Summary: The complainant (Miss X) complained about the quality of care provided to her mother (Mrs Y) by The Yews Residential Care Home. We found The Yews Residential Care Home actions caused injustice to Mrs Y and Miss X. We recommend the care provider apologise, reduce the outstanding invoice for Mrs Y’s residential care and make a symbolic payment to recognise Mrs Y’s and Miss X’s distress. We also recommend some service improvements in relation to keeping care and medication records and making Deprivation of Liberty Safeguards applications.

The complaint

1. Miss X complains about the quality of care provided to Mrs Y by The Yews Residential Care Home (the Care Provider). Miss X says the Care Provider’s actions caused decline in Mrs Y’s well-being and health and caused Miss X significant distress.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
5. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
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. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I spoke with Miss X and considered the information she provided.
9. I considered documents provided by the Care Provider.
10. Miss 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

Legislative and administrative framework

Record keeping

11. Registered care providers must maintain securely accurate, complete and contemporaneous records in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
12. Social care providers must maintain secure, accurate and up to date records about medicines for each person receiving medicines support. Paper based or electronic medicines administration records should:
• be legible
• be signed by the care home staff or care worker
• be clear and accurate
• have the correct date and time (either the exact time or the time of day the medicine was taken)
• be completed as soon as possible after the person has taken the medicine
• avoid jargon and abbreviations

Fundamental standards of care

13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) issued guidance (the Guidance) in March 2015 on how to meet the fundamental standards.
14. The fundamental standards are the standards below which the care must never fall. Everybody has the right to expect the following standards:
1. Person-centered care – you must have care or treatment that is tailored to you and meets your needs and preferences;
2. Dignity and respect – you must always be treated with dignity and respect while you are receiving care and treatment. This includes making sure you have privacy when you need and want it.
3. Safety – you must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Providers must assess the risks to your health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep you safe.
4. Safeguarding from abuse – you must not suffer any form of abuse or improper treatment while receiving care. This includes neglect and degrading treatment.
5. Food and drink – you must have enough to eat and drink to keep you in good health while you receive care and treatment.
6. Premises and equipment – the places where you receive care and treatment and the equipment used in it must be clean, suitable and looked after properly.
7. Good governance – the provider of your care must have plans that ensure they can meet fundamental standards. They must have effective governance and systems to check on the quality and safety of care. These must help the service improve and reduce any risks to your health, safety and welfare. The records kept for you should be accurate, complete and contemporaneous.
8. Staffing - The provider of your care must have enough suitably qualified, competent and experienced staff to make sure they can meet these standards. Their staff must be given the support, training and supervision they need to help them do their job.
15. Risk assessments relating to the health, safety and welfare of people using services must be completed and reviewed regularly by people with the qualifications, skills, competence and experience to do so. Risk assessments should include plans for managing risks. Providers should use risk assessments to make required adjustments.

Mental capacity

16. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
17. When a person using a service or a person acting lawfully on their behalf refuses to give consent or withdraws it, all people providing care and treatment must respect this. Where a person lacks mental capacity to make an informed decision, or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.

What happened

18. Mrs Y has dementia. Until the early February 2024 she lived with her daughter Miss X, who cared for her.
19. In January 2024 Mrs Y fell and was taken to the hospital. The best interest meeting took place to discuss Mrs Y’s care after the hospital discharge. Miss X, Mrs Y’s son, social worker and the community mental health team took part.
20. It was decided:
• Mrs Y would be placed for a respite care in The Yews Residential Care Home until adaptation to her home, which she shared with Miss X, were completed;
• the residential care home would be self-funded at the cost of £1,020 per week for at least three weeks;
• before Mrs Y returning home, Miss X should contact the Council to ensure a suitable care package for her;
• Mrs Y’s doctor would review her medication;
• the member of the Community Psychiatric team (the Nurse) would remain involved in Mrs Y’s care.
21. Mrs Y received residential care at The Yews Residential Care Home in February and the first days of March 2024. She had several falls at the Care Provider’s. After two of them she went to the hospital where she spent a few days on both occasions.
22. From the third day the Care Provider’s staff was noting Mrs Y’s challenging behaviours. She would regularly refuse to take medication and eat, was often unsettled and agitated. She had irregular sleep patterns, often being awake at night and sleeping in the day. Mrs Y would often fall asleep sitting in a chair, even at night.
23. After the fall in mid-February 2024 the medical staff who helped to take Mrs Y to the hospital noted she had not been taking her medication.
24. After her return from the hospital Mrs Y had another fall. Miss X raised concerns about her mother’s condition. Later the same day the Care Provider received advice on Mrs Y’s medication from the doctor. Following the doctor’s advice the Care Provider stopped one of Mrs Y’s medication.
25. After three weeks of Mrs Y’s stay at the Care Provider’s the Nurse told the Care Provider Mrs Y would be staying for a few more days with them as there was no care package ready to support Mrs Y in her own home.
26. At the end of February the Nurse discussed Mrs Y’s needs and care with the Care Provider. She reviewed Mrs Y’s medication with the doctor. The Care Provider applied for the Deprivation of Liberty Safeguards.
27. Two days later the Care Provider told the nursing team they could not meet Mrs Y’s care needs and would need extra funding until she found a place in another care home.
28. After another fall at the beginning of March 2024 Mrs Y was taken to the hospital and a few days later was discharged to another residential care home.
29. The Care Provider sent an invoice to Miss X for £2,185.71, which covered the period of the last two weeks at the rate of £1,020 per week and an extra day at the rate of £145.71. This was the second invoice sent to Miss X for Mrs Y’s residential care at the Care Provider’s.
30. Miss X refused to pay the second invoice as she was not happy with the care Mrs Y received at the Care Provider’s.
31. The Care Provider explained that after the first three weeks no alternative arrangements were made for Mrs Y so her placement at the Care Provider’s continued at the same rate as agreed before she started.
32. In response to Miss X’s concerns about the care provided to Mrs Y, the Care Provider:
• confirmed Mrs Y received 24-hour care. She would decline any personal care at times and could be physically and verbally aggressive;
• apologised for the room not being ready when Mrs Y came back from the hospital;
• explained Mrs Y’s belongings were left in the office for Miss X to put away;
• denied Mrs Y only had a bath and her hair washed twice;
• stated her nutrition and fluid intake and sleep patterns were affected by Mrs Y’s medication.

Analysis

33. I found Mrs Y’s care records sent by The Yews Residential Care Home incomplete and confusing. For some days there were significant gaps in the recordings of care provided. One entry, made on a date Mrs Y was in hospital, says she appeared to be asleep. These failings in record keeping are a breach of the Fundamental Standards. As I cannot show Mrs Y received care, and considering Miss X’s statements I am satisfied, on the balance of probabilities, the Care Provider did not sufficiently meet Mrs Y’s personal care needs. This is also a breach of the Fundamental Standards.
34. The medication administration records for Mrs Y do not meet required standards, as listed in paragraph 14 of this decision. They are not clear and at times do not tally with the care records.
35. The Care Provider’s failings to keep accurate and complete care and medication records caused injustice to Mrs Y and Miss X as there was no way of checking that Mrs Y was receiving sufficient care and her medication plan was followed.
36. I found the Care Provider significantly delayed:
• applying for the Deprivation of Liberty Safeguards;
• consulting with the medical staff in view of Mrs Y's refusal to take medication and worsening of her condition;
• telling Miss X and the Council it could not meet Mrs Y’s care needs.
37. The Care Provider’s delays listed above meant that Mrs Y was not receiving the proper care for a period of a few weeks and at times suffered loss of dignity. This situation caused significant distress to Miss X. She felt responsible for ensuring proper care for her mother and acted with confidence the Care Provider was equipped to support people with dementia. The decline in Mrs Y’s condition which was likely to be aggravated by irregular medication and confusion with what she should be getting, was upsetting for her.
38. I found when providing its services to Mr Y, the Care Provider failed to ensure:
1. dignity;
2. safety;
3. food and drink;
4. good governance;
39. I recognise providing support to Mrs Y proved challenging at times as it involved keeping the balance between respecting her wishes while ensuring her physical and mental health needs were met. If not for the Care Provider’s failings and delays, however, the injustice to Mrs Y and Miss X of the Care Provider’s inability to meet Mrs Y’s care needs could have been mitigated.

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Action

40. To remedy the injustice caused by the Care Provider’s failings, we recommend the Care Provider complete within four weeks of the final decision the following:
• apologise to Mrs Y and Miss X for the injustice caused to them by the failings identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Care Provider should consider this guidance in making the apology I have recommended;
• reduce the outstanding invoice for Mrs Y’s residential care by £437 to recognise the negative impact of the Care Provider’s failings on the care provided to Mrs Y;
• pay Mrs Y and Miss X £250 each to recognise the distress caused to them by the Care Provider’s failings.

The Care Provider will provide the evidence that this has happened.

41. We also recommend the Care Provider within three months of the final decision:
• review the way its staff completes medication administration records and care records and train its staff to ensure these records are accurate, complete and contemporaneous;
• review its processes of making urgent Deprivation of Liberty Safeguards applications to ensure there are no delays.

The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

42. I uphold this complaint. I found the Care Provider’s actions caused injustice to Mrs Y and Miss X. This investigation is at an end.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman