Summary: Mrs X complains the Council’s care provider, Harbledown Lodge: failed to care for her late mother properly, resulting in a decline in her condition; failed to respond properly to concerns about her care; and gave notice rather than address their concerns, causing unnecessary distress. The care provider did not fail to care for Mrs X’s mother. However, it caused unnecessary distress by giving notice in the way that it did. The Council needs to apologise for the distress caused to Mrs X.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care provider, Harbledown Lodge: failed to care for her late mother properly, resulting in a decline in her condition; failed to respond properly to concerns about her care; and gave notice rather than address their concerns, causing unnecessary distress.

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The Ombudsman’s role and powers

2. 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)
3. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), 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)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• invited comments on a draft of this statement from Mrs X and the Council, for me to consider before making my final decision.

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What I found

What happened

6. Mrs X’s mother, Mrs Y, moved to Harbledown Lodge on 3 August 2021. She had been in hospital with a urinary tract infection. The purpose of the move was to enable an assessment of her long-term needs. Mrs Y had dementia and needed help to walk. She had a catheter and needed help with personal care.
7. The NHS initially funded Mrs Y’s placement using COVID-19 funding. Responsibility for long-term funding transferred to the Council, as she did not qualify for NHS Continuing Healthcare. The Council assessed her needs on 8 September and funded her placement from 11 September.
8. Harbledown Lodge kept detailed records of Mrs Y’s condition and the care and support provided for her. They show family visited each day and Mrs X often called when she could not visit to check on her mother’s condition. I refer to the key contents of the records.
9. Mrs Y was unsettled when she arrived and her food and fluid intake was poor, despite encouragement. She would remove her catheter. She had also done this in the hospital, which provided mittens to reduce the risk of her doing this.
10. On 10 August Mrs X had a long conversation with Harbledown Lodge. They spoke about:
• Mrs Y’s food intake, which remained poor;
• the use of mittens to prevent Mrs Y from removing the catheter (Mrs X did not agree with this and asked that Mrs Y wear pyjamas instead);
• talking to the GP about removing the catheter when the infection had settled. Mrs X said this had been tried before but Mrs Y could not pass urine;
• calling Mrs X back when I received the result of a blood test, to discuss a treatment escalation plan.
11. On 11 August Harbledown Lodge told Mrs X her mother had taken her pyjamas off and removed the catheter. Mrs X agreed she should wear mittens when in bed. A GP visited and Mrs Y started taking antibiotics that evening.
12. Mrs Y gradually settled and started accepting food from staff.
13. On 16 August Mrs Y was rolling in bed throwing off the bedding. Her family questioned whether she may have another infection. Harbledown Lodge said it would do another dip test the next day. As this was positive, the GP prescribed another course of antibiotics. Mrs X said she had concerns as this was Mrs Y’s second course of antibiotics since moving to Harbledown Lodge and asked whether there was another plan. Harbledown Lodge tried calling Mrs Y’s family the next day but could not get through.
14. A speech and language therapist assessed Mrs Y on 20 August and made some recommendations (thin fluid, single sips, open cup, minced and moist diet, check mouth clear after eating).
15. On 24 August Harbledown Lodge told Mrs X a urine culture test had given a negative result, showing Mrs Y did not have an infection. Mrs X asked why Mrs Y had been given antibiotics. Harbledown Lodge said this was because the dip test had been positive and Mrs Y had symptoms. Mrs X asked about the date of the urine culture tests. Harbledown Lodge said it was when the GP last visited, so was before she started taking antibiotics. Mrs X asked if they would test Mrs Y’s urine regularly. Harbledown Lodge said it would test if she had symptoms.
16. A dietician visited Mrs Y on 25 August and was content with Mrs Y’s condition. The dietician said to get in contact if it went below 59 kg.
17. When Mrs Y’s family visited on 26 August, they reported her trousers were wet. Mrs Y had released the valve on the catheter bag, emptying it. Staff washed her and changed her clothes. Mrs X is concerned that staff did not notice what had happened until the family pointed it out. She says her mother was in the communal area with just one other resident and a member of staff.
18. On 27 August Mrs Y was unsettled in the morning, removing blankets and clothes. After she was sat in a chair she tried to fiddle with the catheter. In the afternoon, when her husband was there, she tried to remove the catheter strap. Mrs X called as she was concerned about Mrs Y touching the catheter. She says staff responded defensively to her questions and a manager called back who was rude to her.
19. On 30 August Mrs Y was upset and wanted to go home. She tried to pull the catheter out from her trousers. Staff tried distracting her but after a few minutes she tried again. They spoke to her family about getting some different trousers which would make it more difficult for her to do this.
20. On 5 September Mrs Y’s catheter came out. Harbledown Lodge noted to watch her and encourage her to take fluids.
21. On 9 September Mrs Y’s urine dip test was positive. Harbledown Lodge told Mrs X about the result and said it would test again the next day.
22. On 10 September Mrs Y had an unwitnessed fall in her room. She had a painful lump on her forehead. Harbledown Lodge called 999 and followed advice to check Mrs Y for any changes in her condition. It noted her family had brought her a cushion which would have increased the risk of falling from her chair and that this should not be used. Mrs X agreed to remove the cushion. A GP prescribed a course of antibiotics as a further urine dip test was positive.
23. On 14 September the Council asked Harbledown Lodge about providing a sensor mat for Mrs Y, given her recent fall. Harbledown Lodge pointed out the fall was due to the cushion, rather than Mrs Y trying to get up from her chair, but said it would monitor her. The records say Mrs Y was rapidly deteriorating.
24. On 17 September Mrs X asked how long Mrs Y’s course of antibiotics was for. She suggested asking the GP to prescribe a prophylactic course of antibiotics, which Harbledown Lodge agreed to do.
25. On 20 September the Council noted Mrs Y’s family had not decided whether she should remain at Harbledown Lodge, but wanted somewhere close to where Mr Y lived so he could visit regularly if she moved. The Council sent Mrs X a list of care homes.
26. On 22 September a GP prescribed prophylactic antibiotics to ward against further infections.
27. On 28 September Mrs X told the Council the family wanted Mrs Y to stay at Harbledown Lodge as she had settled there, so a move would be detrimental to her well-being. She said staff had got to know her “needs and ways” and they were working together to manage her recurring urinary tract infections. However, Harbledown Lodge told the Council it could not provide a long-term placement for Mrs Y. The Council asked it to explain why. It said one daughter was very rude to staff and stayed longer than allowed under current COVID-19 restrictions. The Council told Mrs X Mrs Y could not remain at Harbledown Lodge and sent her another list of care homes.
28. On 29 September Mrs X said she was upset that Harbledown Lodge did not want her mother to stay there. The Council told her it may be due to “family dynamics” but did not provide details. Mrs X told the Council a manager was aggressive with her and asked it to talk to Harbledown Lodge. The Council asked Harbledown Lodge to let Mrs Y stay in the short-term to see if the two sides could “work things out”. The Council noted this would be in Mrs Y’s best interests.
29. On 30 September Mrs X told the Council she was not happy with the way some of Mrs Y’s care had been managed by Harbledown Lodge but wanted to resolve the situation. She told the Council she would “raise issues differently”.
30. On 1 October Harbledown Lodge told the Council about several incidents where Mrs X “had challenged them”. But it said it would consider extending Mrs Y’s placement. The Council noted they could work on better ways of communicating issues.
31. On 4 October Mrs X told the Council they did not think the breakdown in communication could be resolved. Mrs Y’s urine dip test was positive.
32. On 5 October Harbledown Lodge agreed Mrs Y could stay for a four-week trial to see if “things improve”.
33. The Council told Mrs X about the offer of a four-week trial. She said she was not keen and any continued stay at Harbledown Lodge would have to be temporary as the family’s trust had gone.
34. On 7 October a GP prescribed more antibiotics, as Mrs Y was confused and had blood in her urine.
35. On 10 October Mrs Y’s right hand was swollen and in pain. Staff tried to remove her rings but could not do so. With her family’s consent, an ambulance was called and the rings were cut off. Mrs X puts this down to the use of the mittens, which she says Harbledown Lodge continued to use.
36. On 11 October Mrs X agreed Mrs Y could stay at Harbledown Lodge until they found another placement, to see if communication improved. Harbledown Lodge confirmed she could stay for a few weeks but had “reservations” as Mrs X was threatening to complain about the management of care workers who did not see Mrs Y pull out her catheter.
37. On 19 October the Council noted Harbledown Lodge had given notice from 12 October and started looking for another care home.
38. On 21 October Harbledown Lodge gave formal notice to the Council. It also gave notice to Mrs Y’s family. It said:
• staff had felt pressurised by Mrs X;
• it understood Mrs X was worried about Mrs Y’s care, but every conversation with her was very stressful for staff;
• on one occasion a member of staff had been very upset after speaking to her;
• trust and mutual understanding were needed to provide good care;
• the worst experience with Mrs X was her not being willing to listen, but saying staff were argumentative and were not managed properly.
39. On 4 November Mrs Y moved to another care home.
40. Mrs X complained to Harbledown Lodge on 8 November. She said:
• she had frequently been met with defensiveness and abruptness, and was made to feel like a nuisance;
• she had continued to ask questions politely, especially after Mrs Y had a fall, so she could reassure Mr Y about her wellbeing and evolving care plan;
• she was appalled and confused by the claim that conversations with her had been stressful;
• staff should have been open to discussions and should have worked with them for the benefit of Mrs Y’s health;
• the care workers were mainly very helpful and her concerns related to management;
• after the incident on 26 August, she had contacted Harbledown Lodge as they were concerned Mrs Y had managed roll up her trousers, release the catheter and turn on the drainage tap, despite a member of staff being sat close by, and wanted to reduce the risk of this happening again. She said the response was to excuse it by saying it was probably handover time, so she asked for it to be looked into further. She denied being rude or aggressive but had been upset at her mother’s loss of dignity. A few minutes later she had received a call about her “complaint”, despite not having made one, and been shouted at and continually interrupted.
41. The care provider’s response to Mrs X’s complaint is dated 4 December. It said:
• it was satisfied Mrs Y had received care to meet her needs, and that staff at Harbledown Lodge had consulted GPs and external professionals as required;
• staff had maintained professional communication with her, despite at times finding communication with her difficult;
• the decision to give notice was because staff had been unable to build a relationship with her;
• the recordings of three calls with Mrs X showed staff had remained calm and tried to communicate with her in a professional manner;
• on several occasions Mrs Y tampered with her catheter bag. Staff tried different ways to secure the bag in the least restrictive ways and always acted in her best interests;
• on 26 August, staff acted appropriately to support Mrs Y and took her to her room to preserve her dignity and privacy. It apologised if the incident had distressed her family;
42. Mrs X did not receive the care provider’s response to her complaint until after she contacted it again in May 2022. She then complained to the Ombudsman.
43. The care provider no longer has access to the recordings of Mrs X’s telephone calls with Harbledown Lodge. It says this is because its system only has the capacity to retain calls for 12 months. The care provider has also been unable to provide evidence of e-mailing its response to Mrs X’s complaint on 4 December 2021. It says this is because an e-mail account was hacked in January 2022 and messages were destroyed.

Is there evidence of fault by the Council which caused injustice?

44. The evidence does not support the claim that Harbledown lodge did not meet Mrs Y’s needs. Mrs Y moved to residential care because her condition had declined. It continued to decline after the move, but there is nothing to suggest this was due to anything other than the fact she had a degenerative illness (dementia).
45. Mrs X wanted to be actively involved in the decisions relating to her mother’s care. It appears she lacked trust in Harbledown Lodge and managers may have been defensive in response to her questions. The relationship between Mrs X and Harbledown Lodge broke down. They have both accused each other of rudeness. Unfortunately the call recordings which should have helped me reach a view on this no longer exist. That may not have been the case if the care provider had acted more promptly on my request for the recordings, which the Council passed on to it on 9 September 2022. However, the care provider’s claim that staff at Harbledown Lodge maintained professional communication with Mrs X is undermined by the e-mail sent to Mrs Y’s family on 21 October 2021. The contents and tone of that e-mail were inappropriate and unnecessarily hurtful.
46. Giving notice to an elderly resident should be a last resort, particularly one who was declining rapidly, as Mrs Y was. People are entitled to raise questions about the care of their relatives or indeed make complaints. That a family member has done so should not provide grounds for asking someone to leave. Furthermore, when the relationship between a relative and a care home has broken down, steps should be taken to resolve the problem. Such steps could include:
• writing to the person about any inappropriate behaviour;
• asking the Council to mediate; or
• asking someone to address any concerns to the Council, rather than to staff at the care home.
47. But Harbledown Lodge did not do any of these things. That was fault for which the Council is accountable. The Council was also at fault because, despite being aware of the problems between Mrs X and Harbledown Lodge and that they threatened Mrs Y’s placement, it failed to offer any help and simply hoped things would sort themselves out.
48. These faults caused avoidable distress to Mrs X.

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Agreed action

49. 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 found fault with the actions of the care provider and the Council, I have only made recommendations to the Council.
50. I recommended the Council:
• within four weeks writes to Mrs X apologising for the avoidable distress caused to her; and
• within eight weeks identifies the action it is going to take to ensure officers take more proactive action to avoid people being moved to another care home when steps could be taken to avoid this.

The Council has agreed to do this.

51. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

52. I have completed my investigation on the basis there has been fault causing injustice which requires a remedy.

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Investigator's decision on behalf of the Ombudsman