Summary: Mrs X complains the Council’s care provider, Valley Wood care home, failed to look after her late mother properly causing avoidable distress. Valley Wood’s care planning did not take account of all Mrs Y’s needs. The support it provided was not always in line with her assessed needs. It has been unable to provide Mrs Y’s medication administration records. The Council needs to apologise to Mrs X and pay her £250 for the distress she has been caused.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care provider, Valley Wood care home, failed to look after her late mother properly causing avoidable distress.

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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. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
4. 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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• invited comments on a draft of this statement from Mrs X, the Council and Valley Wood (via the Council), for me to consider before making my final decision.

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What I found

What happened

6. Mrs X’s mother, Mrs Y, had dementia. She lived at home with her husband. The Council first supported her when she returned home from hospital in December 2022. It first provided reablement support but in January 2023 it agreed to provide longer-term support in the form of four calls a day. This was to help with washing, dressing, medication, continence, meal preparation (including making sure she drank fortified drinks (high calorie nutritional supplements) three times a day, to reduce the risk of malnutrition).
7. In February the Council agreed Mrs Y should access day services, to prevent social isolation and provide respite for Mr Y.
8. The Council reassessed Mrs Y’s needs in March. The assessment said rolling respite had been agreed as part of her care and support plan. It said the family had asked the Council to arrange a respite placement, as Mr Y was struggling to cope because Mrs Y was wandering around at night. The assessment said Mrs Y could walk independently, only needing occasional help if she went outside the home. It also said she rarely left the home.
9. The assessment said Mrs Y needed help maintaining her nutrition and hydration. It said she needed prompting to take three prescribed fortified drinks a day and had a dietician monitoring her. It said family supported Mrs Y with meals and drinks (preparing them). The Council updated Mrs Y’s care and support plan. This said she needed help with:
• Stoma care
• Personal care
• Administering medication
• Ensuring she had her fortified drinks, as prescribed
• Making meals and drinks
10. The Council sent Valley Wood a copy of Mrs Y’s care and support plan. Mrs Y went to stay there on 21 March. It produced a respite care plan for her which said she:
• Was not a falls risk.
• Did not need help with eating and there were no issues with nutrition.
• Would wander around the unit at night.
• Needed hourly checks at night.
• Had a yellow and purple bruise on her left shoulder (she could not say how she got the injury but said her husband had been there when it happened).
• Would not allow herself to be weighed.
11. The care home kept records of the support provided for Mrs Y. It has been unable to provide Mrs Y’s medication administration records and assumes they have been misfiled. I refer to the key contents of the retained records below.
12. The care home did night checks:
• 22 March at 00.37, 01.40, 03.27 & 07.58
• 23 March at 00.58, 02.04, 03.14, 05.21, 06.35 and 07.46
• 24 March at 22.52, 01.52, 03.49 & 07.46
• 25 March at 22.53, 00.48, 02.55 & 03.53
13. The care home did not formally record Mrs Y’s food and fluid intake, as it had not identified her as at risk of malnutrition or needing any help. The care home recorded some of what she ate and drank. While not comprehensive, they suggest Mrs Y ate and drank most of what she was given.
14. By 25 March staff were helping Mrs Y walk and get into and out of chairs.
15. On 26 March, Mrs Y had an unwitnessed fall around 06.45. Around 07.08 staff called an ambulance. The ambulance took Mrs Y to hospital around 08.06.
16. The care home’s incident report, completed on 6 April, said staff had just delivered personal care and, after leaving the room to help someone else, they heard a bang. They returned to find Mrs Y on the floor with a cut to her head. They contacted 999 and were advised to leave Mrs Y on the floor and to stem the blood with a cold compress while waiting for the paramedics. The paramedics took Mrs Y to hospital, where she was also found to have broken her collarbone.
17. In April the care provider (SheffCare Ltd) which runs Valley Wood, completed an investigation report into the incident. It sent this to Mrs Y’s family on 14 April. It said:
• It had suspended a member of staff whose attitude, and approach to care and care delivery needed further investigation.
• It was providing refresher training to other members of staff on privacy, dignity and respect, customer care, person centred care, diet and nutrition, duty of care, falls prevention and safeguarding.
• Management of the care home were arranging working groups on communication, staff attitudes and ensuring daily huddle meetings took place where the focus would be on its values and leadership charter.
• It accepted it had been distressing for Mrs Y to be on the floor for an hour after her fall, but put this down to the time taken for the ambulance to arrive and following advice not to move her until it arrived.
• It accepted not all the relevant paperwork had been sent with Mrs Y to the hospital but said it would ensure this was always available for staff to access in future.
• When it became clear that Mrs Y was leaning, the care home should have sought medical intervention, rather than just put her on the list for the GP’s next visit.
• It had accepted a lack of care and compassion had been shown to Mrs Y and her family, and apologised.
18. The Council received safeguarding concerns from Mrs Y’s family, the care home, and the ambulance service. The care home said Mrs Y had an unwitnessed fall after staff left her in her room having delivered personal care. The ambulance service said:
• Mrs Y was covered in bruises.
• All the care workers at the care home were new and could not access Mrs Y’s records (care plans), as they were locked away.
• The care home’s telephone number for Mrs Y’s next of kin was the number for her mobile phone.
• A care worker told them Mrs Y had been up all night banging her head and shoulder on doors.
• The staff had not known the code to let them out of the building.
• There was a strong smell of cannabis in the entrance to the care home.
19. The Council made safeguarding enquiries into the safeguarding concerns. It completed its enquiries in July addressing eight concerns:
• Dehydration – the care home’s care plan said Mrs Y was independent with nutrition and Mrs X confirmed this.
• Medication records had been “locked away” so were not provided to the paramedics – staff gave the paramedics the medication administration records but they left them on her bed. It had tried calling the hospital about the medication records but could not get through.
• Mrs Y told her family on 25 March that she had fallen, so may have fallen more than once – Mrs Y did not have a prior fall. The care home asked Mrs Y about a bruise and she said she fell at home and her husband was aware. The Council noted the care home should have clarified with Mrs Y’s family about the injury to prevent safeguarding concerns being raised against it.
• Mrs Y was covered in bruising, staff were inexperienced, her records were not accessible and the telephone number for her next of kin was incorrect – she had bruising because she had fallen. The staff were all well established. Mrs Y’s care plan was available, but as a new resident it was still being completed. The ambulance crew did not wait for staff to locate the care plan. Mrs Y’s family provided the next of kin details. The Council noted the care home should have access to care records when needed, even in an emergency, and they should not be locked away.
• Mrs Y had been banging her head and shoulder on doors all night – Mrs Y had been walking around the unit and was unsettled, but had not been banging her head on door frames. If this had happened staff would have sought assistance.
• Mrs Y had significant bruising down her left side, including a purple bruise on her left shoulder, and dried blood on her head which did not reflect a recent injury – Mrs Y had the purple bruise when she arrived on 21 March. Staff used a wet towel to stem the blood. Mrs Y said she had fallen at home and her husband was aware of the fall.
• Staff did not know the codes to let the paramedics out of the building – codes are needed to enter and exit the building, so staff must have known the codes to let the paramedics in.
• There was a strong smell of cannabis at the entrance to the building – none of the night staff on duty smoked. Perhaps the smell came from outside the building.
20. Mrs Y left hospital on 28 April and went to stay in another care home, where she died on 7 May.

Is there evidence of fault by the Council which caused injustice?

21. 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. Regulation 12 requires care providers to provide care in a safe way, which includes following care plans. Regulation 14 requires care providers to include people’s nutrition and hydration needs when they make an initial assessment of their care and support needs. Regulation 17 requires care providers to maintain an accurate, complete and contemporaneous record of the care provided for each service user. This includes retaining the records for a period of time after someone has left a care home.
22. Neither the Council nor the care home had assessed Mrs Y as being at risk of falls. Within the context of the safeguarding enquiries, the care home told the Council Mrs Y reported a fall at home. But its records show Mrs Y could not say how she bruised her shoulder, just that it happened at home and her husband had been there (so could have said what happened). However, while at the care home Mrs Y started leaning her head to one side. Its records also show she needed help walking and getting up from and into chairs on 25 March. The care provider accepts more should have been done to address this, than putting Mrs Y down to be seen by a GP on their next visit (although it has provided no evidence of having done this). However, even if it had done more, there is no reason to assume it would have prevented Mrs Y’s fall on 26 March, as she would still have been left alone in her room.
23. Mrs Y had not been assessed as needing help eating and drinking, so there was no reason to record her food and fluid intake. However, she was being seen by a dietician and had been prescribed fortified drinks. The Council’s care and support plan said someone needed to prompt her to take them. There is nothing in the care home’s records about the fortified drinks, despite its care plan having a section where the need for them should be identified. The care home has been unable to evidence giving Mrs Y her fortified drinks. That is fault for which the Council is accountable.
24. The care home assessed Mrs Y as needing hourly checks at night. Its records show it did not provide hourly checks. That was further fault, which put Mrs Y at risk of harm.
25. The care provider accepted Mrs Y’s care records had not been available when the paramedics arrived to take her to hospital. There was no reason to expect them to wait while staff tried to retrieve the records. The fact they were not readily available may help to explain why staff were not checking on Mrs Y hourly at night. They may not have known this was necessary, if they had been unable to check her care plan.
26. The care provider has been unable to provide copies of Mrs Y’s medication administration records. This means it cannot evidence giving Mrs Y her medication. That is further fault.
27. It is no longer possible to remedy the injustice to Mrs Y as she has died. However, the Council should apologise to Mrs X, make a symbolic payment to her for the distress she has been caused and work with the care home to improve its practices. The faults identified raise the possibility that there have been breaches of the fundamental standards (see paragraph 21 above).

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Agreed action

28. 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 I found fault with the actions of the care provider/organisation, I have made recommendations to the Council.
29. I recommended the Council:
• Within four weeks, writes to Mrs X apologising for the failings identified in this statement and the distress they have caused, and pays her £250.
• Within eight weeks, work with the care home to identify the action it needs to take to ensure:
1. it does not overlook the need to prompt people to take fortified drinks and documents this properly;
2. its staff have access to people’s care plans and follow them when delivering care; and
3. care records are not misplaced after someone has left the care home.
30. The Council and Valley Wood have agreed to do this. The Council should provide us with evidence it has complied with the above actions.
31. Under the terms of our Memorandum of Understanding and information sharing protocol with CQC, I will send it a copy of my final decision statement.

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Final decision

32. I have completed my investigation on the basis there has been fault causing injustice which requires a remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman