Summary: Ms X complains the Council was at fault in the way staff at its care home cared for her father Mr X. We found fault as there were problems with the care given to Mr X. This caused uncertainty for Ms X. The Council agreed to apologise to Ms X and make a payment to her for the uncertainty caused.

The complaint

1. Ms X complains about the standard of care her late father received at a care home.

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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 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. (Local Government Act 1974, section 26A or 34C)
4. 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 we may find fault with the actions of the service provider, we will make recommendations to the council.
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)

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How I considered this complaint

6. As part of this investigation, I considered the information provided by Ms X and the Council. I discussed the complaint over the telephone with Ms X. I made enquiries with the Council and considered the information received in response. I sent a draft of this decision to Ms X and the Council for comments.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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What I found

The Care Act 2014

8. Some people need extra care or support, practical or emotional, to lead an active life. The need for social care may arise when a person becomes frailer with age as one example. A care and support plan is a detailed document setting out what services will be provided by the local authority. It also explains how it will meet the person’s needs, when they will be provided, and who will provide them. A care and support plan should be reviewed regularly by the local authority.
9. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. Once a needs assessment has been completed, the Care and Support (Eligibility Criteria) Regulations 2014 are used to identify the needs which must be met by a council. Where a council has determined a person has eligible needs, it has a legal duty to meet these needs, subject to certain financial criteria.

Fundamental standards of care

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 of care include:
• Person-centred care. A person must have care that is tailored to their needs and preferences.
• Dignity and respect. This includes giving a person support to remain independent and privacy when the need and want it.
• Premises and equipment. The place where a person receives care must be clean and suitable looked after.

Safeguarding

11. 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. (Care Act 2014, section 42)

What happened

12. In November 2021, Mr X moved into a care home. This was following a period of time he spent in hospital after suffering a fall.
13. In December 2021, the Council carried out a care assessment to assess Mr X’s care needs. The assessment concluded Mr X was at high risk of choking, falls and needed support with all aspects of daily living.
14. In March 2022, Ms X initially contacted the care home as she had concerns about Mr X’s care. Mr X had suffered with chest infections and was given a course of antibiotics on 11 March 2022 for seven days.
15. On 14 March 2022, Mr X suffered a fall at the care home. Mr X was checked by a GP on 14 March 2022. The GP noted Mr X had no symptoms of concussion.
16. On 19 March 2022, Ms X visited Mr X and reported to staff at the care home that she felt Mr X had deteriorated following the fall and that he was still suffering from chest infections. Ms X said the staff should have sought medical advice. Ms X also questioned why he had not been given another course of anti-biotics. Ms X emailed the care home on the 19 March 2022 with the following concerns:
• Mr X was wearing a continence pad and being told to go to the toilet in the pad.
• No further investigation was carried out on Mr X following his fall on 14 March 2022.
• Asked why Mr X’s phone had been taken from him.
• Asked why he was being laid down flat when he had a chest infection and should not be left this way.
• Asked when he last showered.
• Asked what protocols were in place for Covid.
17. Following Ms X’s reports, Mr X was reviewed by a doctor four days later at an emergency medical unit. The results of the tests carried out on Mr X all came back normal and showed no long term damage to Mr X.
18. On 25 March 2022, the care home responded to Ms X’s concerns. The care home said:
• Some new staff did not know Mr X did not need a continence pad. The care provider said it had organised induction training for new staff so they know each resident’s needs.
• Following Mr X’s fall on 14 March 2022, he was reviewed by a GP who felt there was no need for a scan.
• After Mr X’s course of medication ended the GP explained to her why they did not prescribe another course, however the GP then did decide to prescribe another course later.
• Mr X’s phone is placed on his bedside table, however the care home would ensure staff give this to him to have in bed.
• It had advised staff Mr X should not be laid flat in bed.
• Staff had been assisting Mr X to shower, however this had not been recorded on the personal hygiene record.
• It had procedures in place for cleaning and testing staff and residents for Covid.
19. On 10 April 2022, Mr X suffered another fall at the care home. Mr X’s partner visited him on 12 April 2022, and asked staff at the care home to contact the GP. The GP prescribed Mr X more medication on 12 April 2022, however the care home did not get Mr X’s prescription until 13 April 2022.
20. On 13 April 2022, Mr X was admitted to hospital with pneumonia as a result of lasting chest infections.
21. Ms X contacted the Council and the CQC on 22 April 2022 to raise concerns about Mr X’s care. Ms X said a lack of care from the care home resulted in Mr X’s hospital admission.
22. On 28 April 2022, Mr X passed away while in hospital.
23. Following Ms X’s reports the Council started a safeguarding investigation in May 2022. The Council held several meetings with Ms X and the care home from September 2022 to November 2022 to investigate the concerns. The Council considered the incident reports, care home case records, medical notes, correspondence between the parties and interviewed staff.
24. In November 2022, the Council held a meeting to discuss the outcome of the safeguarding enquiry. The Council considered six concerns raised by Ms X:
• Concern one – Mr X was not provided with medical attention in a timely manner for his chest infection. The Council decided this was partially substantiated as there was a four day delay in seeking medical attention for Mr X after Ms X raised concerns on 19 March 2022. The Council said this unlikely caused any long term damage to Mr X as when he was assessed at the emergency medical unit his test results were normal.
• Concern two – Delay in accessing Mr X’s antibiotic prescription. The Council decided this was partially substantiated as there was a delay of one day when antibiotics were prescribed and then the prescription was collected.
• Concern three – The protocol the care home had for managing high risk residents such as Mr X. This concerned his frequent falls, chest infections and staff not sitting him up in bed. The Council partially upheld this concern. The Council found the risks of Mr X’s decision making were documented. This included his decisions on medication and decision whether to sit upright. The Council did find that the care home missed opportunities to carry out a more collaborative approach with Mr X’s family to promote his wellbeing and involve his family.
• Concern four – The quality of care Mr X received. The Council found this concern partially substantiated as the personal hygiene records were not kept up to date and Ms X reported Mr X was unkept at times.
• Concern five – Mr X’s room was untidy. The Council upheld this concern as there was evidence to show the condition of Mr X’s room and the care home also said it would not clean a resident’s room when they were not there.
• Concern six – Mr X’s clothes were stained with bleach. The Council upheld this concern as the care home confirmed on some occasions the washing machines were being overloaded.
25. Following the safeguarding investigation, the care home put the following recommendations in place:
• Medical attention will be sought in a timely manner either GP or NHS 111.
• Daily situation reports will be completed for residents and will be discussed during daily flash meetings with managers to find out whether incidents require escalation.
• Multidisciplinary Team meetings (MDT) will be held every third Friday of the month. All residents in the unit will be discussed by the MDT to avoid being selective, so that each resident has a fair chance of discussion.
• Care staff will be aware of policy for discussing residents at the daily flash meetings and know how/when to escalate concerns. This should also be reiterated during supervision.
• Accurate clear and accurate recording of notes.
• Ensuring other professionals e.g. GPs are recording outcomes of their visits in the Professionals Visitor Logbook.
• If something is not clear in notes, this will be double-checked.
• Medication will be obtained in a timely manner.
• Medication policy is reviewed and updated accordingly along with policies on care management and care planning. The medication policy should be clear and easy to read so that staff can know what to do in in various eventualities.
• Mental capacity to be considered and documented when residents are making risky decisions. When unwise decisions are made by residents, efforts will be made to consult with residents relatives (when specific consent is given by the resident) or the local authority in order to enable the resident to consider the best option for him/her with the minimal impact on their health and wellbeing.
• Policies on care management and care planning will be reviewed and updated accordingly for each resident.
• Care home staff and managers will meet regularly with residents and their families face-to-face to address any issues, such as quality of care.
• Findings from this s.42 safeguarding enquiry will be escalated across
  care home staff and managers to meet regularly with residents and their families face-to-face.
• Rooms will be cleaned daily at a time that is suitable for resident and a thorough clean when a resident is in hospital.
• Policies for medication housekeeping will be updated and kept user-friendly for all staff and regular refreshers to be offered.
26. Ms X remained dissatisfied and complained to the Ombudsman.

Analysis

27. Ms X complains about the care Mr X received from the care home. I am satisfied the care provider was at fault for the level of care provided to Mr X. The Care home did not seek medical attention right away for Mr X following Ms X raising concerns on 19 March 2022. The care provider also delayed in obtaining a prescription for Mr X in April 2022.
28. Ms X also raised concerns about how Mr X was being placed onto his bed and that he was also having large pieces of food. While the care home has documented Mr X’s decision making I cannot see that it properly communicated this with Mr X’s family. This was fault. If it had it could have addressed some of these issues sooner with the family or at least made them aware of Mr X’s choices.
29. The care home also did not keep adequate records of Mr X’s personal hygiene and left him at times in a continence pad when he was able to use the toilet. This was fault. While the care home said Mr X was showered there were gaps in the records and Ms X reported Mr X was unkept at times. In addition, the fact that new staff at the care home did not know that Mr X did not need a continence pad before they were allowed to provide care is concerning.
30. The care home was also at fault as it did not clean Mr X’s room when he was taken to hospital, despite the care home’s housekeeping policy saying rooms should be cleaned daily. This was fault. In addition, there were also concerns raised by Ms X about the state of Mr X’s clothes after being washed at the care home. The care home has admitted there were times it overloaded the washing machines which could have contributed to this. This was also fault.
31. Following Ms X reporting her concerns to the Council, it carried out a safeguarding investigation. I am satisfied with the investigation the Council carried out. The Council held several meetings with the parties, obtained all of the care home records and considered these as part of the investigation. The Council also interviewed staff and obtained relevant internal policies from the care home. The Council mainly upheld the concerns Ms X raised and has worked with the care home to put in place a list of recommendations to improve its service. While this is welcomed and the recommendations put in place will improve the care home’s services, I am satisfied Ms X has suffered injustice from the faults of the care home, however this has not been recognised by the Council.
32. While I cannot say whether the above faults with the care home caused Mr X’s health to deteriorate, I do recognise Ms X believed they did. The fact there were issues with the care Mr X received will have caused Ms X uncertainty about whether Mr X would have lived for longer if the faults had not occurred. This is an injustice.

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Agreed action

33. Within one month of my final decision the Council agreed to carry out the following and provide evidence to the Ombudsman it has done so:
• Provide a written apology to Ms X for the faults identified.
• Pay Ms X £500 to recognise the distress and uncertainty caused to her as a result of the care provided to Mr X.
34. The Council should provide us with evidence it has complied with the above actions.

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Final decision

35. I have completed my investigation and found there was fault which caused injustice. The Council has agreed to the above actions to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman