Summary: Ms X complained about a care home funded by a council and integrated care board at which her sister, Dr Y, was a resident. Ms X said poor care and communication led to distress for her. We will not investigate this complaint as it is unlikely we would add to the remedial action which the Home has already carried out.

The complaint

1. Ms X has complained about her sister, Dr Y’s care at a care home (the Home) in 2022 and 2023. The care was funded by both the Council and ICB under s117 of the Mental Health Act.
2. Specifically, Ms X has complained:

• staff made defamatory statements about her in the Home’s records,
• a staff member assaulted her,
• staff were rude to her,
• record keeping was poor,
• the Home delayed referrals,
• the Home communicated poorly,
• pain relief was poor,
• the Home placed her sister in a wheelchair facing a wall,
• the Home handled the complaint poorly,
• palliative care was obstructed by the Home.

3. The impact of these issues is Ms X is still upset by her sister’s care and a feeling she has not been listened to.
4. As a result of this complaint Ms X would like the Home to follow its complaints procedure, work in a person-centred manner, tell the truth, be consistent and be open to expanding its knowledge. In addition, Ms X said the Home needs to acknowledge the hurt staff caused her with their behaviour.

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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 provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• it is unlikely we could add to any previous investigation by the bodies, or
  (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

7. I considered evidence provided by Ms X and the Home as well as relevant law, policy and guidance.
8. I considered Ms X’s comments on my draft decision before making this final decision.

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What I found

Background

9. Dr Y was diagnosed with early onset dementia and entered the Home in 2021.
10. She was diagnosed with cancer and died in 2023.
11. Ms X complained to the Home. The Home investigated and provided a response before Ms X approached the Ombudsmen.

Staff behaviour

12. Ms X outlined incidents she had with staff including an alleged assault, and rude behaviour from the staff. She also took issue with comments made in her sister’s records about her behaviour.
13. The Home explained about the alleged assault stating that a staff member tried to hold up an arm to block being recording on Ms X’s phone, but stated that the staff member denied it was assault. It also apologised for upset caused by comments in the notes. It provided training to staff on respectful wording and empathetic documentation and put a note in the records about any comments made by staff which Ms X took issue with. It said it could not delete the records as they were a clinical record.

Analysis

14. For us to investigate a complaint we must find potential fault which may have led to an injustice and that we can add to a previous investigation. We would not be able to come to a conclusion about the alleged assault or the rude behaviour with a lack of any further independent evidence. In addition, the Home took appropriate action in providing training and putting a note in Dr Y’s records. Therefore, we would not add any further to what the Home’s investigation has already done regarding these issues.

Record keeping

15. Ms X said her sister’s care plans sometimes lacked essential details, such as her cancer diagnosis and Ms X’s role as Lasting Power of Attorney (LPA).
16. The Home found that Ms X was correct that useful information such as this was not included consistently across all documentation.
17. The Home said it put in place training to improve record keeping and to ensure information such as LPA was included. The Home would regularly review this.

Analysis

18. The Home has already taken appropriate action in admitting fault and putting in place remedial action and an investigation by the Ombudsmen would be unlikely to recommend anything further.

Delayed referrals and communication

19. Ms X complained the Home was slow to make referrals for services like Speech and Language Therapy (SALT) and wheelchair services. Ms X said that her sister was having swallowing issues three months before the SALT specialist (who could advise on this) attended the Home. She was also not kept informed by the Home about these referrals.
20. The Home said it made swift referrals but was then subject to waiting times that were beyond its control.
21. The Home said communication about the referrals could have been better. It said it would review how it communicated with relatives and ensure updates are provided in a manner and frequency which the relatives prefer and that this is clearly documented in the care plan.

Analysis

22. Regarding SALT, the Home made a referral and a SALT specialist attended. An investigation would be unlikely to find that a SALT referral should have been made three months before and because of the delay Dr Y had swallowing difficulties for three months.
23. There is evidence the Home made the wheelchair referral promptly then there was a month’s wait for the service to attend. An investigation would be unlikely to find fault in the Home’s actions.
24. In addition the Home has taken appropriate action to keep relatives informed in the future.

Pain management

25. Ms X noted occasions when the Home was late in administering her sister’s pain medication.
26. The Home said there was no record of medication being missed or late but they had instituted a competency check for the member of staff mentioned in the complaint.

Analysis

27. An investigation would be unlikely to find medication was missed if there is no record of it in the documentation and so we will not be investigating this aspect of the complaint.

Wheelchair placed facing a wall

28. Ms X complained her sister was placed in her wheelchair facing a wall. She felt the Home did this as a punishment to her sister.
29. The Home said although it had not been able to find out why Dr Y was placed in this position, it was unacceptable and apologised. It put in place additional training for all staff about positioning of residents in communal areas.

Analysis

30. Whilst we accept this was distressing for Ms X to witness, an investigation would not be able to uncover the reasons why her sister was positioned this way. In addition the Home took appropriate action in apologising and putting training in place and we would be unlikely to add to this as a result of an investigation.

Complaint handling

31. Ms X complained about delays in complaint handling which led to further frustration for her.
32. The Home agreed the complaint was not handled well. It apologised and said it would review how it handled complaints in future.

Analysis

33. This seems like an acceptable response from the Home and we would be unlikely to take further action.

Palliative care

34. Ms X said that the Home obstructed her sister’s palliative care by telling the palliative care team that she was not in pain and did not have any needs.
35. The Home disputed this version of events. It said it cooperated with the palliative care team and attended Multi-Disciplinary meetings with the team to contribute to Dr Y’s care.

Analysis

36. An investigation would be unlikely to find sufficient evidence that the Home obstructed palliative care and what effect it may have had on the treatment of Dr Y.

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Decision

37. We will not investigate this complaint as even if we found fault we would be unlikely to make recommendations to add to the work the Home has already carried out to address any injustice Ms X and her sister suffered. The Home has also outlined training and learning it is carrying out which is the outcome Ms X wanted as a result of the complaint.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman