Summary: Ms X complained about the actions of Care Provider, Trinity Care at Home Ltd, on behalf of her late father, Mr Y. The Care Provider was not at fault for how it provided care to Mr Y. However, we found the Care Provider was at fault for poorly communicating with Ms X. It has put measures in place to prevent a recurrence of fault which is appropriate. The Care Provider will also apologise to Ms X for the distress and frustration it caused her.

The complaint

1. Ms X complained about the actions of care provider, Trinity Care at Home Ltd, on behalf of her late father, Mr Y. She said:
• a care worker caused her father to have an accident which ultimately resulted in his death; and
• the Care Provider did not properly respond to her concerns about the care and treatment her late father had received.
2. Ms X said this has caused her significant distress and upset. She wants the Care Provider to apologise to her and put in place service improvements to prevent a recurrence of fault.

Back to top

The Ombudsman’s role and powers

3. 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. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

5. 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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

7. I spoke with Ms X and considered the information she provided.
8. I considered the information the Care Provider provided.
9. I considered our new ‘Guidance on Remedies’.
10. Ms X and the Care Provider had the opportunity to comment on the draft version of this decision. I considered their comments before making a final decision.

Back to top

What I found

Legislation and guidance

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out fundamental standards of care which registered care providers must achieve. The Care Quality Commission (CQC) is the statutory regulator of care services and has guidance for care providers which they must comply with to meet the fundamental standards of care. The guidance includes:
• Regulation 16 which states where a care provider has received a complaint about its service, it must keep the complainant informed of the status of the complaint and respond without delay.
• Regulation 12 which states a care provider should use risk assessments about the health, safety and welfare of people using its service. Relevant health and safety concerns should be part of the care plan.
• Regulation 12 which states a care provider must have arrangements in place to take appropriate action in the case of an emergency. Accidents and incidents that affect the health, safety and welfare of people using its service must be reported internally and to relevant external bodies.
• Regulation 18 which states staff should receive appropriate support and training to enable them to carry out their duties they are employed to perform.

The Care Provider’s complaints policy

12. The Care Provider’s policy states upon receiving a complaint, it should respond to the complainant with the outcome of its investigation within 21 working days. If the Care Provider cannot complete its investigation within that timeframe, it will inform the complainant and provide a proposed response date.

The Care Provider’s accident and incident policy

13. The policy states when a person using the service has experienced an accident or an incident, staff should inform the office and record what has happened in the daily notes.

Background

14. Mr Y had health problems and required care and support in his home.
15. Mr Y was able to mobilise independently with the support of a walking frame, a walking stick and a stair lift. He had a low history of falls and a medium risk of tripping due to excessive furniture in his home. Mr Y required support with his personal care such as continence care in the bathroom.
16. Since June 2021, Mr Y had different care workers who lived with him. The care workers provided Mr Y with care and support he required. In October 2021, a new care worker started their role with Mr Y. The Care Worker had completed training in people moving and handling and emergency first aid.
17. The Care Worker was entitled to take two hours a day for their break. Mr Y’s care plan did not indicate the Care Worker was required to be present with Mr Y during their break time.

What happened

18. In November 2021, Mr Y had a fall in the bathroom. Ms X said the Care Worker was on their break during this time. The Care Worker heard Mr Y call for help and so attended to him. Mr Y was conscious but had pain in his leg. The Care Worker called for an ambulance and notified the office. The ambulance arrived and took Mr Y into hospital for treatment. Whilst Mr Y was in hospital, he developed pneumonia and sepsis. Mr Y died a few days after his hospital admission.
19. In mid-November 2021, Ms X contacted the Care Provider as she was concerned about what happened on the day her father had fallen. She said:
• on the day of the incident, the Care Worker recorded in the daily notes that they had taken their two-hour break between 4.30pm and 6.30pm. Ms X said the Care Worker had lied and they had taken a longer break. Ms X said she was present for some of the day and saw the Care Worker had taken their break at 4pm. She also had CCTV footage which showed the Care Worker did not return from their break until 6.40pm;
• the CCTV footage showed her father calling for help before he had gone to the bathroom. She said her father wanted support with going to the bathroom and if the Care Worker had been present, he would have received the support he needed and so would not have fallen; and
• her father’s death was being investigated by the Coroner.
20. A few days later, the Care Provider acknowledged Ms X’s complaint and said it would investigate the matter further. It asked Ms X to share the CCTV footage with it. Ms X was unable to send the Care Provider CCTV footage due to technical issues.
21. Between November 2021 and May 2022, the Coroner completed an inquest into Mr Y’s death. It concluded Mr Y died from sepsis after developing pneumonia and it was an accident.
22. Towards the end of December 2022, Ms X contacted the Care Provider again. She was unhappy as it had not responded to her concerns she had raised in November 2021. Ms X reiterated she believed the Care Provider was at fault for her father having a fall. She wanted the Care Provider to put actions in place to improve its service.
23. On the same day, the Care Provider acknowledged Ms X’s complaint. It said it required more time to investigate her complaint and would reply once it had all the information it required.
24. At the beginning of February 2023, the Care Provider responded to Ms X’s complaint. The Care Provider:
• recognised Ms X initially complained in November 2021;
• started an investigation into Ms X’s complaint in November 2021 however had to pause it due to the Coroner’s involvement and it was normal practice to do this whilst the Coroner completed its investigation. The Care Provider continued and said the Care Worker in question resigned from their post in December 2021 and so the Care Provider was not able to ask them further questions;
• was not aware the Coroner had completed its inquest until Ms X complained again; and
• did not receive the CCTV footage due to technical issues.
25. The Care Provider added, “I apologise if you feel we didn’t respond and communicate as expected and I hope this review of events explains why this was”.
26. Ms X remained unhappy and complained to us. In her complaint, Ms X sent us the CCTV footage which showed her father calling for help before he went to the bathroom.
27. In response to my enquiries, the Care Provider said it:
• recognised it had poorly communicated with Ms X;
• should have contacted the Coroner to get an update on its investigation; and
• now had a system in place where it would alert staff to action any pending investigations so that the Care Provider responds to complainants in line with its policy and the Care Provider is aware when it needs to follow up an investigation which is being conducted by an authority such as the Coroner.

Back to top

Findings

The Care Provider’s response to Ms X’s complaint

28. Ms X initially contacted the Care Provider in November 2021, following the death of her father. The Care Provider acknowledged her complaint and assured Ms X it would investigate her concerns. However, the Care Provider had to pause its investigation due to the Coroner’s involvement. It was appropriate for the Care Provider to pause its investigation whilst the Coroner completed the inquest but it failed to inform Ms X of this. This was fault. It was not in line with its policy or the CQC regulation outlined in paragraph 11 and caused Ms X distress and frustration.
29. Ms X contacted the Care Provider again in December 2022 and reiterated her concerns. The Care Provider again, acknowledged her complaint and said it would investigate her concerns. It did not respond to Ms X’s concerns within 21 working days, in line with its policy. The Care Provider should have updated Ms X with the reasons for its delay within the 21 working day response time or sooner. This was fault and caused Ms X further distress and frustration.
30. The Care Provider told us it recognised its communication with Ms X was poor and it should have contacted the Coroner for an update on the inquest. It has now put measures in place to prevent a recurrence of fault. This is appropriate. However, the Care Provider did not tell Ms X about these service improvements in its complaint response to her and it is unclear why. Its apology to Ms X was inadequate because it did not express that it acknowledged its service had been poor. This was fault and added to Ms X’s distress and frustration.

The accident

31. Ms X said the Care Worker caused her father to fall which ultimately led to his death. The Coroner’s inquest determined Mr Y’s death was caused by sepsis and pneumonia and was an accident. It did not place fault on the Care Provider.
32. Ms X said the Care Worker was on an unauthorised extended break when they should have been available to support her father. Ms X said the Care Worker lied when they took their break. Ms X provided me with CCTV footage which she said supported her claim the Care Worker was on an unauthorised extended break. The footage shows Mr Y getting up and calling for help a few minutes after 6.30pm but does not show what the Care Worker was doing at that time. The evidence therefore does not allow me to say, even on the balance of probability, whether the Care Worker was on an unauthorised extended break.
33. In addition, I reviewed:
• Mr Y’s care and support needs assessment and care plan which show the Care Provider properly considered Mr Y's mobility and associated risks;
• the Care Worker’s records which show they had completed appropriate training to deliver care to Mr Y such as supporting people to mobilise and any associated risks with it; and
• the Care Provider’s accident and incident policy which it followed when Mr Y had his fall.

These were all in line with the CQC regulations. I did not find any fault with how the Care Provider delivered care to Mr Y.

Back to top

Agreed action

34. Within one month of the final decision, the Care Provider will apologise to Ms X for the distress and frustration it caused her for poorly communicating with her. The apology will reflect what the Care Provider did wrong and how it caused an injustice to Ms X. The Care Provider will refer to our new ‘Guidance on Remedies’ on how to make an effective apology.
35. The Care Provider will provide us with evidence it has complied with the above actions.

Back to top

Final decision

36. I have now completed my investigation. The Care Provider was at fault. It has agreed to take action to remedy the injustice caused.

Back to top

Investigator's decision on behalf of the Ombudsman