Summary: The Care Provider failed to identify some upheld points of complaint as poor care. It also failed to properly acknowledge Ms X’s distress.

The complaint

1. Ms X complains about the care provided to her late mother, Mrs Y, in a residential care home.

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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. 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)
3. 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

4. I have:

• considered the complaint and discussed it with Ms X;
• considered the correspondence between Ms X and the Care Provider, including the Care Provider’s response to his complaint;
• considered the Care Provider’s complaint investigation report dated 24 January 2022;
• taken account of relevant legislation;
• offered Ms X and the Care Provider an opportunity to comment on a draft of this statement, and considered the comments made.

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What I found

Relevant legislation

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
6. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
7. Regulation 9 Person Centred Care says Care Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs.

Key facts

8. Mrs Y was in her eighties. She had been resident in Highfield Residential Care Home (the Care Provider) since January 2021. She sadly passed away in hospital in November 2021.
9. During Mrs Y’s stay Ms X raised numerous concerns about various issues relating to Mrs Y’s care. She says she received varying and often conflicting responses depending on who she spoke to. She says there were frequent changes of staff and that the deputy manager told her a replacement manager left after one day.
10. Ms X says this caused her concern, but she tried to retain a positive relationship with all care staff because they were caring for Mrs Y
11. Following Mrs Y death, Ms X submitted a formal complaint to the Care Provider with 24 points of complaint. For example, she complained about poor communication from care staff, that Ms X had medication in her handbag, that she was often wearing someone else’s clothes, her own clothes were lost, gifts from family were lost and after Mrs Y’s death someone else’s clothes were returned to her (Ms X)
12. The Care Provider conducted a formal investigation. I have had sight of the investigation report dated 24 January 2022. The investigating officer said she found it unacceptable that Mrs Y had medication in her handbag, and that the company had recorded this as a ‘near miss incident’. The officer apologised that:

• Mrs Y had worn someone else’s clothes
• there had been poor communication from care staff when Ms X had telephoned the care home to enquire about Mrs Y’s wellbeing,
• a wheelchair loaned to Mrs Y was dirty
• there had been a lack of communication about reordering of medication

13. The officer said there had been a lot of changes at the care home in a short period of time, including the regional manager, home manager and multiple care changes of care staff. She said the care home now had a stable management structure that it was on the right track and improvements were made as necessary.
14. The officer concluded “there was some areas of neglect towards mum’s personal belongings, there have been no areas of neglect with regards to mum’s care and seeking medical attention”.
15. Ms X received a formal response to her complaint on 24 January 2022. The author attached her report and summarised her findings. She said she had found no evidence of neglect in relation to the care Mrs Y received but said she had found ‘omission’ regarding the care of Mrs Y’s personal belongings. She offered Ms X £250 as a gesture of goodwill for the loss and destruction of Mrs Y’s property.
16. Ms X was dissatisfied with the findings and wrote to the Care Provider addressing the points on which she disagreed and the reasons why. The Care Provider responded in February 2022. The author of the letter concurred with the initial investigation findings and said there was no evidence to show the care provided to Mrs Y had been neglectful. She acknowledged that Mrs Y’s belongings had not been dealt with respectfully and reiterated the offer of £250 as a gesture of goodwill.
17. Ms X says the Care Provider failed to fully acknowledge its failings and failed to acknowledge her distress. She would also like assurances the company has learnt from the ‘mistakes’.

Analysis

18. People have a right to expect safe, effective, and appropriate care that meets their needs.
19. In this case, by the Care Provider’s own admission, some of the care provided to Mrs Y fell short of what is acceptable. It acknowledged a near miss incident in relation to Mrs Y having medication in her possession. It is by good luck, not good management that no harm came to Mrs Y, or indeed any other resident with whom she may have shared the medication. It is not acceptable for people to be wearing someone else’s clothes, and for their personal belongings to be lost. This is evidence of poor care and fault by the Care Provider.
20. The Care Provider’s investigation report is somewhat contradictory, in that it acknowledges the above issues but concludes there was no evidence to support what it terms neglect. Whilst it may not constitute neglect it is evidence of poor care.
21. Sadly, Mrs Y has died, so it is not possible to provide a remedy. Where a person has died we will not normally seek a substantive remedy in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment that would enrich a person’s estate.
22. However, Ms X has also suffered an injustice. She has suffered stress and distress at the events involving Mrs Y but also in raising complaints about this at a time she was grieving the loss of Mrs Y. It must have been incredibly distressing for Ms X to receive someone else’s belongings after Mrs Y’s death. This compounded her grief and sense of injustice.
23. Both complaint responses from the Care Provider failed to correctly identify some upheld points of complaint as poor care, and failed to properly acknowledge the distress caused to Mrs X.

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Agreed action

24. The Care Provider will, within four weeks of the final decision:

• provide Ms X with a sincere written apology for the failings highlighted above;
• pay her £500 to acknowledge her distress, and her time and trouble pursuing the complaint with the Care Provider and the Ombudsman;
• reiterate its offer of £250 to acknowledge the loss of Mrs Y’s personal items;
• provide evidence of the above to this office.

25. The Care Provider has provided evidence of the action taken in response to the lessons learnt from this complaint.

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Final decision

26. The Care Provider failed to correctly identify some upheld points of complaint as poor care. It also failed to properly acknowledge Ms X’s distress.
27. The above recommendations are a suitable way to settle the complaint.
28. It is on this basis; the complaint will be closed.
29. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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Investigator's decision on behalf of the Ombudsman