Summary: Mrs X complained about the care her late mother, Mrs Y, received in a Council commissioned care home and a delayed response to her complaint. The Council commissioned care home responded appropriately to changes in Mrs Y’s condition. The Council commissioned care home was at fault for not updating Mrs X of Mrs Y’s condition, not telling her Mrs Y was in hospital and the Council was at fault for the delay in responding to Mrs X’s complaint. The Council will apologise and pay Mrs X £300 for the distress, uncertainty and frustration caused by the faults identified.

The complaint

1. Mrs X complained about the care her mother, Mrs Y, received in the Council commissioned care home in mid-December 2022. She says care staff delayed acting when Mrs Y needed medical intervention, then did not tell the family it had called an ambulance. Mrs X says the Council and care provider delayed responding to her complaint which exacerbated her grief process. She says the Council accepted the care provider’s version of events without enough scrutiny. Mrs X wants an apology and service improvements.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
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)
5. 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

6. I have considered:
• the information Mrs X provided and discussed the complaint with her on the telephone;
• the Council comments about the complaint, response to our enquiries and relevant law and guidance; and
• our guidance on remedies.
7. Mrs X and the Council had an opportunity to comment on this draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

8. 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 states care and treatment must be given in a safe way and prevent avoidable harm or risks. It states the care provider must assess health and safety risks and do all they can to mitigate any risks.
• Regulation 14 sets out people must have acceptable nutrition and hydration to aid good health. It states people must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition.
• Regulation 16 states complaints to a provider must be investigated thoroughly and any necessary action taken where failures have been identified.
• Regulation 17 states providers must securely maintain accurate, complete and detailed records about each person using their service.

Council complaint procedure

9. The Council’s adult social care complaints procedure is to respond to complaints within 20 working days of receiving the complaint. If it is a complicated complaint the procedure is to agree an extension with the complainant.

What happened

10. Mrs Y had dementia and suffered from swollen ankles. Mrs Y moved into the Council commissioned care home in August 2022.
11. Mrs Y’s care plan said she had a risk of sores and deterioration of skin. It said the care home would check her skin, report if needed and give Mrs Y a full body wash in the morning.
12. Mrs Y’s physical wellbeing care plan said:
• the care home would tell Mrs X of deterioration in Mrs Y’s health;
• encourage Mrs Y to raise her legs if they became swollen; and
• ensure Mrs Y wore pressure stockings every day.
13. Mrs Y’s care plan for skin integrity said:
• staff to check skin for sore or redness when helping with personal care and complete body map;
• tell the GP or district nurse if concerned; and
• help with applying prescribed creams.
14. In early December 2022 Mrs X was discharged from hospital back to the care home following suspected sepsis and a urine infection. Two days later Mrs Y’s leg was leaking. The care home body mapping record showed:
• On the first day Mrs Y’s leg was leaking, the care home called the district nurse and the care home applied a temporary dressing following district nurse advice.
• The second day the care home renewed Mrs Y’s leg dressing.
• The third day a district nurse redressed Mrs Y’s leg.
• The fourth day the care home contacted the district nurse and they called the care home back later that afternoon and asked the care home to change Mrs Y’s dressing.
• The fifth day the care home redressed Mrs Y’s leg.
• The sixth day the district nurse saw Mrs Y’s leg and renewed the dressing. The same day Mrs Y had a fall and hit her head late at night.
15. The daily personal care checklist showed in this period, Mrs Y had a full body wash, had daily skin checks, was in good spirits, was mobile with an aid and ate and drank well.
16. After Mrs Y’s fall the care home called 111 and an ambulance arrived the next evening. Mrs Y’s temperature was low at 34.6 degrees Celsius and the ambulance gave Mrs Y extra blankets and a hot water bottle. Her temperature rose to 35.1 degrees Celsius. The care records said ambulance staff told the care home to carry out regular checks on Mrs Y and to call 111 if Mrs Y became dizzy or vomited. The ambulance records advised care home staff to keep monitoring Mrs Y regularly and check for any signs of deterioration in Mrs Y’s health.
17. Mrs X said the care home did not give information to the ambulance staff about her leg and they just examined her head. The care home gave Mrs X an update on Mrs Y’s condition. Care home records showed it checked Mrs Y every 25 minutes through the night and the body map record said Mrs Y’s leg dressing ‘remained intact’.
18. The next morning Mrs X visited Mrs Y in the care home and she said Mrs Y was shivering and refusing food. The care home notes said ‘right top foot leaking contact district nurse, left swollen hot to touch, call to 111, they said to keep an eye on Mrs Y if vomiting, feels sleepy or dizzy phone back. District nurse came late afternoon and dressed both legs right leg and bruises on half the leg advised to call 111 she might have an infection, bruises from fall’. The care home notes record it called 111.
19. The same evening Mrs X called the care home for an update. The care home said Mrs Y was in the main communal area eating. The care home told Mrs X it would ring her later that day, but it did not.
20. The ambulance arrived early the next morning. Ambulance staff noted Mrs Y had signs of a potential infection, she had a rash on her leg and had a temperature of 35.6 degrees Celsius. The ambulance staff thought Mrs Y had sepsis. The ambulance took Mrs Y to hospital. The care home records showed ambulance staff asked next of kin details and said it would get in touch with Mrs Y’s family to tell them she was in hospital. The care home did not tell Mrs X or her family that Mrs Y was in hospital.
21. The following day Mrs X had a prearranged visit with the care home to see Mrs Y. The care home told Mrs X at that point, Mrs Y was in hospital. Mrs X said she ‘was shocked’ when she was told by the hospital Mrs Y had suspected sepsis and dehydration. Mrs Y was on end of life care in hospital and died four days later.
22. The coroner recorded Mrs Y’s death was from natural causes.
23. In late December 2022 Mrs X made a complaint to the Council through an online complaint form. She said in mid-December 2022 she was unhappy with Mrs Y’s care in the care home. She was not told Mrs Y was in hospital with suspected dehydration and sepsis, causing her distress. Mrs X said the care home should have acted sooner.
24. In mid-February 2023 the safeguarding team carried out early safeguarding enquiries and offered advice but closed the referral.
25. The Council responded to Mrs X’s complaint in mid-June 2022 and offered its condolences for her loss. It said the care home apologised and said a member of staff should have contacted the family to tell them Mrs Y was in hospital. The Council said it had recommended the care home put in place procedures to answer telephone calls or take messages and contact people as soon as possible. It said management at the care home should communicate with families about emergency admissions, routine checks at hospital and visits by health care professionals and this would be monitored. It explained the sequence of events the day before Mrs Y was taken to hospital and confirmed the coroner had advised the Council Mrs Y died of natural causes.
26. Mrs X remained unhappy and complained to us.

Enquiries

27. In response to my enquiries, the Council:
• provided evidence the care home had actioned its recommendations to communicate with families about emergency admissions or routine checks at hospital and any visits by healthcare professionals and introduced a new emergency falls procedure.
• said ‘staff endeavour to answer the telephone as soon as possible’; and
• said in early 2022 there were significant staffing changes at the Council which led to lack of continuity in awareness of Mrs X’s complaint and did not send a response until mid-June 2023.

My findings

Medical professionals involvement

28. The care home records show following discharge from hospital in early December 2022 Mrs Y’s leg was leaking. The records showed the care home contacted the district nurse who initially visited twice. The care home checked Mrs Y’s skin while carrying out personal care and redressed a wound on her leg, as advised by the district nurses. The care home rang 111 and an ambulance after Mrs Y’s fall which was appropriate. There is no evidence the care home told the ambulance about Mrs Y’s leg leaking at that point.
29. The ambulance records show the paramedics asked the care home to monitor Mrs Y regularly and check for any signs of deterioration in her health. The care home records show it monitored Mrs Y every 25 minutes that night which was appropriate.
30. When Mrs X noticed Mrs Y was not well, her leg was leaking and hot to touch and her foot was swollen the care home rang the district nurses. The nurse came later that day and the care home called 111 on the nurse’s advice. The care home had agreed to update Mrs X but did not do so. The care home had a duty of care and should have rung Mrs X when it said it would to update her on Mrs Y’s condition once the district nurse had seen Mrs Y. The care home did not update Mrs X on Mrs Y’s condition which was fault and caused Mrs X uncertainty.
31. The ambulance arrived early the next morning and noted Mrs Y’s temperature was normal but was concerned about sepsis and took her to hospital. The care home did not tell Mrs X that Mrs Y had been taken to hospital which was fault and caused Mrs X distress.
32. The evidence shows the care home staff sought advice from the relevant professionals. We cannot say for certain if the care home had advised the ambulance of Mrs Y’s leg leaking after her fall or if it had told the district nurse to come earlier in the day it would have made a difference.

Service improvements

33. The Council recommended service improvements to the care home to tell families of medical changes, admissions to hospital, recording professional visits, recording communication with families and a new falls procedure. The Council provided evidence of these actions and no further recommendations were needed.

Council complaint response

34. Mrs X complained to the Council in late December 2022. To be in line with the Council complaint timescales it should have responded in 20 working days by late January 2023 or agreed an extension with Mrs X. Due to staffing changes the Council did not respond to Mrs X until mid-June 2023 and did not agree this extension with Mrs X. This was a delay of four and a half months and was fault causing Mrs X frustration. The Council has provided evidence of a new customer feedback procedure for adult social care complaints and no further recommendations were needed.

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Agreed action

35. Within one month of the final decision the Council will apologise and pay Mrs X £300 for the uncertainty and distress caused by the delays by the Council commissioned care home in updating her on Mrs Y’s condition, delay in telling her Mrs Y was in hospital and for the frustration caused by the Council’s delay in responding to her complaint.

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Final decision

36. I have completed my investigation finding fault causing personal injustice. The Council has agreed to take action to remedy the injustice caused and prevent reoccurrence of the faults.

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Investigator's decision on behalf of the Ombudsman