Summary: The care provided to Mrs Y in a residential care home fell short of expected standards. I am satisfied this has been properly investigated by the relevant Council under safeguarding. I do not consider the Care Provider’s complaint response to be adequate because it lacks an apology for the faults identified and fails to acknowledge the distress caused to Mrs Y’s representative.

The complaint

1. Mrs X complains about the care provided to her late mother in a residential care home.
2. Mrs X is dissatisfied with the Care Provider’s response to her complaint about the above.

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The Ombudsman’s role and powers

3. 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)
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)

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How I considered this complaint

5. I have:

• considered the complaint and discussed it with Mrs X;
• considered the correspondence between Mrs X and the Care Provider, including the Care Provider’s response to the complaint;
• considered the safeguarding documents completed by the relevant Council;
• considered relevant legislation;
• offered Mrs X and the Care Provider an opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. These include:

• Person-centred care: people must have care or treatment that is tailored to them and meets their needs and preferences. Providers must carry out an assessment of the needs and preferences for care and treatment of the service user. Each person's needs and preferences should be assessed by people with the required levels of skills and knowledge.
• Safety: people must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Providers must assess the risks to a person’s health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep people safe.

7. Providers must do all that is reasonably practicable to mitigate risks. Incidents that affect the health, safety and welfare of people using services must be reported internally and to relevant external authorities.
8. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• has needs for care and support
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

9. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

Key facts

10. Mrs Y moved to Collingtree Park Residential Care Home on 21 July 2021. She had numerous health problems along with a diagnosis of dementia.
11. In 2022, Mrs X and other family members made numerous complaints to the care home and the Care Quality Commission about the standard of care provided to Mrs Y. Mrs X says the care home manager reassured her improvements would be made, which Mrs X says did not happen.
12. Following Mrs Y’s admission to hospital a doctor had concerns about her physical appearance and made a safeguarding referral to the Council.
13. The Council completed a section 42 safeguarding investigation. I have had sight of the concluding report. It is evident from that the Council conducted a robust investigation The investigation concluded there had been failings in the care provided to Mrs Y. It found:

• Care staff had not given any consideration to assisting Mrs Y to eat and drink. No advice was given to the care staff on what to do to encourage Mrs Y to eat and/or assist her to eat, and what to do should food/drink go cold.
• Mrs Y was losing weight and deemed at high risk of malnutrition, but no food chart was in place.
• Mrs Y needed to drink a lot of fluid daily, but no hydration chart was in place to monitor this.
• Care staff did not follow the company falls policy. They did not seek medical checks following Mrs Y’s fall, and there was a delay in the incident report being signed by the general manager.

14. The Council set out the improvements it expected the Care Provider to implement. The report states:

• Care staff should be reminded of The Barchester Health Care Falls Policy and their role in implementing this.
• Ensure concise record keeping by all staff is essential and regular audits should be completed to ensure a quality standard
• Residents’ refusal to have care and support including repositioning should be raised by staff to managers so issues can be addressed and risk assessments and care plans updated as necessary.
• Regular Audits of Repositioning Charts by senior staff to identify if care plans are being adhered to.
• Accident and Incident Reports – Management at Collingtree Park should review if the current oversight is robust and allows for risks to be identified and action taken in a timely way.
• Consideration should be given about the use of food and fluid charts where residents are at high risk of malnutrition and where hydration is necessary to aid skin integrity and healing.
• Consideration of staff assisting residents to eat and drink should be given where residents are at high risk of malnutrition, where hydration is key to skin integrity.
• Nutritional Care Plans should be more person centred and ensure that staff are acting in the residents’ best interests in cases where they might be slow at eating or drinking and their hot meals or drinks go cold. They should also ensure that Health and Safety is considered if food goes cold and requires reheating and the offering of alternative food options if food cannot be reheated.

15. The Care Provider accepted the findings and recommendations set out in the report. I am not clear if the Council sought evidence from the Care Provider confirming the recommendations had been implemented.
16. The Care Provider provided Mrs X with a final response to her complaint in February 2023. I have had sight of this letter. The author confirmed the Council’s safeguarding investigation had concluded and that he had sight of the outcome report. He said the Care Provider had submitted an action plan to the Council and went onto say, “I can assure you that the home will implement its action plan as a matter of best practice off the back of the Council’s recommendations”. These were summarised as:

• Improved adherence to falls risk management
• Improvements in record keeping
• Review of incident reporting ‘best practice’
• Ensuring that resident’s nutrition and associated care is more ‘person centred’

17. The author went onto say that although the Care Provider was not obliged to refund a deposit of £2,280.00 paid on Mrs Y’s admission to the care home it would do so “…in acknowledgement of both the time it has taken to respond to you and any upset this has caused, and the trouble that you and your family have gone to in raising your concerns both with us and the Ombudsman…”.
18. The author offered no apology for the failings highlighted in the safeguarding report.

Analysis

19. The Council conducted a robust safeguarding investigation into the concerns raised about the care Mrs Y received at the care home. The safeguarding report is comprehensive and concludes the care provided to Mrs Y fell short of expected standards. Mrs X should be reassured that her concerns were taken seriously and investigated thoroughly. I cannot see that any further investigation by this office would add to that already undertaken by the Council.
20. The Care Provider accepted the findings of the safeguarding report and committed to ensuring the recommendations were implemented. However, I have seen no information which shows these actions have been implemented.
21. I also note the Care Provider failed to apologise to Mrs X for the failures highlighted in the safeguarding report and for the distress this must have caused her.
22. When we make recommendations, we seek a remedy for the person affected by the fault. In this case we are unable to do so because Mrs Y passed away.
23. Although the injustice caused cannot be remedied by a payment, I consider the symbolic amount to Mrs X of £500 to be appropriate in acknowledgment of her distress.

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Agreed action

24. The Care Provider should, within four weeks of the final decision:

• provide Mrs X with a written apology for the failures highlighted in the safeguarding report and acknowledge her distress. A copy should be provided to this office;
• make a symbolic payment of £500 to Mrs X in acknowledgment of her distress;
• provide evidence to this office that all the recommendations highlighted in the safeguarding outcome report have been implemented.

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Final decision

25. There is evidence to show the care provided to Mrs Y fell short of expected standards. I am satisfied this has been properly investigated by the relevant Council under safeguarding. I do not consider the Care Provider’s complaint response to be adequate because it lacks an apology for the faults identified and fails to acknowledge the distress caused to Mrs Y’s representative, Mrs X.
26. The above recommendations are a suitable way to settle the complaint.
27. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman