Summary: Ms X complained about the standard of care her mother Mrs Y received when the Council organised respite care at The Old Vicarage Nursing Home. We find the Council at fault regarding the way the care provider managed a cyst on Mrs Y, and subsequently investigated Ms X’s concerns. This caused injustice in the form of distress and frustration. We recommend the Council apologises and makes a symbolic payment.

The complaint

1. Ms X complains about the standard of care arranged by the Council for her mother, Mrs Y, during a short respite stay at The Old Vicarage Nursing Home. She complains the care provider:

• Dressed Mrs Y in pull-up incontinence pants every day, contrary to Ms X’s advice.
• Did not provide timely assistance for Mrs Y to use the toilet so a visitor had to assist instead.
• Failed to ensure Mrs Y ate properly with a specific spoon she is able to use.
• Failed to provide adequate care for a cyst.
• Did not properly respond to Ms X’s concerns.

2. Ms X says the failings caused her to be anxious, stressed, disappointed and angry, which negated the respite break she took.

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The Ombudsman’s role and powers

3. 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)
4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. We normally expect someone to notify the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
8. 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)

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What I have and have not investigated

9. I have investigated the elements of Ms X’s complaint that bring into question Mrs Y’s dignity, food and drink, safety and the staffing levels of the care provider. I decided to do so because fault in those areas had the potential to cause significant injustice
10. I have not investigated Ms X’s complaints regarding an item of particular importance to Mrs Y, her shoes being packed by staff on the day of departure, and Mrs Y not being weighed on arrival. I decided any injustice from those areas of Ms X’s complaint was not significant enough to justify our involvement.

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How I considered this complaint

11. I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance.
12. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

13. 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.
14. 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. The fundamental standards include:

• Person-centred care
• Visting and accompanying
• Dignity and respect
• Safety
• Food and drink
• Staffing
• Fit and proper staff
• Complaints

What happened

15. Ms X cares for her elderly mother Mrs Y. Mrs Y is non-verbal, has limited mobility and several other health issues. She communicates with gestures. In 2024 Mrs Y stayed at a care home for a short period of respite care arranged by the Council.
16. The Care Home was The Old Vicarage Nursing Home in Stoke-on-Trent. It is provided and run by Central England Healthcare (Stoke) Limited.
17. Shortly before the stay, Ms X updated the care guidance folder that records all Mrs Y’s needs, preferences and other useful information including:

• Describing the special bowl and spoon she uses for eating in the “Eating and drinking” section.
• That Mrs Y had a cyst that required a type of cream to relieve itching in the “Other notes about me” section.
• Mrs Y’s illnesses and prescribed medications.

18. Ms X visited the care home and went through a preadmission assessment with a manager. They completed a preadmission assessment form. The form detailed lots of information about the care Mrs Y would receive. The form included information that Mrs Y should only have pull-up incontinence pants when she had diarrhoea. There was no reference to the cyst or cream on the form. However, Ms X said she provided the care home with the care guidance folder which did record the cyst.
19. During Mrs Y’s stay the care home had a digital record of her care plan. It included a lot of information including that Mrs Y needed two hourly safety checks during the day and night as she cannot use the nurse call alarm. It also said Mrs Y had a urinary catheter and staff should monitor her skin every time they emptied it. It did not include information about the cyst.
20. The care home also kept detailed digital records of the various care actions and checks completed daily. The records show the care home staff undertook care actions about 20 times a day. The care actions included assisting with meals, toileting, dressing, washing, moving to and from a chair and administering medicines.
21. The records include an entry regarding Ms X’s complaint that a visitor had to assist Mrs Y to use the toilet because the staff were too busy. The record says Mrs Y had recently been served her evening meal, then a visitor rang the bell and asked a staff member to take Mrs Y to the toilet. The staff member said it would take five to ten minutes to come to help because they were serving meals. The staff member said the visitor shouted towards them. When the staff returned to provide toilet assistance, the visitor said it was already done and Mrs Y was content.
22. On the day Ms X collected Mrs Y from the care home she said she found the cyst had become much larger. She said it burst and required medical treatment from a doctor. Ms X became concerned about the care Mrs Y had received. She complained to the care home about the cyst and the other concerns.
23. The care home replied that it had checked the care records and spoken to some of its staff. It said care decisions had been made to maintain Mrs Y’s dignity, that a visitor had been abusive, its staffing levels were appropriate, the diet charts indicate Mrs Y had an adequate diet, and that a family member who had washed Mrs Y had not mentioned the cyst had got bigger.
24. Ms X was not satisfied with the response to her complaint. She said some of the explanations raised more concerns.
25. Ms X raised her concerns with the Council that had organised the care. Council officers from the Adult Social Care department spoke to the care home and said they did not feel further action was needed.

Analysis

Pull-up incontinence pants

26. Regarding Ms X’s concern the care provider used pull-up pants daily. I note the records show Mrs Y was provided regular toilet assistance throughout her care. The majority of the assistance involved helping Mrs Y to and from a commode. The care home said it used the pull-up pants because there was some faecal smearing on the bed pad. I understand Ms X is upset the care home did not follow her request to only use pull-up pants if Mrs Y had diarrhoea, however I have not seen evidence the care provider used the pull-up pants as an alternative to providing appropriate toileting assistance. For this reason I do not find the care provider at fault.

Delay in toilet assistance

27. Regarding Ms X’s concern the care home did not provide timely assistance for Mrs Y to use the toilet when a visitor had to intervene. I appreciate a five or ten minute wait for the toilet may have upset Mrs Y and frustrated her visitor. However the records demonstrate the staff acknowledged the need, were engaged in serving meals at the time, returned to Mrs Y to assist, and made a record of the event. The records show the care home provided Mrs Y regular toileting assistance throughout her care. I have seen no evidence of a regular delay in assistance. I do not consider an isolated five or ten minute delay demonstrates poor care. For these reasons I do not find the care home at fault.

Not providing the specific spoon for Mrs Y’s meals

28. Regarding Ms X’s concern the care home did not provide Mrs Y the specific spoon. I appreciate Ms X was disappointed the care home did not utilise the spoon she had asked it to. However, the care records provide lots of information about the meals, snacks and drinks that Mrs Y was served and ate or declined. It also details the assistance and encouragement provided to her. I have seen no evidence of a poor standard of care regarding Mrs Y’s food and drink. I do not find the care home at fault.

Care for the cyst

29. Regarding Ms X’s concern the care provider failed to provide adequate care and treatment for the cyst. I note the cyst was not recorded on the electronic care plan, the preassessment form completed with Ms X or in the illness section of the care folder she left with the care home.
30. However, the cyst was recorded in a different section of the care folder that was left with the care home. I find the care home should have identified the reference to the cyst in the care folder and included it on its care plan.
31. I have also considered the care records that demonstrate the care home dressed and undressed Mrs Y and checked her catheter, bed pad and skin integrity regularly.
32. Given Ms X’s account of the cyst the day Mrs Y was discharged, I find the care home should have identified and recorded the cyst and sought medical advice. I find the care home’s failure to do so was fault which caused injustice in the form of distress to Mrs Y and Ms X.

Response to her complaints

33. I have only focused on the parts of the Council’s complaint response which relate to the matters I have investigated .
34. Regarding the care home’s responses to the complaints of the pull-up incontinence pants, delay in toilet assistance and the specific spoon. I understand Ms X disagrees with elements of the responses, however I find the care home had due regard to the concerns raised and the relevant records. Therefore I do not find fault with the way it responded to those complaints.
35. However, I note the care home’s response to Ms X’s complaint of the cyst makes reference to an instance where a visitor allegedly applied an antiseptic liquid to where the cyst was. I have not seen evidence that the staff made a record of this in the care notes. I also do not think that this, if it did occur, has a significant bearing on the care home’s duties to identify, record and treat the cyst. For these reasons I find the response into this concern was not adequate. This was fault and caused injustice to Ms X in the form of distress and frustration.

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Action

36. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care provider and make the following recommendations to the Council.
37. Within four weeks of my final decision, the Council should:

• Apologise to Ms X and Mrs Y for the injustice caused by poor care of the cyst and subsequent inadequate investigation and response to Ms X’s complaint. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Pay Ms X a symbolic payment of £100 to acknowledge the injustice caused.

38. The Council should provide us with evidence it has complied with the above actions.

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Decision

39. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman