Summary: Miss A complained about the care her grandmother, Mrs B, received while at Hesketh Park Lodge (the Care Home), owned and run by Athena Healthcare Group. Sefton Metropolitan Borough Council (the Council) part funded the placement and Mrs B also received NHS Continuing Healthcare funding. The family also paid extra to have 1:1 care when the Council reduced the funded hours. Since making her complaint, the Care Home has different management and a fully staffed care team. It has changed its processes and uses different systems to help care for its residents. I discontinue the investigation on the basis we can achieve nothing more.

The complaint

1. Miss A complains about the care and treatment provided to her late grandmother, Mrs B, while she was a resident in Hesketh Park Lodge (the Care Home) which was partly funded by Sefton Metropolitan Borough Council (the Council) and later funded by NHS Continuing Healthcare funding.
2. Specifically, Miss A complains about:
• Miss A was not given enough food or drinks and she lost a lot of weight.
• Staff insisted placing her in incontinence pads when she was willing to use the toilet.
• She was often in bed when she should have been encouraged to be mobile and to sit up. This increased her risk of developing pressure sores.
• The overall level of care she received was poor; she was sometimes found dirty, she had falls and she deteriorated due to staff being uninterested in her wellbeing.
3. Miss A says she saw her grandmother receiving poor care and the family had to step in to make sure she ate or drank anything. She feels the poor care contributed to her decline in the Care Home, and when she left she seemed to improve. Miss A has had to pursue the complaint for several years to get answers but feels her concerns have not been addressed.
4. Miss A seeks an apology, a financial remedy and for lessons to be learnt.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. We investigate 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’.
7. It is our decision whether to start, and when to end an investigation into something the law allows us to investigate. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide there is no worthwhile outcome achievable by our investigation.
   (Local Government Act 1974, section 24A(6), as amended, section 34(B))
8. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I considered evidence provided by Miss A, Athena Healthcare Group and relevant law, policy and guidance.
10. Miss A had the opportunity to comment on the draft decision. I considered any comments before making a final decision.

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What I found

11. Mrs B was living at home up until the end of August 2021 when she taken to hospital after wandering the streets in a confused state.
12. Doctors said she had a urinary tract infection, which caused delirium. They also said she had dementia.
13. Mrs B’s family found the Care Home themselves and decided to take Mrs B out of hospital before she was formally discharged. She was however medically well enough to leave. Mrs B was very distressed in hospital, and they wanted her to be in a calmer environment so she could recover. The family hoped this was for a period of respite, so Mrs B could recover before going back to her own home. COVID-19 pandemic procedures were in place at that time.
14. Mrs B stayed in the Care Home from September 2021 to February 2022.
15. Miss A made a complaint to the Care Home in April 2022 which raised many concerns about the care Mrs B received while in the Care Home.
16. The Care Home responded on 31 May 2022. In its letter it said it had no record of the family raising many of the concerns while Mrs B was resident. It agreed there was a difficult discussion with staff and Mrs B’s family, and the Care Home manager had to ask the family to leave Mrs B’s room so it did not upset her.
17. It apologised if Mrs B’s family felt the care she received was not at a standard they expected, but it managed her care in line with her care plan. It said it also got advice from a doctor and district nurses when issues came up and followed the advice they gave. This was sometimes in conflict with the families wishes.
18. The response does not refer to any of the complaints made about the 1:1 care Mrs B received. This was provided by agency staff not staff employed by the Care Home.
19. Miss A and her family were not happy with the response. They felt the Care Home had not investigated and made excuses for its staffs’ poor behaviour. Miss A raised further concerns and escalated the complaint to the next stage of the complaints process.
20. It is not clear why there were delays in responding to Miss A, but on 20 June 2023 Athena Healthcare Group had a meeting with Mrs B’s family. At the meeting, Miss A explained the family were promised a lot before they agreed to Mrs B going there, and none of this happened. The family explained they were unhappy their concerns weren’t recorded in Mrs B records. They felt they weren’t taken seriously. They have had no apology or reassurance the culture at the Care Home has changed.
21. On 10 July 2024, Athena Healthcare Group provided a final response to Miss A. It apologised for the delay in replying to her complaint but explained this was because since the meeting in June 2023 there had been significant changes. These changes have happened at both the Care Home and at Athena Healthcare Group.
22. The letter apologised to Miss A and her family for their experience and explained many of the staff at the Care Home had been replaced since the time of the events. It said there was a new leadership team at the Care Home and this had changed the culture completely. It also said there was a new senior leadership team at Athena Healthcare Group.
23. It explained it now has procedures in place at all its care homes to ensure any concerns raised by family are immediately recorded in the electronic notes. It said at the Care Home, it now had a fully staffed team and it now rarely used agency staff, allowing them to monitor and manage staff better. It also employs a Care Experience Manager, who does unannounced visits to care homes to monitor how the staff are working.
24. In response to some of Miss A’s specific complaints about food and drinks times, it apologised for this and explained its procedures have changed to allow its residents to eat and drink whenever they want, not at set times. It also said it now has procedures where staff will collect and drop off samples to doctors, so family members do not need to do this.
25. The end of the letter says “I am sincerely sorry the experience received by [Mrs B] and for you as a family was not one you expected, I sadly cannot change that, but I can assure you that things are different, experiences are different, and we have adapted and improved all our processes to ensure all our residents and their families have the best possible experience whilst living in our Lodges.”
26. I asked Athena Healthcare Group why it had taken so long to reply to Miss A. It apologised and said it had changed its complaint handling procedure, and now had a policy in place which said all complaints should be responded to within 28 days. It has a quality and assurance team who will regularly check compliance with this policy.
27. Athena Healthcare Group has already recognised that any action it takes cannot change the experience Mrs B and her family had. It has apologised, made changes to its staff and senior leadership team and imposed new policies to ensure the faults in its service do not happen again.
28. I consider the action taken by Athena Healthcare Group to be appropriate. It is therefore unlikely continued Ombudsmen investigation would achieve anything more.

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Final decision

29. I discontinue this investigation on the basis Athena Healthcare Group has already improved its service to ensure the faults it has identified do not happen again. It has apologised to Miss A and reassured her of the changes it has made. Continued investigation by the Ombudsmen is unlikely to achieve anything more.

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Investigator's decision on behalf of the Ombudsman