St George's Nursing Home (17 015 066a)

Category : Health > Other

Decision : Upheld

Decision date : 04 Sep 2019

The Ombudsman's final decision:

Summary: The Ombudsmen found North Somerset Council’s flawed safeguarding enquiry into Mrs D’s care and support caused Mrs C distress and uncertainty. St George’s Nursing Home’s (the Home) poor record keeping of Mrs D’s fluid intake and pressure sore care caused Mrs C uncertainty. The Home should remedy the distress Mrs C suffered when she found an antibiotic next to Mrs D’s bed. The Ombudsmen also found Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group compounded Mrs C’s distress by significantly delaying handling her complaint.

The complaint

  1. Mrs C complains about the care and treatment provided to her late mother, Mrs D, from June to August 2015 by Weston Areas Health NHS Trust (the Trust) and St George’s Nursing Home (the Home).
  2. Specifically, she complains the Trust did not:
  • Place Mrs D on a stroke ward;
  • Offer Mrs D rehabilitation or follow her up;
  • Send Mrs D’s medical history to the Home (including oncology, monthly blood test needs and information about sudden loss of sight); and
  • Wrongly said Mrs D had capacity to make her own decisions.
  1. Mrs C complains the Home did not:
  • Complete a robust assessment of Mrs D’s care needs;
  • Meet Mrs D’s basic care needs;
  • Provide the gold standard end of life care it promised;
  • Increase care and support towards the end of Mrs D’s life;
  • Provide enough fluids to Mrs D;
  • Refer Mrs D to a falls team when she fell out of bed;
  • Refer Mrs D to a GP when she was confused;
  • Supervise Mrs D when visitors found her isolated;
  • Check if Mrs D could use the call buzzer;
  • Manage Mrs D’s medications correctly on 1 August 2015;
  • Have enough staff from 30 July to 2 August 2015;
  • Stop residents from entering Mrs D’s room; and
  • Consider her issues as a formal complaint.
  1. Mrs C says the failings in her mother’s care caused both her mother and her family significant distress at the time she was nearing the end of her life. Mrs C felt she could not return home or return to work after seeing the care at the Home.
  2. Mrs C complains how North Somerset Council (the Council) managed a safeguarding referral. Specifically, she complains the Council:
  • Did not safeguard her mother after she raised concerns;
  • Did not identify all the issues of concern on 30 July 2015, and instead closed the matter;
  • Seek the views of the family;
  • Tell the family it approached the Home about the safeguarding referral;
  • Wrongly decided it did not meet the threshold for formal investigation; and
  • Did not provide verbal or written feedback about the result of the referral.
  1. Mrs C says she had to move her mother to a hospice, despite this being against her mother’s wishes. Also, moving her was against medical advice.
  2. Mrs C complains about how the Care Quality Comission (CQC):
  • Did not include details of her complaint in its 9 June 2016 inspection report; and
  • Wrongly assumed the complaint was closed, when it was not.
  1. Mrs C complains that Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group (the CCG) significantly delayed handling her complaint.
  2. Mrs C says poor complaint handling caused significant avoidable distress, time and trouble and frustration, and stopped the family from achieving any closure.
  3. Mrs C would like apologies for all this issues above, and for the organisations to ensure they learn from these events, and to prevent this from happening to others.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
  2. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
  3. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
  4. The Ombudsmen cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant responsible body has to make. Therefore, my investigation has focused on the way that the body made its decision.
  5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their 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

  1. I have considered the complaint information Mrs C provided to me. I have asked all organisations to comment on the complaint and provide supporting documentation. I have taken the relevant law and guidance into account.
  2. I wrote to Mrs C and all the organisations involved with a draft decision and considered their comments.

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What I found

  1. Mrs D suffered with bone and breast cancer, and hip fractures.
  2. In May 2015, Mrs D suffered a stroke and the Trust admitted her. Before the Trust admitted Mrs D in May 2015, she mobilised with a frame and had daily help from carers. After the stroke she was confused, her eyesight worsened and needed two people to mobilise. The Trust discharged Mrs D to the Home on 9 June.
  3. At the Home, Mrs D received end of life care (commissioned by the CCG). This was provided by the Home and a community hospice nurse (the hospice nurse) who was employed by Weston Hospicecare. The CCG also commissioned North Somerset Community Partnership (the Partnership) to coordinate Mrs D’s end of life care.
  4. Mrs C raised safeguarding concerns about the Home on 29 July 2015 to the hospice nurse, and to the CCG a day later. Mrs C decided to move Mrs D to a hospice on 3 August. Mrs D died five days later.

The Trust

The stroke ward

  1. Mrs C says the Trust did not place her mother on a stroke ward.
  2. The Trust agreed Mrs D was not on a stroke-specific ward. However, it treated her in line with the stroke pathway (with aspirin) and referred her to the stroke team. The stroke team also asked for an orthopaedic review because of her high-risk of fractures.
  3. I do not consider the Trust was at fault. The Trust provided the same treatment to Mrs D as if she was on a stroke ward.

The lack of rehabilitation or follow up after discharge

  1. Mrs C says the Trust did not offer Mrs D rehabilitation, or follow her up after discharge.
  2. The Trust said an orthopaedic review found Mrs D needed end of life care, to manage her symptoms. This was considering how her condition deteriorated.
  3. I do not consider this was fault. The Trust appropriately identified Mrs D for fast track CHC. The evidence shows her condition worsened to the point where she had no rehabilitation potential. Therefore, I do not find fault in the decision not to arrange rehabilitation services or follow Mrs D up after discharge. The CCG took responsibility for managing her health care at that stage.

Not sending Mrs D’s medical history to the Home

  1. In Mrs D’s case, copies of her discharge summary and the transfer letter went with her to the Home. The Home Manager also assessed Mrs D at the Trust and reviewed her notes there.
  2. I consider the Trust provided an appropriate amount of information to the Home before it discharged Mrs D. The discharge letter contained a medical history and list of Mrs D’s symptoms. Also, the Home’s end of life care plan showed it was aware of Mrs D’s medical history. Therefore, I do not consider the Trust was at fault.
  3. The Trust accepted it did not fax Mrs D’s medical notes to the Home. It has apologised to Mrs C for its omission. The Trust agreed to make sure discharge summaries and care plans are in the medical notes, which will all go with the patient to the nursing home.

Mrs D’s capacity

  1. Mrs C says the Trust wrongly said her mother had capacity to make decisions.
  2. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so themselves.
  3. A person must be presumed to have capacity to make a decision unless it is established that he or she lacks capacity. A person should not be treated as unable to make a decision:
  • because he or she makes an unwise decision;
  • based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
  • before all practicable steps to help the person to do so have been taken without success.
  1. The authority must assess someone’s ability to make a decision, when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
  2. An assessment of someone’s capacity is specific to the decision to be made at a particular time. When assessing somebody’s capacity, the assessor needs to find out:
  • Does the person have a general understanding of what decision they need to make and why they need to make it?
  • Does the person have a general understanding of the likely effects of making, or not making, this decision?
  • Is the person able to understand, retain, use, and weigh up the information relevant to this decision?
  • Can the person communicate their decision?
  1. The person to assess an individual’s capacity will usually be the person who is directly concerned with the individual when the decision needs to be made. More complex decisions are likely to need more formal assessments.
  2. If there is a conflict about whether a person has capacity to make a decision, and all efforts to resolve this have failed, the court of protection might need to decide if a person has capacity to make the decision.
  3. On 28 May 2015, the Trust completed an abbreviated mental test (AMT) for Mrs D and she scored 5/10. The score showed Mrs D had significantly impaired cognition. A junior doctor assessed Mrs D six days later, and again she scored 5/10. The junior doctor discussed Mrs D’s discharge with a senior doctor and said: “[Mrs D] was able to understand, retain, weigh up and communicate” the decision.
  4. The junior doctor ensured Mrs D understood the discharge decision, the impacts of moving to the Home, could weigh that up, and then communicate her decision. I do not consider the junior doctor’s mental capacity assessment was fault. The doctor carried out the decision correctly and specific to the discharge.

The Home

The lack of a robust assessment of Mrs D’s needs

  1. The Department of Health’s National Framework for NHS Continuing Healthcare and NHS‑funded Nursing Care (November 2012 (Revised)) (the National Framework) is the key guidance about CHC. It states that where an individual is eligible for CHC funding the CCG is responsible for care planning, commissioning services and case management.
  2. The National Framework states: “Where a person qualifies for NHS continuing healthcare, the package to be provided is that which the CCG assesses is appropriate to meet all of the individual’s assessed health and associated care needs”.
  3. As Mrs D was CHC funded, the Home was responsible for assessing and providing support for Mrs D’s health and associated social care needs.
  4. The Partnership identified Mrs D’s needs from the CHC assessment. Those were:
  • Can get a low mood and decline medication.
  • Wore glasses and partially sighted in her right eye.
  • Bedbound and can only transfer as pain allowed.
  • Needed help and prompting to eat.
  • Fully continent.
  • Grade four pressure sore to sacrum (lower back bone).
  • Medication being administered.
  1. The Home completed an end of life specific care plan, with help from the Partnership (above) and other professionals involved in Mrs D’s care. It said Mrs D needed:
  • Regular assessment of needs as she approached the end of her life.
  • Two staff to help for personal care needs. This included full help washing and dressing, daily bed baths and routine freshen ups.
  • Two staff to help for all manual handling.
  • Help with all diet and fluids and to take food and drink to her lips if unable to open to her mouth.
  • A commode regularly.
  • Pressure sore care every two to three hours with regular repositioning.
  1. I consider the Home noted Mrs D’s main issues including her grade four pressure sore, limited mobility and medication instructions. The Home detailed how it would assist Mrs D with those issues, and it kept her care plan regularly updated.
  2. The Home even challenged needs the Partnership identified. For example, the Partnership said Mrs D was fully continent. The Home disagreed, and instead found that Mrs D could be incontinent, and her preference was to use a commode. The Home was listening to Mrs D’s views and did not take the Partnership’s assessment at face value.
  3. Overall, I consider the Home’s assessment of Mrs D’s needs was robust and made without fault.

The lack of support for Mrs D’s care needs

  1. The Home identified Mrs D’s needs in the end of life care plan (above). However, Mrs C felt the Home were not providing enough support for Mrs D’s care needs. On 3 August 2015, the Home said it did all it could for Mrs D.
  2. The Home has only been able to provide me with the daily care checklists for Mrs D from 10 June to 6 July 2015. I have relied on the Home’s daily record to review its support outside those dates.
  3. The Home regularly assessed Mrs D’s needs throughout her stay. The Home amended her care plan many times considering changes to her medication, reviews with Mrs C, and input from health professionals. The entries got more frequent toward the end of her stay at the Home. There was a handwritten record of those changes on the back, and staff entered significant changes digitally into the document.
  4. The Home’s daily care checklists and daily record show it provided personal and continence care to Mrs D in line with her care plan. Two staff helped Mrs D throughout the day. In the mornings staff washed or bathed Mrs D, cleaned her fingernails, provided mouth care and brushed her hair. There was regular documentation of further personal care during the day. This included offering her the choice to use a commode. In the evenings, there is evidence two staff provided continence care to Mrs D. The Home documented when Mrs D refused any personal or continence care.
  5. The Home’s daily care checklists and daily record show two staff supported Mrs D when she needed to transfer. This included when they used a hoist to move Mrs D to a commode or to a wheelchair.
  6. I consider the Home clearly documented changing Mrs D’s wound dressings in the wound care plan. However, there is limited evidence in the daily care checklists and daily record of how often the Home repositioned Mrs D. This should have been done at least every two to three hours. This was fault considering how severe Mrs D’s pressure sore was. I cannot say how often the Home repositioned Mrs D. This leaves Mrs C with a sense of uncertainty about that part of her mother’s care at the Home.
  7. The Home Manager told me she did not think the Home routinely recorded repositioning residents in 2015. The latest CQC inspection report in January 2019 identified that record keeping for repositioning residents was not robust. I consider the Home needs to do more to remedy the injustice Mrs C has suffered.

The missed opportunity to increase support

  1. The Home increased its support to hourly checks in late July 2015 after a request by Mrs C. However, I do not consider the Home missed any opportunities to increase support. The Home documented changes to Mrs D’s condition, sought professional help and provided that support.

The lack of referral to a falls team when Mrs D fell out of bed

  1. In the end of life care plan, Mrs D was a risk of falling out of bed. She was confused, needed help to mobilise and taking sedatives. The Home decided her bed should be on the lowest setting, with crash mats next to it. Mrs D was also a risk of falling from her chair, so sensor mats needed to be in place.
  2. I reviewed the Home’s daily care record and found evidence of Mrs D’s falls on 26 June, 7, 9, 12, 14 and 15 July 2015. Each time staff found her on the crash mat next to her bed and hoisted back to bed.
  3. The Home’s accident forms show that:
  • On 9 July Mrs D was in some pain, but staff felt this was most likely caused by a potential urine infection. The Home called the GP, who later prescribed antibiotics to treat it.
  • On 12 July Mrs D suffered skin tears on her right elbow and arm. Staff provided wound care.
  • On all other occasions, Mrs D had no complaints of pain, or obvious injuries.
  1. I consider the use of crash mats and a lower bed setting for Mrs D was appropriate. The Home decided the risk of Mrs D trying to climb over bed rails was too high, especially considering her worsening confusion.
  2. I do not consider the Home was at fault for not referring Mrs D to a falls team. I understand Mrs D was falling often in July 2015. However, the Home has shown it was managing the falls as best it could to minimise the impact to Mrs D. This was successful most of the time. Mrs D suffered injuries on one occasion and the Home provided appropriate wound care to her. Also, the Home referred Mrs D to a GP when she complained of pain. Overall, I do not consider the Home needed to refer Mrs D to a falls team.

The lack of referral to a GP for Mrs D’s confusion

  1. Mrs D suffered with confusion caused after her stroke and then worsened with her condition.
  2. I have considered the Home’s record of professional contact and found that:
  • On 7 July 2015, a GP visited Mrs D and staff told the GP Mrs D had become more “muddled”. Staff agreed to try and get a urine sample. Staff sent this two days later.
  • On 15 July 2015, staff asked the GP to review Mrs D due to her confusion, and two days later told the GP she remained “muddled at times”.
  • On 20 July 2015, staff called told a GP Mrs D’s confusion was worse. The GP said this was due to her worsening condition.
  1. Confusion is a common symptom when someone nears the end of their life. Mrs D was confused during her stay at the Home. I consider the Home correctly referred Mrs D to a GP when she was confused.

The lack of supervision when visitors found Mrs D isolated

  1. Mrs C said visitors found Mrs D isolated in the dining room. This was most likely on 17 July 2015, but Mrs C could not remember if that was the correct date.
  2. I have considered the Home’s records. I do not doubt Mrs C’s version of events. However, I have not seen any evidence from the time where Mrs D was isolated at any point during her stay.

Not checking if Mrs D could use the call buzzer

  1. The Home’s initial care plan said Mrs D could use the call buzzer. The end of life care plan also said staff should regularly check the call bell was in Mrs D’s reach.
  2. Mrs C said after two weeks at the Home, the family told staff Mrs D did not know how to use the buzzer, and staff were unaware of that.
  3. I have considered the Home’s daily care records and found that staff noted “call bell given” many times. Also, Mrs D used the call bell on 20 July when she was falling of her chair.
  4. During my investigation, the Home told me Mrs D always had a call bell, and staff did not take it away. The Home said “call bell given” most likely meant staff completed personal care and return the bell to Mrs D before they left.
  5. I consider the Home most likely did not remove the call bell from Mrs D’s room. It appropriately checked Mrs D could use it on admission. While Mrs D rarely used the call bell, she did so on 20 July. This showed she was aware how to use it. While the Home’s records do not directly note it was regularly checking if Mrs D could use it, I am satisfied she could.

The lack of fluids

  1. During the Home’s assessment of Mrs D, it said: “Staff to regularly check [Mrs D] and offer fluids...documenting accurately what has been offered and taken”.
  2. The Home used its daily record to note Mrs D’s fluid intake between 10 June and 10 July 2015. Staff did not complete this often or in detail.
  3. From 11 to 24 July, the Home used a combination of fluid charts and the daily record.
  4. On 22 July the GP said he was aware of Mrs D’s poor fluid intake. This was most likely due to her worsening condition rather than dehydration.
  5. Between 25 and 29 July the Home returned to using the daily record to note Mrs D’s fluid intake.
  6. On 30 July, the hospice nurse raised concerns about the Home’s fluid intake record keeping. The Home agreed to keep fluid charts in Mrs D’s room to relieve Mrs C’s anxiety that her mother was not receiving any. The Home also agreed to complete hourly checks on Mrs D.
  7. The next day Mrs C said the Home was dehydrating her mother. The hospice nurse tried to allay Mrs C’s concerns, and the GP asked the Home to encourage Mrs D to take fluids.
  8. On 3 August, the Home Manager met with the hospice nurse, two clinical managers and a GP to discuss recent events. The Home noted:
    • Mrs C wanted her mother to receive subcutaneous fluids, but all agreed this was not necessary.
    • All agreed the documentation in Mrs D’s room about fluids was misleading for Mrs C. Staff were reminded of the importance of clear documentation. Poor documentation will lead to disciplinary action.
  9. I consider the Home’s documentation of fluid intake was fault.
  10. There are seven entries in the daily record Mrs D was offered or encouraged to drink fluids. This was not in line with the care plan. It was not regular or an accurate record of what was offered or taken. During that period, I cannot say what fluids staff offered to Mrs D. This leaves Mrs C with a sense of uncertainty about her mother’s fluid levels during that period.
  11. However, when the Home used fluid charts, they accurately documented how regular drinks were offered to Mrs D. Also, what fluids were offered and how much she had. This was an appropriate record of Mrs D’s fluids at that time.
  12. Between 11 and 24 July, Mrs D’s daily fluid intake ranged from 150 to 1000mls. On the days her fluid intake was low, staff were offering Mrs D’s fluids, but she refused them. I appreciate the Home could not force Mrs D to take fluids.
  13. Between 30 July and 3 August, Mrs D’s daily fluid intake had decreased from 575mls to 260mls. Again, staff were recording what they offered to Mrs D; however, she was refusing them. Mrs D’s intake had reduced because, on the balance of probabilities, she was nearing the end of her life. Towards the end of someone’s life, it is normal for someone to lose their appetite and reduce their fluid intake.
  14. Overall, I consider the Home was at fault when it used the daily record to check Mrs D’s fluid intake. The Home has accepted it did not document clearly Mrs D’s fluids. However, the Home need to remedy the uncertainty this caused to Mrs C.

Mismanagement of Mrs D’s medications

  1. Mrs C said she found a tablet on Mrs D’s dressing table on 1 August 2015.
  2. The Home’s mediation administration records show it gave an antibiotic to Mrs D at 8am and 3pm on 1 August. At 10am, Mrs C told a nurse she found a tablet on Mrs D’s dressing table. The nurse completed an accident form. The nurse said it was an antibiotic and contacted the GP. The GP said missing one antibiotic caused Mrs D no adverse effects to her health. The GP added staff could crush antibiotics in future.
  3. The nurse said the Home will check Mrs D after they give her medication to ensure she has taken it. Also, the nurse would speak to staff about what had happened, so it does not happen again.
  4. I consider, the Home most likely gave Mrs D the antibiotic at 8am but she did not take it. Mrs D’s care plan does not clearly state staff should make sure Mrs D takes her medication. However, I would have reasonably expected staff to be doing that regardless as she had previously struggled with her swallowing. The Home did not make sure Mrs D took her medication and this was fault.
  5. I am not persuaded there was an adverse impact to Mrs D’s health. The Home gave Mrs D another antibiotic at 3pm. However, I understand the fault would have been distressing for Mrs C when she found the antibiotic on the table.
  6. In the accident form, the nurse explained what action she took. The nurse put “feedback to [Mrs C]” with a tick next to it. However, from the ‘Record of Relative Contacts’ I cannot see the nurse discussed the outcome of the incident with Mrs C. Also, the CCG complaint responses do not address this part of her complaint. The Home needs to remedy the injustice to Mrs C.

The lack of staff from 30 July to 2 August 2015

  1. The Home said its staffing levels between 30 July and 2 August 2015 were in line with the recommended guidance. Also, the Council said it visited the home in November and their staffing levels were appropriate.
  2. The Home told me Mrs C was under the impression her mother would receive one-to-one support, but this would not have been possible.
  3. I have considered the Home’s records, and I cannot see staffing levels were below the needed level. Between 30 July and 2 August, Mrs C spoke with nurses and the Home manager many times and did not raise staffing levels as an issue.
  4. I have also not seen any evidence staffing levels impacted the quality of personal care the Home provided to Mrs D between 30 July and 2 August 2015.

Not stopping residents from entering Mrs D’s room

  1. I have considered the Home’s records. While I do not doubt Mrs C’s version of events as she remembers them, I have not seen any evidence from the Home’s records that other residents entered Mrs D’s room.

The lack of gold standard end of life care

  1. The National Gold Standards Framework Centre provide training to staff in care homes to ensure they can provide high quality end of life care.
  2. The Home told the family that staff had received training from the National Gold Standards Framework Centre.
  3. The Home told me the clinical managers in 2015 had received National Gold Standards Framework training. However, it could not provide evidence of that training as they had both since left the Home.
  4. I understand Mrs C feels the Home did not provide enough support to her mother. I have already highlighted where I consider the Home’s care or record keeping amounted to fault.

Safeguarding

  1. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
  2. The National Framework states: “Local authorities may not provide community care services to anyone in a care home who gets NHS Continuing Healthcare, although they have a role in relation to their wider responsibilities such as safeguarding vulnerable adults…”
  3. The care and support statutory guidance also states: “Where an individual is eligible for NHS CHC, the relevant Clinical Commissioning Group (CCG) is responsible for care planning, commissioning health and care and support services, and for case management. Local authorities will continue to have a wider role, for example in relation to safeguarding responsibilities.”
  4. The Council’s Joint Safeguarding Adults Policy (2015) says:
  • Adults should be involved from the beginning of the safeguarding enquiry unless there are exceptional circumstances that increase the risk of abuse. They can be supported by an independent advocate if there is no suitable person to represent and support them.
  • The wishes of the adult are very important, attending to those wishes and preferred outcomes ensure the process is about promoting their rights as well as protecting them.
  • Adults with care and support needs/their carer/their representative should be informed they will be kept involved with the process to the degree they wish to be.
  1. The North Somerset Multi-Agency Adult Safeguarding Procedures (2015) says:
  • The person who raises the concern will be informed whether a safeguarding response will be provided.
  • The safeguarding response will consider the wishes and views of the adult at risk and will work with them or their representative to achieve their desired outcomes.
  1. The 2014 (pre-Care Act) North Somerset Safeguarding Adults Procedure (Practice Guidance) says:
  • If the safeguarding referral meets the threshold, there should be a discussion or meeting within five days
  • The threshold decision should be made within 48 hours of a referral
  1. On 29 and 30 July 2015, Mrs C discussed Mrs D’s care with the hospice nurse. The hospice nurse and the CCG visited the Home and agreed fluid charts were poor, and there was a wrong reference to brain metastases in Mrs D’s care plan. The hospice nurse made a safeguarding referral to the Council about Mrs D’s care and treatment.
  2. On 31 July 2015, the Council agreed a safeguarding investigation was necessary. The manager of the safeguarding adults team agreed a safeguarding enquiry was necessary, to find out if Mrs D was receiving suitable care at the Home. The Council asked the Home Manager to carry out the investigation into Mrs C’s concerns.
  3. On 7 August 2015, the Home Manager found:
  • Mrs D was not on hourly observations, but these were introduced later due to her worsening condition.
  • Food and fluid charts were not completed fully, but there was information in the daily record.
  • Mrs D appeared dehydrated due to her worsening condition.
  • Changes in record keeping led to Mrs C believing days were missing from Mrs D’s care records. This information needed to be made clear to families. Staff have undergone supervision about documentation.
  • Mrs D spent more time in bed because of her worsening condition, but staff were reviewing her regularly.
  • Only staff trained in administering medication could help Mrs D.
  • Mrs D wanted Mrs C to go into a hospice.
  1. In response to the above, the Council told the Nursing Home Mrs D did not need a safeguarding investigation. The Council later told me this was wrong.

Analysis

  1. I do not consider the CCG, or the hospice nurse, were responsible for carrying out the safeguarding investigation. I agree with the hospice nurse and the CCG’s decision to refer these to the Council to consider. The Council was responsible for carrying out the safeguarding investigation into Mrs C’s allegation of neglect of Mrs D at the Home.
  2. I do not consider the Council carried out the safeguarding investigation in line with its own policy. I will explain why.
  3. First, I understand why the Council asked the Home to carry out the safeguarding investigation. They were best placed to consider Mrs C’s concerns. I do not disagree with the Council’s decision to do this.
  4. However, I have not seen any evidence the Council told Mrs C that Mrs D’s case had met the threshold for a safeguarding investigation on 31 July 2015. Also, there was no evidence the Council explained how it was going to try and resolve her safeguarding concerns.
  5. The Home said it spoke to Mrs C as part of the safeguarding investigation. Mrs C said this was not true. I can understand Mrs C’s view on this, because she was not aware there was an ongoing safeguarding investigation after 31 July 2015.
  6. When the Home Manager sent her report the Council, the Council should have communicated the result of the investigation to the family. That did not happen. Mrs C is still unsure if a safeguarding investigation was completed or not. This was due to the lack of communication from the Council. Therefore, I can understand why Mrs C felt the matter was closed. This was fault.
  7. I do not consider the safeguarding policies were flawed. It was simply the Council did not follow them.

Injustice

  1. Mrs C said the unresolved safeguarding concerns meant she felt she had to move her mother to a hospice, which was against her best interests.
  2. I understand how the fault caused Mrs C distress and uncertainty from the flawed safeguarding investigation. The Council needs to remedy this injustice for Mrs C.

Complaint handling

The Home

  1. Mrs C says the Home did not consider her issues as a formal complaint.
  2. When Mrs C raised issues about the Home’s care in July and August 2015, the Council addressed those as part of a safeguarding enquiry. I have not seen evidence in the Home’s records to show Mrs C wished to raise a formal complaint until March 2016. I consider the CCG was the responsible body for managing Mrs C’s complaint about the Home after March 2016. I will consider the CCG’s actions below.

The CCG

  1. Mrs C says the CCG significantly delayed handling her complaint.
  2. Organisations should have clear procedures for dealing with health and social care complaints. Regulations and guidance say they should investigate a complaint in a way which will resolve it speedily and efficiently. A single stage procedure should be enough. The organisation should say in its response to the complaint:
  • how it has considered the complaint; and
  • what conclusions it has reached about the complaint, including any matters which may need remedial action; and
  • whether the responsible body is satisfied it has taken or will take necessary action; and
  • details of the complainant’s right to complain to the Local Government and Social Care, and/or Parliamentary and Health Service Ombudsman.

(Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)

  1. Where a complaint concerns more than one responsible body, they must co‑operate in handling the complaint. This includes duties to: settle who will lead the process; share relevant information; and, provide the complainant with a coordinated response. (Reg 9, Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)
  2. Regulations do not say how long a complaint investigation should take, but expect this will be determined at the start of the procedure, usually in discussion with the complainant. If the complainant does not want to discuss, the responsible body must decide the timescales itself and confirm them to the complainant in writing. During the investigation, the body must keep the complainant informed of progress ‘as far as reasonably practicable’. If the responsible body has not provided a response after six months (or, after any previously agreed longer period), it must write to the complainant to explain why. (Regs 13 and 14, Local Authority Social Services and National Health Service Complaints (England) Regulations 2009)
  3. In January 2016, Mrs C’s advocate (the advocate) sought a copy of safeguarding investigation report. The CCG referred the advocate to the Council.
  4. On 14 March 2016, the advocate made a formal complaint to the Council detailing Mrs C’s concerns about the Home, the Trust, the Council and the CQC.
  5. On 24 March 2016, the CCG told the advocate, after speaking to the Council, it would provide a response as it was better placed to do so. It would provide responses on behalf of other organisations for the issues outside its jurisdiction. The CCG also asked the advocate for Mrs C’s consent. While Mrs C provided consent, the CCG does not know when it received the consent.
  6. On 29 April 2016, the advocate asked the CCG how long its investigation would take. The advocate chased a response a week later.
  7. On 16 May 2016, the CCG apologised for its delayed response. It had issues with its IT server not receiving emails. The CCG agreed to provide an update on 20 May.
  8. The advocate chased the CCG on 7 June 2016. A week later (15 June), the CCG apologised. It said there had been changes in their department.
  9. On 24 June 2016, the advocate chased a response. Three days later, the CCG said it hoped to complete the response by the next day.
  10. The advocate chased the CCG on 30 June 2016. The next day, the CCG apologised to Mrs C for the delays. It also said:
  • It needed to liaise with several organisations which took time.
  • It referred her issues about the Home, the Council and the CQC to investigate and respond back.
  • It provided a response regarding the safeguarding alert.
  1. Four days later, the CCG told the advocate the final response would be sent to Mrs C on 8 July. It apologised for the delays.
  2. On 11 July 2016, the advocate chased the final response. The CCG said it sent the response to Mrs C.
  3. Four days later, the advocate said Mrs C had not received their response.
  4. On 19 July 2016, the CCG said the Director was not happy with the written response to Mrs C so it did not send it. It agreed to send it to Mrs C the next day in post and electronically.
  5. On 12 September 2016, Mrs C’s advocate raised further issues about the Home (to the CCG), the Partnership, the Council and the CQC.
  6. On 23 September 2016, the CCG recognised Mrs C’s complaints.
  7. On 28 September 2016, the CCG referred Mrs C’s complaints to the Home and Trust. The CCG asked them both to respond back by 17 October.
  8. On 20 October 2016, the CCG made enquiries to the CQC.
  9. On 28 November 2016, the CCG provide a final response for the Council, the Trust, the CQC, the Home and the Partnership.
  10. I consider the CCG started the complaints process on 24 March 2016 when it agreed to provide a response for the Council, Trust, CQC and Home.
  11. After 24 March 2016, the CCG took over three months to provide its first written response to Mrs C on 1 July. That response did not address the substance of Mrs C’s complaint. It only answered her safeguarding complaint. After three months I consider the CCG should have addressed more than one part of Mrs C’s complaint. During that three months, Mrs C’s advocate chased the CCG for updates. The CCG apologised twice for the delays and did not meet its deadlines.
  12. In Mrs C’s follow up response on 12 September 2016, she described her frustration at not receiving any responses to her complaints about the Home and the Trust. I understand that frustration. The CCG only asked the Home and Trust to comment on her complaints on 28 September. This was more than six months after Mrs C registered her complaints. The CCG should have sent the Home and Trust Mrs C’s complaints in March 2016 for comments. This was fault.
  13. The CCG gave the Home and the Trust until 17 October 2016 to provide its responses. The Home provided its response on 14 October, but the Trust took until 10 November. I have not seen any evidence the CCG was chasing the Trust for its response after 17 October. I consider this was fault.
  14. Overall, the CCG significantly delayed handling Mrs C’s complaint. This understandably caused Mrs C time and trouble, frustration and compounded the distress she had already suffered. The CCG needs to remedy the injustice Mrs C suffered.

The CQC

  1. In September and October 2016, Mrs C’s advocate asked why the CQC’s July 2015 and June 2016 inspection reports on the Home did not include Mrs C’s complaints about the Home.
  2. On 24 October 2016, the CQC said:
  • It confirmed receipt of Mrs C’s complaint in March 2016 and referred Mrs C to the North Somerset Safeguarding Team (NSST).
  • The NSST told the CQC it closed the safeguarding investigation in July 2015 as Mrs D was CHC funded. Therefore, an investigation would need to be carried out by the CCG.
  • The CCG told the CQC there had been no communication from Mrs C so assumed the safeguarding investigation was complete.
  • The July 2015 inspection report said the Home had failed to follow its complaints procedure.
  • The June 2016 inspection report said the Home responded timely to complaints.
  1. On 28 November 2016, the CCG provided a response for the CQC. It said the Council and the Home followed safeguarding procedures after July, so there was no need to raise the issue in its June 2016 report.

Analysis

  1. Mrs C says the CQC should have included details of her complaint in the June 2016 inspection report.
  2. The CQC told me it does not always record concerns and complaints on reports. Rather it gathers evidence from various sources to see if the provider is meeting the needs of the service users. Information from Mrs C was used to contribute to the June 2016 inspection report.
  3. I do not consider the CQC’s actions were fault. There is no need for the CQC to detail complaints in its inspection reports. I am also satisfied the CQC considered Mrs C’s comments about the Home when completing its inspection report.
  4. Mrs C also says the CQC wrongly assumed her complaint about safeguarding was closed.
  5. I do not consider it was the CQC’s responsibility to chase the Council’s investigation into Mrs C’s safeguarding concerns.

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Recommendations

  1. Within four weeks, the Home should:
  • Apologise to Mrs C for the uncertainty caused by its inconsistent record keeping of Mrs D’s fluid intake and repositioning;
  • Provide Mrs C with the evidence it sent to the CQC in January 2019 that staff understood the importance of keeping accurate position change charts.
  • Apologise to Mrs C for the distress caused by not communicating what action it took after she found an antibiotic next to Mrs D’s bed; and
  • Pay £200 to remedy the injustice Mrs C suffered.
  1. Within four weeks, the Council should:
  • Apologise to Mrs C for the distress and uncertainty caused by its flawed safeguarding investigation into Mrs D’s care and support at the Home; and
  • Pay £200 to remedy the injustice Mrs C suffered.
  1. Within eight weeks, the Council should:
  • Ensure the relevant staff are aware of the safeguarding policy and procedures to ensure similar fault does not happen to others. Specifically, staff should confirm when the threshold for a safeguarding investigation has been met and communicating the outcome.
  1. With four weeks, the CCG should:
  • Apologise to Mrs C for the time and trouble and compounding the distress she had already suffered by significant delays handling her complaint.
  • Pay £100 to remedy the injustice Mrs C suffered.

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Final decision

  1. I do not consider there was fault in the Trust’s care and treatment of Mrs D.
  2. The Home’s fluids and pressure sore care record keeping, and lack of communication with Mrs C after the incident with the tablet was fault.
  3. The Council’s safeguarding enquiry was flawed. It did not tell Mrs C her concerns met the threshold for an enquiry, involve her in the process or communicate the outcome to her.
  4. I do not consider the CQC was at fault when it did not include her complaint in one of its inspection reports. Also, it was not responsible for chasing the Council’s response to her safeguarding concerns.
  5. The CCG was at fault for the significant delays when handling Mrs C’s complaint.

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Investigator's decision on behalf of the Ombudsman

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