Summary: Ms X complained about some aspects of care her friend, Ms Z, received at a care home. She said this caused Ms Z distress and she had to move to a different care home. The care provider has already said it was at fault when it failed to administer Ms X’s eye drops on four occasions. It has taken satisfactory steps to amend its procedures and remedy the injustice this caused.

The complaint

1. Ms X complains about the care Ms Z received at a care home between June and December 2018. In particular she complains the care home:
• failed to take the appropriate action when Ms Z complained of breathlessness;
• did not amend Ms Z’s prescription for eye drops which led to them running out. As a result, carers failed to give Ms Z her eye drops on 4 occasions in December 2018; and
• did not provide Ms X with a varied, well-balanced diet.
2. As a result, Ms X said Ms Z experienced significant distress. She was also forced to move to a new care home which caused Ms Z inconvenience.
3. Ms X would like the care provider to apologise and reimburse one month’s care fees.

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The Ombudsman’s role and powers

4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
5. In this case I have decided to exercise my discretion and consider events from June 2018 onwards. This is because Ms X states Ms Z would not complain about the events at the time because she was afraid of reprisals. And once Ms Z had moved to a new care home, she took timely action to raise her complaints.
6. 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)
7. We cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
8. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with the CQC.

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How I considered this complaint

10. I spoke to Ms X and considered her view of her complaint.
11. I made enquiries of the care provider and considered the information it provided. This included Ms Z’s care records and the complaints correspondence.
12. I wrote to Ms X and the care provider with my draft decision and considered their comments before I made my final decision.

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What I found

Ownership of the care home

13. This complaint concerns a care home which was owned by Hadrian Healthcare until July 2019 when ownership transferred to another company.
14. The events which form this complaint occurred between June and December 2018, when the care home was still owned by Hadrian Healthcare.

Background

15. Ms X was a resident at the care home for around 4½ years until she moved into a new care home on 31 January 2019.
16. On 14 February 2019, Ms X complained about Ms Z’s care. Details of these complaints are provided below.

Complaint 1 – Breathlessness

17. Ms Z had been to her doctor complaining of breathlessness. The doctor had arranged a hospital consultation for Ms Z which was due to take place on 2 July.
18. On 21 June 2018 Ms Z informed carers she felt breathless and unwell. She needed help with some of her personal care. The care home made an appointment for Ms Z to see her doctor later that morning.
19. Ms X arrived at the care home around 9.20am to take Ms Z to her doctor’s appointment. She said Ms Z told her she had needed help with her personal care because she was feeling breathless. Ms X this was out of character for Ms Z who usually was very independent. She said none of the carers saw this as a matter for concern and failed to ask Ms Z about her symptoms or to check on her.
20. Ms Z told the doctor she had been experiencing mild chest pain and problems breathing for around four hours. Ms Z was admitted to hospital and Ms X says she was diagnosed as having had a heart attack. Ms X said if staff had been more diligent, Ms Z would have been admitted to hospital four hours earlier than she was.

Complaint 2 - provision of eye drops

21. Ms Z telephoned Ms X in December 2018 to say she had not had her eye drops for four days to treat her glaucoma and macular degeneration. Ms X says the manager told her the care home had run out.
22. Ms X said the doctor had changed Ms Z’s eye drop prescription in May 2018. The new prescription only allowed for 100 doses per month whereas Ms Z needed 112 doses. Ms X said the reason Ms Z did not have her eye drops in December 2018 was because the care home had run out, despite it having had seven months to have the prescription increased.

Complaint 3 - Food at the care home

23. Ms X said Ms Z only liked to eat plain food and there were days when she did not like the choices available for the main meal. As a result, around once a week Ms Z had baked beans on toast for her main meal. Ms X said this was not a balanced diet and the care home should have provided Ms Z with options that she liked.

Response to Ms X’s complaints

24. The care provider carried out an investigation and in April 2019, it provided a response. Its findings are detailed below.

Complaint 1 - breathlessness

25. The investigator said they spoke to staff on duty on the morning of 21 June 2018 and considered the daily records. Staff confirmed that unusually Ms Z had needed help with dressing and showering that morning because she was feeling breathless. A carer stated she had spoken to Ms Z at 6am and 7am and had asked if she was feeling alright. She said Ms Z replied that she “was OK”. The investigator stated “staff were sure that [Ms Z] had her breakfast in the… dining room as she was always first in… and her absence would have been noted… whilst we are all agreed that [Ms Z] is reluctant to express any concerns, and as she said, did herself not realise that she was experiencing a heart attack or that it was anything serious, the staff’s perception was that a GP appointment was the appropriate course of action”.
26. The investigator said with hindsight, Ms Z’s behaviour in needing help with her personal care could have signified she was unwell and should have been escalated or explored further. The care provider said it would treat this as a learning exercise.

Complaint 2 – provision of eye drops

27. The investigator stated Ms Z has missed her eye drops on two occasions although the records did not support Ms X’s complaint that Ms Z had received no drops for four days in December 2018. The investigator stated staff had made some efforts to increase the prescription with the GP but these had been unsuccessful. The investigator said staff should have escalated the matter and resolved it earlier. It apologised for the distress caused to Ms Z. The investigator said they would speak to staff about Ms Z’s comments that they were dismissive when she raised concerns about her eye drops.

Complaint 3 – food at the care home

28. The investigator stated that Ms Z would request baked beans on toast because she liked them and did not like “foreign food” which was sometimes served.
29. Ms X remained unhappy and complained again to the care provider. She said she attempted to arrange a meeting with the care provider but this proved difficult. Once a date was agreed she said she told the care provider that it “needed to have a figure for compensation when [its representative] came otherwise there was no point in him coming”. The care provider cancelled on the day of the meeting because it was not prepared to offer compensation to Ms Z.

My findings

30. During my investigation, I have considered Ms Z’s care records, nutrition charts and medication administration records (MARs) for the relevant periods.

Complaint 1 - breathlessness

31. The Care Home’s daily records show staff saw Ms Z twice before Ms X arrived at 5am and 6am. A later note recorded that Ms Z had experienced pain down her arm but was “chatting” about general matters by this time Ms X arrived to take her to the doctors.
32. Ms Z did not complain of pain although she did say she was feeling unwell and was breathless. The later note said she had pain down her arm. Other than that, Ms Z simply had a general feeling of unwellness and breathlessness. She herself was unaware she had experienced a heart attack.
33. The care provider has said that on reflection, the carers should have escalated the matter. However, they did this when they made an appointment for Ms Z to see her doctor that morning.
34. In response to my first draft decision, the care home said “The arm pain was only expressed at the point whereby Ms X had arrived to take her to the GP surgery; had Ms Z appeared distressed or had staff been unduly alarmed by her presentation, then advice would have been sought from nursing colleagues. In the GP surgery they are more equipped with ECG machines and staff there able to read these”.
35. Ms Z’s symptoms were breathlessness and feeling unwell. She did not ask carers to call an ambulance. She said she had been unaware she had experienced a heart attack. She reported pain in her arm, but this was later once the doctor’s appointment had been made. Under these circumstances, the care home’s actions were proportionate. There was no fault.

Complaint 2 – provision of eye drops

36. Ms Z should have eye drops twice a day. The medication administration record (MAR) charts for December 2018 show that Ms Z missed one dose of eye drops on 13 December. On 17 December, the MAR chart showed Ms Z missed both doses and the morning dose on the 18 December. The related care notes state this was because the care home had run out of drops. This is fault.
37. During the care provider’s investigation, it acknowledged Ms Z was not administered with her eye drops on four occasions. The care provider has already admitted fault, apologised, provided an explanation of why this occurred and said it will address the matter with staff. These are satisfactory steps to have taken.

Complaint 3 – food at the care home

38. I have looked at some of Ms Z’s nutritional records. These do not indicate Ms Z was unhappy with the food she received. Furthermore, Ms Z was aware she could ask for something different if she wished. The entry for 15 March 2018 recorded “…met with [Ms Z] to discuss her thoughts on a guest survey regarding food… We agreed that anything on the new menu not liked that she is to have kitchen informed and we shall make something different”.
39. Ms X complained Ms Z would have baked beans around once a week and her diet was not balanced. I can see no evidence of this. There was no fault in the care provider’s actions.

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Final decision

40. There was fault leading to injustice. The care provider has already taken satisfactory steps to remedy the injustice this caused. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman