Summary: We will not investigate this complaint about adult social care in a care home. The Care Provider has accepted failings, apologised, and taken action to improve service. It is unlikely the Ombudsman could add to that investigation or reach a different outcome. The Ombudsman cannot conclude negligence or say the actions taken on behalf of the Council led to death of a resident.

The complaint

1. Ms B says Lofthouse Grange and Lodge care home (the Care Provider) provided poor care to her mother, Ms C.
2. Ms B says the Care Provider failed to take clinical observation of Ms C when her sister raised concerns Ms C was struggling to breathe. Ms B says the Care Provider failed to give full information to the GP, which delayed the GP visiting. Ms C went to hospital the next day without seeing the GP, where Ms B says Ms C was treated for pneumonia and died a few days later. Ms B says Ms C was left lying in a urine soaked bed and continence pad, which was neglect and would not have helped her health.
3. Ms B is struggling to come to terms with her mother’s death. Ms B feels the Care Provider was negligent and caused Ms C’s death.

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The Ombudsman’s role and powers

4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

5. We have accepted Ms B as suitable to raise a complaint about Ms C’s care.
6. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
7. The Council commissioned Lofthouse Grange and Lodge care home, run by Indigo Care Services (2) Limited (the Care Provider) to meet Ms C’s adult social care needs. 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.
8. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6))

9. 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.

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How I considered this complaint

10. I considered information provided by the complainant.
11. I considered the Ombudsman’s Assessment Code.

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My assessment

12. The Care Provider has accepted some failings in service, it has apologised to Ms B and advised of actions it will take to improve future service. The Care Provider accepted it:
• Gave Ms B differing information about Ms C having a bloody nose. The Care Provider says the cause of the nosebleed was unknown, so staff should not have made assumptions. The Provider has apologised and spoken with staff.
• Placed nicotine patches on Ms C’s breast area, knowing she had breast cancer. It has apologised and advised staff to place patches in a relevant location and seek advice if unsure.
• Missed an application of a patch used to prevent the form of respiratory secretions because it had not reordered it in time. The Provider has apologised and discussed with staff ways to prevent recurrence.
• Either failed to tell family of a GP visit or failed to properly record it had told them. The Provider has apologised and reminded staff of the importance of accurate and contemporaneous record keeping.
• Failed to provide appropriate continence care resulting in Ms C laying in urine. The Provider has apologised and addressed the issue with relevant staff.
13. It is unlikely the Ombudsman can add to the Provider’s investigation or could achieve anything further by investigation. We can provide no remedy to Ms C. The apology to Ms B acknowledges the impact on her, and the actions to improve service reduce the risk of repeated failure.
14. Ms B says the care provided to Ms C was negligent. The Ombudsman cannot make a finding of negligence; only a court can decide that. The Ombudsman also cannot find the Care Provider’s actions, on behalf of the Council, caused Ms C’s death.
15. 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.
16. The Care Provider’s failures in medication management, record keeping, and continence care may be breaches of the CQC fundamental standards.

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Final decision

17. We will not investigate Ms B’s complaint because it is unlikely we could add to the Care Provider’s investigation or reach a different outcome. The Care Provider has taken appropriate action to acknowledge the impact on Ms B and prevent future failings.
18. 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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Investigator's decision on behalf of the Ombudsman