Summary: Mrs X complained Farrington Care Homes Ltd failed to meet her father, Mr Y’s care and support needs while he was a resident at one of their care homes. Mrs X says these failings led to a deterioration on Mr Y’s heath and contributed towards his death. We found the failings in the care Mr Y received at the care home caused him and his family an injustice and have recommended the Care Provider take action to remedy that injustice.

The complaint

1. The complainant, whom I shall refer to as Mrs X complained Farrington Care Homes Ltd failed to meet her father, Mr Y’s care and support needs while he was a resident at one of their care homes as staff
• did not complete an adequate pre-admission assessment or assessment of needs;
• failed to check Mr Y’s blood sugar levels and as a result he was admitted to hospital in a hypoglycaemic condition; and
• failed to care for his feet.
2. Mrs X says these failings led to a deterioration on Mr Y’s heath and contributed towards his death.
3. Mrs X also complains Farrington Care Homes Ltd has failed to respond to her complaint correspondence and has been unsympathetic and insensitive towards the family.

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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. (Local Government Act 1974, sections 34B and 34C)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. 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)
7. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended). In this instance I have named the care provider but not the care home.
8. 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

9. As part of the investigation, I have:
• considered the complaint and the documents provided by Mrs X;
• made enquiries of the Care Provider and considered the comments and documents the Care Provider provided;
• Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Fundamental Standards of Care

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards all registered care providers must achieve. We consider the 2014 Regulations and accompanying CQC guidance when determining complaints alleging poor standards of care.

What happened here

11. Mr Y was a resident at the care home from 2 April 2022 until his death on 20 May 2022. He had a number of medical conditions, including a history of diabetes.
12. On 9 April 2022 staff at the care home called an ambulance as Mr Y appeared unwell and was not communicating verbally. A nurse at the care home had checked Mr Y’s blood oxygen levels, pulse, temperature, and blood pressure, but had not checked his blood sugars. The ambulance crew assessed Mr Y and noted his blood sugars were low and he was in a hypoglycaemic state. The ambulance crew took Mr Y to hospital and raised a safeguarding concern. Mr Y returned to the care home later that evening.
13. Mr Y’s family visited him regularly at the care home and were shocked by his appearance and the decline in his health. They were concerned that on occasion he had not eaten his food, been able to access his water and had been left in the same position for hours on end. They also complained Mr Y’s bed was too small for him and resulted in him having contractures of the legs.
14. Mrs X says that on one occasion they noted an entry in Mr Y’s records saying a carer had re-positioned him in bed at 7pm that evening, when it was only 6:30pm. The Care Provider investigated this falsification of Mr Y’s records and dismissed the carer. It also notified the Care Quality Commission (CQC).
15. Mrs X is concerned other entries in Mr Y’s care records could also have been fabricated and that Mr Y’s care fell well below the level he was entitled to receive. She says another member of staff apologised to the family for incorrect entries in Mr Y’s care records.
16. The local authority carried out a safeguarding investigation. The report identified significant failings in Mr Y’s care at the care home, including:
• Failure to develop a robust care plan and ensure it was updated as Mr Y’s needs changed;
• Failings in Mr Y’s personal care, in particular his oral care;
• Failure to accurately record and update Mr Y’s re-positioning needs and recording incorrect information in the turning charts;
• Failings in the monitoring and recording of Mr Y’s fluid and food charts;
• Failings in relation to the management of Mr Y’s diabetes;
• Failings in the management of Mr Y’s pain and records of his medication; and
• Incomplete progress/ nursing records.
17. It concluded there were evidential acts of neglect and omissions in Mr Y’s care. The report made over a dozen recommendations for changes and improvements at the care home. There would also be ongoing monitoring visits from the local authority’s quality improvement team and CQC.
18. One of the recommendations was that the Care provider send Mr Y’s family a letter of candour. The Care Provider wrote to Mrs X and the family in late July 2022 recognising that the care home was operating with significant shortfalls in its service delivery while Mr Y was a resident. It noted that Mrs X was not aware at the time Mr Y moved to the care home that the CQC had raised concerns about the home at a recent inspection.
19. The Care Provider acknowledged there were shortfalls in the way Mr Y’s care plan was put together, including a proper Mental Capacity Assessment. And that the manager at the care home had failed to ensure there was an adequate assessment of Mr Y’s needs or pre admission assessment.
20. It also acknowledged there were discrepancies between information recorded in the care notes and the care Mr Y received. In addition, the care home failed to carry out certain aspects of the care plan, including monitoring Mr Y’s blood sugars, regular turning, and his oral care.
21. The Care Provider also accepted the home had failed to update Mr Y’s care plan to reflect the SALT recommendations and had failed in its duties regarding skin viability and wound care. It noted concerns about the care of Mr Y’s feet had been a factor in the family’s decision to move Mr Y from his previous care home.
22. The Care Provider acknowledged the shortfalls in care planning and in the recording and management of Mr Y’s diabetes should have been identified by the care home management. It could also have been identified by the Care Provider had there been a more strenuous governance structure in place.
23. It apologised to the family for these issues and confirmed it was working with the CQC, local authority, and an independent consultant to make improvements as part of an ongoing action plan. In addition, it had reported the nurses and manager accountable for some of the shortfalls to the Nursing and Midwifery Council (NMC).
24. Mr Y privately funded his own care at a cost of £1,200 per week. He had also paid a deposit of £6,000 when he moved to the care home. Following Mr Y’s death, Mrs X asked the Care Provider to reimburse any monies due. The Care Provider noted its terms and conditions required a resident’s estate to pay for a two week notice period following their death. Taking into account the fees already paid and the deposit, it calculated the amount to be reimbursed was £5,314.29 and paid this to the family.
25. In November 2022 Mrs X made a formal complaint to the Care Provider about the level of care provided to Mr Y. Based on the shortfalls the family had identified and the findings of the safeguarding investigation, Mrs X asserted the Care Provider had not met its own terms and conditions and was in breach of contract. She asked the Care Provider to refund all fees Mr Y had paid during his residence at the care home.
26. As the Care Provider did not respond Mrs X’s husband, Mr X chased them in December 2022, January 2023, and February 2023. Mrs X says she has also telephoned the Care Provider and staff laughed at her when she asked for the complaints department. She has asked the Ombudsman to investigate her complaint.
27. Mrs X believes the quality and level of care Mr Y received at the care home resulted in a sudden deterioration in his health, leading to a premature end of his life and severe suffering. The family has found it difficult to come to terms with Mr Y’s sudden and unexpected death which Mrs X says has been compounded by the Care provider’s unsympathetic and insensitive responses to their complaint. Mrs X would like the Care Provider to reimburse all fees Mr Y paid.
28. In response to my enquiries the Care Provider says it has made every effort to provide good care to its residents. Upon becoming aware of the issues raised by Mrs X, it says it took immediate and substantial actions to correct the actions of the nurses and the care home. All staff involved were subject to investigatory action, and it has implemented additional training and supervision protocols to prevent similar incidents in the future.
29. The Care provider acknowledges and deeply regrets any impact on Mr Y’s health but believes it would be unfair to reimburse all the fees paid. It says it provided care in full and incurred substantial expenses to address the issues raised. The Care Provider says providing a financial remedy is inherently challenging as care homes operate within tight budgetary constraints. It believes exploring alternative non-financial remedies would be more appropriate and sustainable. But it does not suggest any alternatives.
30. It also notes that it has cooperated fully with investigations by the local authority and the NMC and has been cleared of any wrongdoing and no disciplinary action has been taken against its nurses. It has approached the situation as a valuable learning experience.
31. Mrs X disputes that the Care Provider took substantial or immediate actions to correct the actions of the nurses and care home. She asserts the care home was extremely short staffed and does not believe Mr Y’s experience there was an isolated event. Mrs X also disputes that reimbursing Mr Y’s fees would cause the Care Provider any financial difficulty.
32. The Care Provider has also responded to the draft decision and asserts the care home provided Mr Y with full care. It has reiterated its concerns about the impact refunding Mr Y’s fees could have on the home’s ability to maintain high standards of care.

Analysis

33. It is clear from the documentation that there were significant failings across all areas of the care provided to Mr Y at the care home. This included failings in the provision of Mr Y’s personal care; in the care and management of wounds and the prevention of pressure injuries; in the management Mr Y’s diabetes, and the record keeping. The local authority safeguarding investigation considered these failings in detail and concluded there were evidential acts of neglect and omissions in Mr Y’s care.
34. These failings in Mr Y’s care and acts of neglect caused him unnecessary pain and suffering and caused his family distress and anxiety. Mrs X asserts the failings in Mr Y’s care led to a deterioration in his health and contributed towards his death. I am unable to confirm there is a causal link but recognise the distress arising from this uncertainty is an injustice to the family. This should be recognised through a symbolic payment.
35. Our guidance on remedies sets out our approach to remedying injustice caused by fault. Where a complainant has paid for a service they have not received we can decide to recommend a refund of all or part of the amount paid. The level of refund will reflect the difference between the service provided and the service paid for. In this instance I consider the quality of care provided to Mr Y fell to an unacceptable level and a full refund of the care fees he paid would be appropriate. As Mr Y has died, we can recommend a financial remedy that repays his estate.
36. I recognise the Care Provider cooperated with the safeguarding investigation sent Mrs X and the family a detailed letter of candour. But I would still expect it to respond to Mrs X’s formal complaint in accordance with its complaints procedure. The failure to respond to Mr and Mrs X’s correspondence or provide details of the complaints process caused Mrs X additional distress and frustration.

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Recommended action

37. I recommend the Care Provider refund Mr Y’s estate all of the fees he paid for his placement at the care home between 2 April and 20 May 2022 and the subsequent two week notice period.
38. I also recommend the Care Provider pay Mrs X £350 in recognition of the distress and uncertainty caused to the family by the failings in Mr Y’s care at the care home and by the failure to respond to her complaints.
39. The Care Provider should take this action within one month of the final decision on this complaint and provide us with evidence it has complied with the above actions.

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Final decision

40. I have completed my investigation and uphold Mrs X’s complaint. Mr Y and his family have been caused an injustice by the actions of the Care Provider and I have recommended it take action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman