Summary: there was no fault in the care provided by Saint Jude Residential Care Home Limited to the complainant’s mother or in its consideration of, or planning for, her care needs. However, its handling of Ms B’s complaint did not comply with its own policy on this and amounts to fault that caused Ms B injustice in the form of avoidable frustration. The Home will take the recommended action to recognise this and ensure it does not happen again in future

The complaint

1. The complainant, whom I shall refer to as Ms B, complains about the care and service her mother, whom I shall refer to as Ms Y, received from Saint Jude Residential Care Home Limited between December 2021 and January 2022. Specifically, she complains it failed to:

1. provide adequate care and this failure resulted in Ms Y falling out of bed and later being admitted to hospital as a result of an infected pressure sore;
2. have a care plan detailing what Ms Y’s care needs were and how these would be met; and
3. respond to concerns expressed by Ms B or communicate properly with her.

2. The injustice Ms B describes is distress both for her and her mother.

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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. (Local Government Act 1974, sections 34B and 34C)
4. 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

5. I considered the information Ms B provided with her complaint and discussed the complaint with her. I made written enquiries of Saint Jude Residential Care Home Limited and considered all the information before reaching a draft decision on the complaint.
6. Ms B and the care provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
7. 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 CQC.

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What I found

What should have happened

8. We can investigate complaints about actions by adult social care providers that can be regulated by the Care Quality Commission. Such activities include giving personal care or other practical support in the place where the person lives.
9. The law defines ‘personal care and other practical support’ as ‘physical assistance (or prompting and assistance) given to a person in connection with:

• eating or drinking (including giving nutrition other than by mouth or alimentary canal);
• toileting (including in relation to menstruation);
• washing or bathing;
• dressing;
• oral care; or
• the care of skin, hair and nails (except for nail care provided by a chiropodist or podiatrist)’.

(Health and Social Care Act 2008 (Regulated Activities) Regulations 2010)

10. Saint Jude Residential Care Home Limited has a Fall Management Policy and Procedure. This is dated October 2022 and states that where a member of staff finds a resident has fallen, whether or not this has been witnessed, they should:
• determine whether or not the matter needs to be handled by a senior member of staff;
• if emergency treatment is required follow its local procedures for this;
• if no serious injuries are discovered and the resident appears unaffected, document the incident, either call the GP or 111 if out of hours, use the local moving and handling policy if necessary, monitor the resident completing observations, a visual assessment and record this; and
• where a minor injury is sustained (this includes bruising, minor wounds to skin, slight discomfort) staff should administer first aid, observe for 72 hours, complete a body map, inform relatives and the resident’s GP. For a major injury such as loss of consciousness or head trauma, bleeding or extensive bruising, the resident should not be moved and an ambulance called.
11. Saint Jude Residential Care Home Limited also has a complaints policy statement. This states it welcomes complaints and see them as an opportunity to learn and improve services. The process is that the resident or relative or visitor should first discuss the complaint with the person in charge. If this does not resolve the complaint or they consider the matter or the issue is more serious the complainant can record their complaint in the Complaints Register which they can obtain from the person in charge. The policy says that a full investigation will be conducted and an outcome provided in 28 days. It says that if the complainant remains unhappy at the end of that process the complainant may complain to the local Council’s safeguarding team.

What happened

Background

12. Ms Y moved into Saint Jude Residential Care Home Limited (St Jude’s) in mid- December 2021. Ms B provided St Jude’s with information about the care she had been providing to Ms Y before Ms Y moved there. This included information about Ms Y’s medication, daily care, and aids and adaptations she used for day to day living.
13. Ms Y was in her 90s and had been diagnosed with heart failure and dementia.

Events related to this complaint

14. A senior member of St Jude’s (whom I shall refer to as D) confirms they completed a pre-admission assessment and a care plan for Ms Y in early December 2021. This took place at Ms Y’s home. D says Ms B was present for this meeting.
15. D says that on the day Ms Y moved into the home care in mid-December (a Thursday) staff completed the admission and care planning process. This included producing a “body map” for Ms Y which noted she had a pressure sore on her lower back and “discoloured legs”. The manager says the pressure sore was notified to the safeguarding team: I assume this is its usual process when a new resident moves in with an existing condition such as a pressure sore.
16. D says the paperwork completed before and during the time of Ms Y’s time at St Jude’s included the pre-admission assessment care plan , the body map, a personal hygiene plan, nutrition and hydration care plan, medication care plan, falls risk a personal care chart and daily notes.
17. The day after Ms Y moved into the home (Friday) she fell out of bed during the night. This was not witnessed by any member of staff. Staff at St Jude’s completed the relevant accident form. A copy of this has been provided to me as evidence and is referred to below. The accident form confirms that staff called an ambulance on 999 and that a paramedic attended and checked Ms Y concluding she was fine to stay at the home.
18. St Jude’s say that the Frailty Team (which I understand is a health service provision) visited Ms Y on Sunday. St Jude’s say that this team advised that Ms Y should go to hospital for a head scan and says the home arranged this the same day. When undertaken this scan did not show any concerns and Ms Y returned to St Jude’s the following day (Monday).
19. St Jude’s say that the manager of the home, together with D, Ms B and another relative had a meeting on the same Monday. Email correspondence between Ms B and St Jude’s around this time shows that Ms B expressed a number of concerns about care being provided to Ms Y including:
• staff were not elevating Ms Y’s legs when she was sitting and this was needed due to her heart condition;
• some of her clothes were missing;
• when in bed Ms Y’s feet needed to be raised (due to her heart condition); and
• there were clothes in the wardrobe that did not belong to Ms Y.
20. D provided a response and also points out that these issues were discussed in the meeting on 20 December.
21. St Jude’s say that district nurses were visiting Ms Y daily during her time at St Jude’s to treat the pressure sore on her lower back.
22. St Jude’s confirm that Ms B asked to see an alternative room for Ms Y in January as it had a lower bed and space for a crash mat to be placed next to it. The home agreed.
23. In mid-January Ms Y was admitted to hospital due to the deterioration of the pressure sore. Ms Y did not return to St Jude’s and passed away in hospital in early February.
24. During the period that Ms Y was in St Jude’s Ms B was in frequent contact with staff in the home. She was clearly visiting her mother there daily and also frequently emailed the home with queries about the care being provided to Ms Y and other matters related to her mother’s stay there. Based on the evidence I have seen of these communications care home staff did provide responses to these emails.

Evidence provided

25. The pre-admission assessment and care planning documents noted that:
• Ms Y was moving the home as a result of frailty and dementia;
• she would require a hospital bed;
• she was diagnosed with dementia, deteriorating physical health and mobility and had a pressure sore on her lower back;
• the body map completed on admission notes the pressure sore at the bottom of Ms Y’s back stating the district nurse was already involved with treating this;
• personal needs were assessed to include “regular pressure relief and overlay mattress” (related to pressure sore), need of support by staff when weight-bearing, short-term memory problems but was able to communicate; required help with dressing and undressing; and
• St Judes staff contacted Ms Y’s doctor on the day she was admitted to advise of her admittance and to request her medical history and details of medications and prescription.
26. D has also provided the following evidence from its records in response to my enquiries:
• an accident record dated the day Ms Y had her fall. The record notes a staff member found Ms Y at midnight and states “…the falls alarm was going and I went up and she (Ms Y) laying on the floor next to the bed…possibly rolled out of bed. Paramedics checked over skin tear to left arm and small tear to left cheek”. The note was dated two days after Ms Y moved in – Saturday. Other records confirm that staff called an ambulance using the 999 service, that a paramedic checked Ms Y and decided she was fine to stay at St Jude’s;
• the notes of the manager’s review of the accident also confirmed that Ms Y’s family was told of the fall the following day, that the district nurse recommended a lower bed and that the care home could not provide bed rails as Ms Y did not meet the criteria for this. This form was dated the day after Ms Y’s fall (Saturday);
• a letter dated January from the speech and language therapy (SALT) service to Ms Y’s GP regarding Ms Y’s difficulty swallowing. It notes the SALT visited Ms Y at the care home where staff said she did not always want to eat and was sometimes pushing food away. The SALT provided advice including eating small mouthfuls of food and to remain upright after eating and drinking but found no help was needed with feeding.

Ms B’s complaint to St Jude’s

27. Ms B complained to St Jude’s in early April 2022. Her complaint included those matters that are the subject of Ms B’s complaint to the Ombudsman.
28. A says it did not provide a response directly to Ms B other than an email in late April to say “Our solicitor has looked through the contents of your letter and viewed the many emails you sent, all of which were dealt with and responded to fully and in a timely manner, and has advised us to cease all communication”. Instead it says it sent a response to the Care Quality Commission (CQC) and to the local Council as Ms B had also sent her complaint to them. It did not however tell Ms B this. I have seen a copy of the response the care home provided to the CQC and the Council. Broadly this states:
• D assessed Ms Y in early December before she moved in and sent Ms B copies of various paperwork related to Ms Y’s stay and care shortly before and after Ms Y moved in;
• a care plan was created for Ms Y on the day she moved in and was put together with the pre-admission documentation and a body map;
• the written information Ms B provided about Ms Y by email before she moved in went into St Judes’ SPAM file. Once she was aware of it A printed it and added it to the file. This was on the day she moved in;
• staff responded to emails Ms B sent regarding Ms Y during the time she was living there; and
• details of the care provided including personal care, the actions taken following the fall out of bed, the handling of the pressure sore.

Did the actions taken by St Jude’s cause injustice?

29. There is no evidence that the incident when Ms Y fell out of bed was the result of poor care. The care notes confirm a falls alarm sounded which altered staff to Ms Y having fallen out of bed and the care plan notes that she was to receive two hourly checks by staff during the night. Given the incident was responded to as a result of the alarm going it would seem reasonable to assume it was responded to quite promptly. And the actions taken following the accident seem to have been acceptable and guided by advice form medical professionals. It is clear form the records that Ms Y had a pressure sore before she was admitted to St Judes as it was identified on the body map completed when she moved in. District nurses were visiting daily to treat this and so there are no grounds for me to conclude St Judes did not address this with the seriousness needed. I do note that the district nurse team seem to have recommended that a lower level bed was sought for Ms Y after her fall and it does not seem this was followed up until Ms B requested it in January. As Ms B did not have a further fall out of bed however there are no grounds for me to conclude that any slight delay in considering or following up on this recommendation resulted in any injustice to Ms Y. I therefore find no fault or injustice in relation to part a) of Ms B’s complaint.
30. It is clear from the evidence provided by the care home that it did complete care plans and relevant paperwork to take account of Ms Y’s care needs before she moved in and following a meeting with the staff in the home. I therefore find no fault in relation to part b) of the complaint.
31. I do not consider St Jude’s handled Ms B’s complaint satisfactorily or in accordance its own policy. This amounts to fault. I recognise that it was acting in line with the legal advice it received but consider it should have told Ms B that, as it declined to consider her complaint, she could pursue the matter with the Council as is stated in its policy or that she could complained to the Local Government and Social Care Ombudsman. If St Judes already knew that Ms B had complained to the local Council and/or CQC at that point, it should have referred to this and stated that it would be providing a response to them directly. I do not consider it is satisfactory to simply say it would not respond and not provide an alternative course of action. This response must have been frustrating for Ms B. However, I consider this frustration was limited as she had also complained to the Council and CQC. As Ms B would have been able to complain to the Council if she had been dissatisfied with any response provided by St Jude’s I am not persuaded any injustice caused to Ms B as a result of this poor handling of the complaint was anything greater than frustration.
32. I accept that the care home responded to Ms B’s emails promptly after she sent them during Ms Y’s time at the care home. I recognise that Ms B was not satisfied with these responses but I consider they did address the matters she was raising.

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Agreed action

33. St Jude’s will apologise to Ms B for its poor handling of her complaint within a month of the final decision on this complaint.
34. St Jude’s will ensure that in future is adheres to its policy on handling of complaints or provide the reasons for not doing so and alternative ways to pursue the complaint. Where it does consider a complaint it should also tell complainants they have a right to complain to the Local Government and Social Care Ombudsman if they remain dissatisfied at the end of its consideration. This should be detailed both in its complaints policy and in the written decision it sends to the complainant. St Jude’s will provide us with evidence that it has done this within two months of the final decision on this complaint.

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Final decision

35. There was no fault in the care provided to Ms Y or in its consideration or planning for her care needs. However its handling of Ms B’s complaint did not comply with its own policy on this and amounts to fault that caused Ms B injustice in the form of avoidable frustration. The Home will take the recommended action to recognise this and ensure it does not happen again in future.

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Investigator's decision on behalf of the Ombudsman