Summary: Mr X complained about the care and treatment his late grandmother, Ms Y, received at a Council commissioned Care Home, The Maple Care Home. The Care Home was at fault. There were errors in how the Care Home recorded information about Ms Y’s care and how it communicated information about Ms Y to other health care providers. The Council’s safeguarding investigation had identified the faults and put measures in place to improve its service. The Council will provide evidence to us the Care Home has implemented the service improvements. The Council has agreed it will also apologise to Mr X and his family and make a payment of £200 to them to acknowledge the distress and frustration the faults caused them.

The complaint

1. Mr X complained about the care and treatment his late grandmother, Ms Y, received at the Council commissioned Care Home, The Maple Care Home. He said the Care Home:
• did not properly investigate Ms Y’s complaint about the care and treatment staff had delivered to her;
• failed to record accurate and complete information about Ms Y’s care and treatment;
• failed to respond properly when Ms Y became acutely unwell and;
• did not communicate properly with the hospital when she was admitted into hospital.
2. Mr X said the matter caused him and his family significant distress. He wants the Care Home to apologise to him and his family. He also wants the Care Home to put measures in place to improve the service it provides to residents.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), 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)

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How I considered this complaint

6. I spoke with Mr X and considered the information he provided.
7. I considered the information provided by the Council.
8. Mr X and the Council had the opportunity to comment on the draft version of this decision. I considered any comments I received before making a final decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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What I found

Safeguarding Adults

10. A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

The Care Quality Commission

11. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall.
13. Regulation 12 states care providers must have arrangements in place to support people who are in transition between services and/or other providers. This is to ensure care providers share relevant information promptly with other services and/or other providers.
14. Regulation 17 sets out what care providers must do to securely maintain accurate, complete and detailed records in respect of each person using the service and the overall management of the regulated activity.

What happened

Ms Y’s complaint

15. Ms Y had been a resident of the Care Home since March 2020.
16. In January 2021, Ms Y told her family, a Care Worker had been unpleasant towards her whilst they assisted her with personal care. Ms Y was significantly upset by the matter. Ms Y’s family reported the matter to the Care Home. They did not want the Care Worker to deliver care to Ms Y again. Later on, Ms Y’s family raised a safeguarding alert with the Council.
17. A social worker investigated the alleged incident and spoke with Ms Y, her family and staff at the Care Home including the Registered Manager. As part of the safeguarding investigation, a multi-agency meeting took place with the Council, the Care Home, CQC and Ms Y’s family. The Council reviewed Care Home records such as daily notes and Ms Y’s care plan as part of the investigation. The safeguarding investigation found:
• Ms Y wanted the Care Worker in question to apply a topical treatment to an area of her body however the Care Worker had declined to do this as the topical treatment was not prescribed for that purpose.
• in addition, Ms Y had a history of having frequent infections which could have been caused by inappropriate topical treatment. The Care Home had failed to investigate this further.
• although Ms Y’s family had reported the incident to the Registered Manager on the day it happened, the Registered Manager did not address it on the same day. The Care Home had also not recorded that Ms Y’s family had called to raise their concerns.
• there was a poor relationship between Ms Y and her family and the Care Home. This was because Ms Y did not communicate with the Care Home directly about any concerns she had. Instead, she told her family.
18. After the safeguarding investigation, the Care Home agreed to the following actions:
• the Care Worker was not to deliver care to Ms Y again.
• the Registered Manager was to investigate the issue further in relation to Ms Y having frequent infections and the possibility of it being linked to topical treatment.
• the Registered Manager was to improve record keeping within the Care Home.
• the Registered Manager was to assign a key worker to Ms Y. Ms Y would be able to express any concerns she had with the Care Home or wishes she had, to the key worker. This would allow the Care Home to build a better relationship with Ms Y and her family.

Ms Y’s death

19. On 2 April 2021, Ms Y talked with her family over the telephone. Ms Y’s family believed Ms Y was unwell. She was suffering with back pain and had a cough. They contacted the Care Home and told staff Ms Y was unwell. Ms Y’s family said in response, staff said Ms Y appeared to be fine and she was coughing due to having liquid medication.
20. On 3 April 2021, staff observed Ms Y’s health had declined. The Care Home called for an ambulance. Ms Y was then taken into hospital in the evening. The following morning, the hospital staff discharged Ms Y back to the Care Home. At the Care Home, staff observed Ms Y’s condition had worsened. They called for an ambulance again. Ms Y was admitted into hospital where she died on 4 April 2021. However, the Care Home was not aware Ms Y had died and called Ms Y’s family on 7 April 2021 to discuss Ms Y’s condition. This caused significant distress to Ms Y’s family.
21. The Council and Ms Y’s family were concerned the Care Home had delayed seeking medical attention when Ms Y was unwell on 2 April 2021. The Council therefore investigated the matter under the current safeguarding investigation. The Council also wanted to investigate why the Care Home had called Ms Y’s family after she had died.
22. As part of the safeguarding investigation, the Council reviewed Ms Y’s observation records such as blood pressure and temperature records. It also reviewed Ms Y’s repositioning charts and Ms Y’s daily notes approximately a week before Ms Y was unwell until Ms Y was admitted into hospital on the second occasion. The Council, with other agencies such as the hospital and the paramedics, conducted multiple meetings with the Care Provider to establish what had happened. During this time, the Care Home had a new Registered Manager who also took part in the investigation.
23. The safeguarding investigation found:
• on 31 March 2021, Ms Y became unwell. Staff at the Care Home took Ms Y’s blood and urine for testing. The outcome of the tests was unknown at the time however, staff observed there was blood present in the urine sample. The Care Home did not inform the paramedics or the hospital of this. Furthermore, the Care Home did not share any other current observations of Ms Y with the paramedics or the hospital.
• although Ms Y’s family contacted the Care Home on 2 April 2021 and informed staff Ms Y appeared to be unwell, staff failed to document the call.
• the Care Home explained why it had called Ms Y’s family after she had died. The Care Home was not aware Ms Y had died. It said it contacted the hospital on 7 April 2021 to enquire about Ms Y’s condition. The hospital told the Care Home Ms Y was currently being treated for a severe condition in her abdomen. However, the Care Home did not make a record of the discussion it had with the hospital. As there was no record, the Council was unable to investigate this further.
• the Care Home was unable to provide a detailed chronology of what had happened due to poor record keeping. Information was inaccurate, missing and it was not presented in a chronological order. For example, the Care Home’s notes in relation to when it requested medical intervention from paramedics, did not correspond to the ambulance service’s records.
• the Care Home’s records stated staff repositioned Ms Y in her bed during the night of 3 April 2021. However, Ms Y’s family said Ms Y was still at the hospital during that time. The Care Home could not establish when Ms Y returned to the Care Home due to poor record keeping. The Council was unable to investigate this further.
24. During the safeguarding investigation, it was discussed that the new Registered Manager was to deliver training to staff in relation to good record keeping. In addition to this, the Registered Manager said the Care Home had a new system in place for record keeping which would improve how care workers updated records. The Council was to continue monitoring the Care Home’s record keeping to establish any improvement.
25. Following the safeguarding investigation, the Council shared lessons learned with the Care Home in relation to it properly communicating with hospitals. It recognised the Care Home did not have a proper system in place to ensure important information was shared with hospitals during admission of a resident. It told the Care Home in such cases it must share with hospitals: current symptoms and observations of a resident, their medical history, any assessments it had conducted with the resident and any recommendations the Care Home may have.
26. The Council was satisfied its safeguarding investigation had identified areas of improvement for the Care Home to action.
27. Mr X remained unhappy and complained to us.

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Findings

28. Ms Y’s complaint and what happened around Ms Y’s death, were both looked into via the Council’s safeguarding investigation. I am satisfied the Council properly investigated the safeguarding concerns. The safeguarding investigation highlighted faults in the Care Home’s record keeping. During the investigation, the Council discussed with the Care Home that it needed to improve its record keeping. The Care Home said it would do this by:
• delivering training to staff in relation to robust record keeping and;
• implementing a new system.
29. The Council said it would monitor any improvements the Care Home had made. I am satisfied these actions addressed the faults identified however, I have seen no evidence the Care Home has actioned them.
30. The safeguarding investigation also highlighted the Care Home did not properly communicate with the ambulance service or hospital. Following the safeguarding investigation, the Council shared lessons learned from the incident with the Care Home and what it needed to do to improve its communication with other healthcare providers. I am satisfied with the Council’s actions and that it addressed the fault identified.
31. As Ms Y has died, I cannot provide a remedy for any injustice these faults caused to her. However, the faults have left Mr X and the family with a sense of uncertainty over whether Ms Y was properly cared for and caused them distress and frustration.

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Agreed action

32. When a council commissions another organisation to provide services on its behalf, it remains responsible for those services and for the actions of the organisation providing them. So, although I have found fault with the actions/service of the Care Provider, I have made recommendations to the Council.
33. Within one month of the final decision, the Council has agreed it will:
• apologise to Mr X and his family for the distress and frustration the matter caused them and;
• make a symbolic payment of £200 to them, to acknowledge the distress, frustration and uncertainty caused by the faults identified.
34. Within one month of the final decision, the Council has also agreed it will provide us with evidence that the Care Provider has:
• delivered training to staff in relation to robust record keeping and;
• has implemented a new system which has improved record keeping at the Care Home.

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Final decision

I have now completed my investigation. The Council’s commissioned Care Home was at fault which caused an injustice. The Council has agreed to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman