Summary: We have completed our investigation and found Miss X suffered injustice due to fault in the way the Care Home handled her complaint about the quality of care provided to her father, Mr Z, and its communication with her. But we did not find fault with the standard of care it provided to Mr Z.

The complaint

1. Miss X made this complaint on behalf of her late father, Mr Z, and in her own right.
2. She complained that Ferndene Care Home did not keep her properly informed and involved about matters relating to her father’s care. She also complained that it failed to provide her father with an adequate standard of care. She alleged he was neglected, harassed and not treated with dignity and respect by the former home manager.
3. Miss X said this caused her distress and inconvenience. She lives a long way from the Care Home. As she lacked confidence in the Care Home management, she says she visited her father more frequently to check his care needs were being met. This caused her some additional expense, disruption and inconvenience. It also reduced the time she had available to be with her partner while he was undergoing medical treatment.
4. Mr Z passed away in October 2019. Miss X accepts it is now too late to provide a personal remedy for him. But she wants the Care Home to recognise the impact on her, improve its service and ensure it uses existing procedures to investigate concerns raised by relatives in a timely and appropriate way.

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The Ombudsman’s role and powers

5. 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)

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. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

8. I have considered notes made by a colleague who discussed the complaint with Miss X.
9. I considered the Care Home’s response to our enquiries and the records it sent me.
10. Miss X and the Care Home had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

The background to this complaint

11. Ferndene Care Home (“the Care Home”) is a residential care home which provides nursing and personal care for adults.
12. Mr Z was in his eighties when he was admitted to the Care Home on a self‑funding basis in late April 2019. He had been discharged from hospital following a stroke which left him with impaired speech and communication skills. A speech and language therapist visited Mr Z in the care home for six weeks following his hospital discharge, along with other health professionals, as part of his rehabilitation programme. Mr Z used gestures and visual speech cards to help him communicate. Mr Z’s wife was also a resident in the Care Home and staff knew Mr Z as he visited her daily.

13. Mr Z was a residential client who needed some care and treatment from district nurses. As well as recovering from a stroke, he had many other pre-existing medical conditions. He had a urinary catheter and a colostomy bag.

14. A doctor assessed Mr Z’s mental capacity in May 2019 when the Care Home applied to the Council for a Deprivation of Liberty Safeguards authorisation. The doctor found Mr Z was aware of his care needs and knew he needed 24 hour care and support. The assessment confirmed he had capacity to make decisions about his place of residence. He had expressed a wish to stay in the Care Home where his wife was also a resident.

15. Miss X had registered with the Office of the Public Guardian as Mr Z’s attorney for health and welfare in 2016. A Lasting Power of Attorney only comes into effect when the donor (in this case Mr Z) no longer has capacity to make decisions. Mr Z was assessed as having capacity when he was a resident in the Care Home.

16. Mr Z was admitted to hospital four times in the six months he stayed in the Care Home. Miss X believes these admissions were a direct consequence of shortcomings in his care, specifically in relation to his nutritional needs. Sadly, Mr Z passed away in hospital in mid-October 2019.

Mr Z’s Care Plan

17. Mr Z’s Care Plan was created on 6 May 2019. It was reviewed on 16 October 2019.
18. The Care Plan states that Mr Z had no cognitive impairment and he could understand others. His speech was slurred and he sometimes struggled to find the right words but he could express and communicate his wishes.
19. The Care Plan recorded Mr Z needed support from staff with:
• Dressing and undressing;
• Transferring to a bath;
• Maintaining adequate nourishment and hydration – staff needed to encourage him to maintain his fluid intake, help cut up his food, and prompt him to eat;
• Managing his catheter and stoma care during the day and night.
20. It said Mr Z’s weight would be monitored weekly and recorded in the Weight Chart.

Miss X’s request for information about Mr Z’s care

21. In mid-May 2019 Miss X asked the care home to send her regular information about her father’s care. She requested details of his food and fluid intake, activities of daily living, bowel and bladder management, weight, treatment plans, and medication.
22. A senior manager, Ms A, discussed this request with Mr Z. According to the Care Home’s records, he said he did not understand why his daughter needed this information. He also expressed concern about the extra work it would create for staff.  Ms A reassured him about that. Mr Z gave consent for the Care Home to share this information with Miss X.
23. The Operations Manager was visiting the Care Home and met Miss X. She says she felt they had agreed on the information that would be sent at weekly intervals. However Miss X was concerned by the quality of the first set of records she received so she then asked for daily updates for an interim period. The Care Home said Miss X also requested information from other members of the staff team.
24. Miss X scrutinised the records she received and sent emails with several detailed observations and queries which she feels were not adequately addressed.
25. Miss X sometimes complained that staff did not send her comprehensive information at the agreed intervals. A manager from the Regional Office later assumed responsibility for communicating with Miss X and forwarding relevant information to her on a daily basis.  Miss X says she did not always receive the agreed information, or it was inaccurate or did not address her concerns.

Analysis

26. Miss X lives a long way from the Care Home so she could not visit her father every week to check on his welfare. Understandably she wanted to reassure herself he was safe and being properly cared for.
27. The Care Home initially agreed to provide Miss X with care records and charts on a weekly basis. Miss X expressed concern about the quality and accuracy of these records and asked for daily updates. The Care Home agreed to this request. However this went above and beyond what we would usually expect a care home to do when it communicates and shares information with a close relative. We are therefore unlikely to find fault and criticise the Care Home when it sometimes fell short of this exceptionally high standard. The Care Home may wish to reflect on the way it responded to Miss X’s request and consider whether to make more realistic and achievable commitments to relatives in the future.

The standard of care provided to Mr Z

28. The Care Home sent us the daily care records. We decided not to share these records with Miss X because:
• They are Mr Z’s personal information; and
• Miss X did not have authority to act as his personal representative when Mr Z was a resident in the care home. The Power of Attorney for health and welfare was not active then because Mr Z had been assessed as having capacity to make decisions by the doctor who assessed him.
29. I did not review Mr Z’s care records for the entire six months he was a resident in the care home. We do not explore someone’s subjective experience or personal journey, or carry out ‘reviews’ to establish the story of events. We investigate – by establishing a clear statement of complaint, then focussing on objective benchmarks to make an assessment of whether there are any gaps between what happened and what should have happened. I therefore focused on what happened in the week leading up to each of Mr Z’s hospital admissions.
30. The records show a care assistant called the NHS advice line to report that Mr Z was vomiting and had high blood pressure in the early morning in mid-July. She was told someone would call back. She telephoned 999 a few hours later when she checked on Mr Z and found he had vomited a brown grainy substance. .An ambulance took Mr Z to hospital. A care assistant telephoned Miss X to inform her at lunchtime. Miss X visited her father while he was in hospital. He was discharged six days later with a diagnosis of suspected viral gastroenteritis. The discharge report says there were no issues with his stoma and the vomiting had resolved spontaneously.

31. On 18 August the care assistant called the NHS advice line again because Mr Z had similar symptoms. An ambulance attended and Mr Z was readmitted to hospital. The hospital admission records refer to a reduced output from his stoma and his history of bowel obstructions. A care assistant called Miss X to inform her.

32. Mr Z was admitted to hospital twice in October 2019 with a suspected bowel obstruction. He had stomach pain, a distended abdomen and vomiting. A nurse practitioner visited Mr Z at the home. She suspected one of his medications might have adversely affected his bowel so she arranged for him to be taken by ambulance to hospital. Mr Z was discharged a week later but was readmitted on 11 October. He died in hospital five days later.

33. The Care Home’s records show a steady deterioration in Mr Z’s health between July and October 2019. The bowel charts show that staff regularly emptied and changed his stoma bag and observed he had loose bowel movements. The Care Home made a referral to a dietician due to observed weight loss. Mr Z’s catheter sometimes blocked and overflowed. The Care Home requested visits by the District Nurses to deal with the catheter issues and informed his GP. It also took further action when the District Nurses did not visit promptly to attend to Mr Z’s needs. The evidence we have seen does not lead us to conclude that Mr Z’s hospital admissions were caused by failings by the Care Home. It is important to take into account that Mr Z was an elderly man who was in failing health with several complex underlying health conditions.

34. I have seen evidence that the care home manager sent a statutory notification to the Care Quality Commission and reported a safeguarding incident to the County Council in late July 2019. This incident related to alleged neglect by district nurses who did not respond to the care home’s request to attend to deal with an issue relating to Mr Z’s catheter.
35. The care home manager also made a referral to the Adult Safeguarding team at the County Council in early September 2019. She reported that a member of the Care Home’s nursing staff had instructed a care assistant to perform an invasive procedure to deal with Mr Z’s blocked catheter. This procedure should only have been carried out by a qualified nurse.

Analysis

36. It would not be proportionate for us to conduct an in-depth investigation of the care Mr Z received for the entire six months he was a resident in the Care Home. He was assessed as having capacity to make decisions about his health and welfare throughout his time. Although Miss X had Power of Attorney for his health and welfare it was not active. The records we have seen do not indicate that Mr Z raised concerns about the quality of his care with the Care Home or that he had authorised Miss X to make a complaint to the Care Home on his behalf. The fact that we regard Miss X as a suitable person to act on behalf of her father after he passed away does not override these considerations about his circumstances at the time.

37. The records also show that Care Home staff sought appropriate medical advice when Mr Z’s health deteriorated prior to his hospital admissions in July, August and October 2019. They also informed Miss X of these developments.

38. The safeguarding referral the Care Home made in September 2019 show it was open and transparent in reporting an incident which involved failings by its staff in relation to Mr Z’s catheter care. It complied with the duty of candour by reporting incidents of alleged abuse and neglect to the statutory authorities for investigation.

Complaint-handling

The Care Home’s complaints procedure

39. The Care Home sent us a leaflet dated April 2019 which gave residents and relatives information about its complaints procedure. It says the person should speak to the named nurse or key worker first who will try to resolve the complaint. If they are not satisfied with the outcome, they should approach the manager to make a formal complaint. The complaint will then be logged in the formal Complaints Register and investigated.
40. If the person remains dissatisfied, they are advised to speak to the Regional or Quality Manager or contact the Operations Manager or Director at Head Office.
41. The leaflet says the person is entitled at any stage to register a complaint with the local authority or Care Quality Commission (CQC) as the regulator. It does not mention the right to complain to the Ombudsman.

What happened

42. When she complained to us, Miss X said she had complained to the Care Home in April 2019 but received no response. That complaint would pre-date some of the issues she later raised in her complaint to us.
43. We contacted the Care Home at an early stage to ask if it had considered Miss X’s complaint at the final stage of its complaints procedure. As it did not respond to our enquiry, we decided to investigate the complaint.
44. The Care Home later sent us records of extensive email correspondence between Miss X, the Care Home manager, and other managers over several months. In May 2019 Miss X asked the Care Home manager for a copy of the complaints procedure.
45. Managers engaged with Miss X to respond to the concerns raised in her emails. The Regional Manager later became the named point of contact for Miss X as a way of managing the volume of enquiries and correspondence.
46. In June and August 2019 Miss X raised her concerns with the County Council. In September 2019 it invited Miss X to a resolution meeting to discuss her concerns about the care provided to her father. A contract manager from the County Council chaired the meeting. However, the Care Home could not find any minutes of this meeting or a note of the agreed outcomes. A further meeting was due to be arranged but that did not take place because Mr Z passed away.
47. The Care Home does not seem to have registered Miss X’s expressions of dissatisfaction as a formal complaint in its Complaints Register. Instead, it dealt with her concerns on an informal basis by replying to individual emails and arranging meetings with her.

Analysis

48. Over several months Miss X sent a series of emails to managers expressing concerns about the quality of Mr Z’s care and the Care Home’s communication with her. Although staff replied to emails and met Miss X, it was fault not to follow its complaints procedure by treating this as a formal complaint, logging it in the Complaints Register and dealing with it under the complaints procedure.
49. It was also at fault for not keeping a record of the complaint resolution meeting and not including information in the complaints leaflet about the right to escalate complaints to the Ombudsman.

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Agreed action

50. Within one month of my final decision the Care Provider will:
• apologise in writing to Miss X for not treating her communications as a formal complaint and sending a comprehensive final response which signposted her to the Ombudsman;
• review the information in its current complaints leaflet and confirm that it correctly signposts residents and relatives to the Ombudsman if they are not satisfied with its final response to a complaint;
• remind staff to log complaints in the Complaints Register.

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Final decision

51. I have completed the investigation and found Miss X suffered injustice due to the way the Care Home handled her complaints. She was frustrated not to receive a comprehensive final response.
52. I did not find the Care Home’s actions caused injustice to Miss X in relation to the other aspects of her complaint.

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Investigator's decision on behalf of the Ombudsman