Summary: Miss X complains about the quality of services her grandparents received at Richmond Village Letcombe Regis (the Care Home) and the visiting arrangements. The Care Provider accepts the quality of services was poor. It needs to take action to remedy the injustice this caused to her grandparents and to Miss X, and to deliver sustained improvements at the Care Home.

The complaint

1. The complainant, whom I shall refer to as Miss X, complains about the quality of services her grandparents received at the Care Home and the visiting arrangements. She says her grandparents suffered poor service for a long time and she had to keep complaining about the same issue.

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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 an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Miss X
• discussed the complaint with Miss X;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Miss X and the Care Provider, and taken account of the comments received before issuing my final decision.

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What I found

Key facts

6. Miss X’s grandparents, Mr and Mrs Y, lived at the Care Home, which is run by Richmond Care Villages Holdings Limited (the Care Provider), until they moved to another care home in May 2021. Miss X started raising concerns about the quality of services from July 2020.
7. When the Care Provider responded to Miss X’s complaint at stage two of its complaints procedure in March 2021, it said:
• it apologised for the distress caused and the fact Miss X had to raise the same issues repeatedly;
• it accepted communication over issues such as COVID-19 measures, outbreaks, quarantine procedures, visiting arrangements had not been at the level expected;
• it had intended to send two-weekly updates but sent them monthly;
• a key worker had been away from work and no one picked up communication in their absence;
• it would update families on new COVID-19 cases and provide more regular communication when it had recruited more administrative support;
• it apologised that Miss X had to ask three times for the complaints procedure;
• when Miss X raised concerns about not refilling water jugs, it made changes to ensure this did not happen, which had been successful;
• it accepted the need to improve further the quality of food and the meal service;
• residents should raise concerns at the time so staff could take immediate action;
• it had bought more suitable containers to transport food from the kitchen to improve food temperature and apologised for the delay in doing this;
• it had appointed a new Head Chef who would discuss food preferences with Mr and Mrs Y;
• the Head of Care would have monthly meetings with Mr and Mrs Y to discuss any concerns;
• staff would also check after each meal if residents were content, so they could resolve problems straight away;
• staff would receive refresher training on the Mental Capacity Act;
• it would gather information on residents’ hobbies and interests to better tailor activities to suit them;
• it was looking to make more use of social media, subject to residents providing consent, as a way of sharing information with families;
• it accepted the Care Home had not fully implemented the visiting procedure in August 2020;
• it was now carrying out COVID-19 lateral flow tests in the library and cleaning regularly so as not to affect the frequency of indoor and outdoor “pod” visits;
• it apologised for not explaining the decrease in visits, which was due to new admissions in 2021 and the impact on staffing from COVID-19; and
• it was working to improve staff morale.
8. Miss X raised further concerns with the Care Provider, which it responded to in May 2021 saying:
• it had failed to communicate consistently or follow-up after meetings;
• it apologised for taking too long to rectify the problem of cold food, but it had now done this;
• there was no excuse for not offering Mr and Mrs Y choice over their food, or for bringing them food they had not asked for;
• it would visit the Care Home to make sure it was seeking feedback from residents on their food experience;
• it had raised the quality of meat with its supplier;
• it had reminded staff that compliance with infection protection and control was mandatory and it would check compliance;
• it would audit compliance with the water jug system to make sure it was being followed and, if necessary, provide further training;
• rather than quarantine an Easter egg, staff had removed the packaging so Mr and Mrs Y could eat it;
• the last time a member of the Care Home staff had tested positive for COVID‑19 had been in December 2020; and
• there had been a delay rectifying a problem with the heating pipes at the Care Home, which affected the water temperature, but the major project to rectify this had now started.
9. Mr & Mrs Y moved to another care home on 17 May.
10. Miss X says:
• her grandparents’ food was cold for three months;
• the water in the bathrooms was cold for three weeks; and
• the Care Provider blamed the quality of the food on its suppliers, but the real problem was with food preparation.

Did the care provider’s actions cause injustice?

11. There is no dispute over the fact that:
• food was delivered cold for a significant period of time;
• the quality of the food was not adequate;
• there were problems with hot water which took weeks to resolve;
• communication was poor, which meant Miss X and her parents kept raising the same issues without them being resolved; and
• there was a delay in implementing visitor arrangements in August 2020;.
12. These faults will have caused injustice to Mr & Mrs Y, who did not receive the quality of service they were entitled to expect, including poor food and lack of hot water.
13. The Care Provider’s agreed actions in its complaint responses to Miss X do not fully remedy the injustice caused to Mr and Mrs Y, or to Miss X. I have therefore recommended additional actions and timescales for compliance that more fully remedy outstanding injustice and prevent reoccurrence of the identified faults affecting others.

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Recommended action

14. I recommended the Care Provider:
• within four weeks, writes to Mr & Mrs Y apologising for the lack of service and pays them £250 each for the distress this caused
• within four weeks, writes to Miss X apologising and pays her £150 for the time and trouble she has been put to in pursuing the complaint on behalf of her grandparents;
• within eight weeks produces an action plan identifying the action being taken to deliver sustained improvements in food quality and communications with residents and their families.

The Care Provider has agreed to do this.

15. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I am sending it a copy of this statement.

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Final decision

16. I have completed my investigation on the basis that the Care Provider will take action to remedy the injustice it has caused and deliver sustained improvements at the Care Home.

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Investigator's decision on behalf of the Ombudsman