The Ombudsman's final decision:
Summary: Mr X complained about the quality of care his wife, Mrs X, received at the Council commissioned Care Home. He also complained the Council did not thoroughly investigate his concerns under its safeguarding investigation. The Care Home and the Council were at fault. The Care Home failed to give Mrs X the care she required and the Council failed to thoroughly investigate Mr X’s concerns under its safeguarding investigation. The Council has agreed to apologise to Mr and Mrs X for the poor care it delivered to Mrs X and for the distress and time and trouble the matter caused them. It will also pay Mrs X £1000 to acknowledge the poor care she received and pay Mr X £250 to acknowledge the distress and time and trouble. Furthermore, the Council will review staff knowledge and training and ensure the Care Home has actioned the recommendations from the safeguarding review.
- Mr X complained about the quality of care his wife, Mrs X, received at the Council commissioned care home, The Sands Care Home (Care Home B). He said staff did not properly assess Mrs X’s needs and they did not properly support Mrs X with her personal care and her meals. Mr X also complained the Council did not thoroughly investigate his complaint under its safeguarding investigation. Mr X said he and his family were upset with how his wife was treated. Mr X wanted an apology from the Council. In addition, he wanted to ensure lessons were learned so other people who used the service did not receive the same care as his wife received.
The Ombudsman’s role and powers
- 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)
- 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)
- 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, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- I spoke with Mr X about his complaint and considered the information he provided.
- I considered the information provided by the Council.
- I considered our Guidance on Remedies.
- Mr X and the Council had the opportunity to comment on the draft version of this decision. I considered their comments before making a final decision.
- Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
What I found
Legislation and guidance
- 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) is the statutory regulator of care services. It has issued guidance on how to meet the fundamental standards below which care must never fall:
- Regulation 9 sets out care providers must make sure each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences.
- Regulation 10 requires care providers to make sure people using the service are treated with dignity and respect at all times while they are receiving care and treatment.
- Regulation 12 requires care providers to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.
- Regulation 13 requires care providers to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment.
- Regulation 14 sets out that care providers must make sure people who use services have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment.
- Regulation 17 sets out guidelines for good governance. As part of this regulation, care providers must securely maintain accurate, complete and detailed records in respect of each person using the service.
- Mrs X has a diagnosis of dementia in addition to other health problems. In May 2019, the staff of Care Home B (The Sands Care Home) conducted a pre-assessment with Mrs X, with the intention of Mrs X moving into Care Home B.
- In June 2019, Mrs X moved into Care Home B. The Council’s records note that shortly after Mrs X’s admission into Care Home B, the care provider informed Mrs X’s Social Worker it believed Care Home B was not suitable for Mrs X’s dementia diagnosis. It said Mrs X had been placed in Care Home B as its pre-assessment concluded she had standard nursing needs. The Social Worker expressed they were not aware of this and it should not have happened. Mrs X should have been assessed as having specific nursing needs for her diagnosis of dementia and she should have been in a suitable care home for this. The care provider said when Care Home B carried out a pre-assessment with Mrs X, her nursing needs were greater than her dementia needs. It added it was not informed by Mrs X’s previous place of care, Care Home A and Mr X, that Mrs X could walk independently. It said Mrs X sometimes enters other residents’ bedrooms and this behaviour was something the staff could not manage in a standard nursing placement. Care Home B informed the Social Worker it could manage to support Mrs X until an appropriate placement was found.
- During Mrs X’s stay at Care Home B, the Council’s records note that Mrs X’s daughter raised concerns about the quality of care her mother was receiving. She said she was concerned about Mrs X’s personal hygiene and her appearance. Mrs X’s daughter also expressed her concern about her mother being left in bed and her mother missing meals. It was noted in the records that Care Home B said Mrs X did not often allow staff to assist her with personal care which caused her to be left wet and not dressed. Care Home B believed Mrs X’s mood was better if she was left in her bed until lunch time. It also said Mrs X was having at least two meals per day with snacks.
- In October 2019, Mrs X moved to another care home, Care Home C, which was more appropriate for her needs.
- In November 2019, Mr X complained to Care Home B about the quality of the care Mrs X received whilst she resided there. He said the staff did not properly assess Mrs X, because they were not aware Mrs X was independently mobile. He said Mrs X was often left in her bed for long periods of time with her clothes on and on occasions, she was left wet in her urine. He said staff did not complete personal care with Mrs X which affected her personal hygiene. He added that Mrs X had been getting urinary tract infections. Mr X said staff did not support Mrs X with her meals. Mrs X was not aware the meals were for her and so did not touch them. Mr X said this resulted in Mrs X losing weight.
The Council’s safeguarding investigation
- Care Home B raised a safeguarding alert with the Council. The Council conducted a safeguarding investigation based on evidence from a safeguarding visit, information from an internal investigation provided by Care Home B and supporting documentation. The outcome of the safeguarding investigation was inconclusive. Mr X was unhappy with the outcome as he believed the Council’s investigation was not thorough. He complained to the Council and in response, the Council said it would undertake a review of the investigation. As part of the review, the Council audited the previous investigation and it considered Mrs X’s care plan from her previous place of care, Care Home A. In addition, it considered Mrs X’s care plan, her pre-assessment, falls risk assessment, monthly falls assessment and daily notes from Care Home B.
The Council’s audit of the safeguarding investigation
- The Council reviewed Mrs X’s care plan from Care Home A and said there was evidence Mrs X was mobile. The Council also noted Mrs X had walked independently from the car to Care Home B before her admission. In addition, the Council noted that the care plan from Care Home A instructed staff to refer Mrs X to the Council’s Falls Team if she had two or more falls. Mrs X was at a high risk of falls. It found Mrs X had four falls whilst she was residing at Care Home B and staff did not refer her to the Falls Team. Furthermore, it was found that Care Home B did not correctly complete its falls assessment each time Mrs X had a fall.
- The Council said Mrs X’s pre-assessment completed by Care Home B contradicted the content of Mrs X’s care plan from Care Home A. Care Home A’s care plan indicated staff were to assist Mrs X to eat and drink, monitor her food and diet intake and complete food charts to monitor oral intake. Care Home B’s care plan indicated Mrs X did not require assistance to eat and drink but did need prompting.
- The Council found nothing in Mrs X’s care plan that described the best way to interact with Mrs X. There was no personalised care plan for managing Mrs X’s behaviour and there was no evidence that staff had considered different tactics in responding to different behaviours from Mrs X. The Council noted Mrs X was up and dressed in the mornings at Care Home A and at her current place of care, Care Home C. It was only at Care Home B, where Mrs X stayed in her bed until lunch time.
- The Council said Mrs X’s care plan detailed that Mrs X was doubly incontinent, she required full assistance with her personal care and she could be resistive to the assistance. On one occasion, Mrs X’s daughter had visited her and found her wet from waist below. Prior to Mrs X’s daughter visiting, staff had noted they had given Mrs X full assistance with personal care however after Mrs X’s daughter had raised her concerns, staff changed the record to say staff had tried to assist Mrs X but she refused. The Council continued and said it found Mrs X had a moisture lesion caused by poor personal hygiene. The Council said there was nothing documented in Mrs X’s care plan on how best to manage Mrs X’s personal care and the best strategies to use when approaching.
- Following the Council’s audit of the safeguarding investigation, the Council changed the outcome to substantiated, supporting Mr X’s concerns about the quality of the care Mrs X received at Care Home B. It made the following recommendations:
- When an individual is resistive to care, further consideration may be needed to identify alternative approaches and adopt different techniques to complete the task.
- When an individual is deemed to lack capacity around a specific decision, a best interest decision should be made and the care plan should be updated.
- If concerns are raised regarding an individual's diet and/or fluid intake, a diary or food/fluid chart could be used to monitor this.
- The Council has already acknowledged its safeguarding investigation initially relied heavily on the provider led investigation and that the Social Worker did not properly cross-check the evidence. This was fault. Upon Mr X’s further complaint, the Council conducted a review of its investigation. I considered the care records from Care Home B and I am satisfied that this review was thorough.
- The Council found that Care Home B:
- Did not properly assess Mrs X’s needs and therefore Mrs X was not in an appropriate care setting and she was not receiving the care she required.
- Did not properly consider Mrs X’s risk of falls and did not take appropriate actions to lower the risk.
- Did not keep an accurate and correct record of Mrs X’s care. This was found in Mrs X’s falls assessment and in Mrs X’s daily notes regarding her personal care.
- Did not properly consider Mrs X’s nutrition and hydration needs and the risks associated if this was not maintained.
- Did not have a personalised plan in place for managing Mrs X’s behaviour. It did not explain in Mrs X’s care plan the best way to manage Mrs X’s personal care and what methods to use if Mrs X was being resistive to care.
- The faults identified above caused an injustice to Mrs X. Mrs X had a moisture lesion and so suffered harm due to the care she received at Care Home B. She was also at risk of harm in other areas of the care she received. She did not receive appropriate support to maintain her nutrition and her personal care needs were not met. This meant Mrs X’s dignity and respect were affected.
- The faults identified above also caused an injustice to Mr X. Mr X was distressed and underwent time and trouble raising his concerns about Mrs X’s care and the safeguarding investigation with the Council.
- Within one month of the final decision, the Council has agreed to:
- Provide a written apology to Mr and Mrs X for the poor quality of care Mrs X received at Care Home B and to acknowledge the distress and time and trouble this matter caused them.
- Pay Mrs X £1000 to acknowledge the poor care received at Care Home B.
- Pay Mr X £250 to acknowledge the distress and time and trouble caused to him.
- Staff knowledge and training in assessment and care planning.
- Staff knowledge and training in managing risk and what arrangements they have in place to manage risk with falls, food and nutrition, personal care and hygiene.
- Staff knowledge and understanding of respecting people’s dignity.
- Staff knowledge and training in managing challenging behaviours of people who use the service.
- Staff knowledge and training in good record keeping.
- What arrangements the Care Home has in place when things go wrong, how lessons are learned, what action it takes and how it is shared amongst staff.
- Provide appropriate training and guidance to relevant staff in completing a safeguarding investigation.
- Provide evidence on how it has ensured the recommendations it put in place following the safeguarding investigation have been actioned by Care Home B.
- I have now completed my investigation. There was evidence of fault causing injustice which the Council has agreed to remedy.
Investigator's decision on behalf of the Ombudsman