case notes say that she was found on the floor of her room on the morning of 14 August 2022. Staff alerted the team leader, but due to a misunderstanding as to who would act, an ambulance was not called until two hours later. Staff supported Mrs Y to remain on the floor to await the paramedics.
26. The Provider met with Mr B’s sister about what had happened and she followed this up with an email to the Provider. Mr B made this part of his ongoing complaint. However, the Provider both in its response to him in October, and later in its response to my investigation, said that this matter had been dealt with in a meeting and an email to him. Mr B has confirmed that he had no meeting or email with the Provider about this.
27. I can see that the Provider considered it had already explained what had happened to Mr B’s sister, but there is no reason why the Provider could not have addressed this issue in its response to Mr B’s complaint, rather than rely on information given to his sister.
28. Some days after the fall, Mrs Y was in increasing pain. The Provider consulted the doctor and following his direction increased the pain relief. However, the pain persisted and was unbearable, so Mrs Y was admitted to hospital. The hospital discharged Mrs Y but later asked Mr B to collect stronger pain relief because on reviewing x-rays, it realised that Mrs Y had a fracture. Mr B took the pain relief to Mrs Y’s care home, however, due to a miscommunication between staff, the Care Provider did not give this to Mrs Y. She telephoned Mr B in the early hours of the morning, in great distress. The Provider gave Mrs Y the correct medication two hours later.
29. Mr B complained to the Provider. In September, the Provider said it had already responded to his complaint about this. In October, the Provider apologised and said that it should have directed him to the complaints procedure when he raised this, and it would conduct a training session with staff and supervision on the receiving in of medication and the handover of information at shift change over.
30. In response to my enquiries, the Provider explained that it had increased Mrs Y’s pain relief in consultation with the doctor and acute community care team. It did not however, address whether there had been a misunderstanding that left Mrs Y without the medication that the hospital had asked Mr B to collect immediately, or what it had done to make sure this did not recur.
31. There was fault by the Provider and a misunderstanding which meant that Mrs Y’s medication was not given to her as soon as it could have been. Again, the Provider’s failure to address this properly in its initial response to Mr B’s complaint or to my enquiries, indicates that the Provider does not have a good grasp of the issues, or what Mr B can expect to happen as a result of his complaint.

The Provider’s complaint handling

32. The Provider did not always handle Mr B’s complaint properly and did not always address the issues he raised. It sometimes relied on contact it had with his sister and not him. When Mr B complained formally about the issues it had already discussed with his sister, the Provider should have addressed these in its response. It also took too long to respond, and could have resolved some matters much more quickly.
33. The Provider’s later responses and its response to my investigation have made it unclear whether it has acknowledged its shortcomings and what Mr B can expect to happen as a result.
34. Overall, the Provider caused distress to Mrs Y by not ensuring she is treated with dignity and respect, not being clear about calling an ambulance, and not administering pain relief appropriately. The Provider caused Mr B distress, frustration and uncertainty when it did not always deal with his complaints and enquiries properly.

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Recommended action

35. Within one month of the date of this decision, the Provider should:
• Apologise to Mr B for the distress and frustration it caused him;
• Pay Mr B £300 in recognition of this; and
• Pay a further £300 for the benefit of Mrs Y in recognition of the impact on her of the delayed medication and its failure to treat her with dignity and respect.
36. Within three months of the date of this decision, the Provider should:
• conduct a training session with staff and supervision on the receiving in of medication and the handover of information at shift change over;
• ensure changes to supervision to strengthen safeguarding and whistle blowing; and
• share this decision with relevant staff to ensure that complaints are handled properly in future.
37. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

38. I have completed my investigation. There was fault causing injustice.

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Investigator's decision on behalf of the Ombudsman