Summary: Mr X complained about The Granby Care Home, Brighterkind and the care and treatment it provided to his late father, Mr Y. The Care Provider was at fault for the care and treatment it provided to Mr Y which caused Mr X distress and frustration. Since the Care Provider’s internal investigation and the Council’s safeguarding investigation, the Care Provider has made service improvements which were appropriate. The Care Provider also failed to write to Mr X following the Council’s safeguarding investigation which caused Mr X further distress and frustration. It has agreed to apologise to Mr X and provide him with a symbolic payment. The Care Provider will also remind staff the importance of contacting complainants following a safeguarding investigation.

The complaint

1. Mr X complained about The Granby Care Home, Brighterkind and the care and treatment it provided to his late father, Mr Y. Mr X said the Care Home:
• delivered poor personal care to his father;
• left his father’s room unclean;
• did not ventilate his father’s room during hot weather conditions;
• failed to document in care records when his father had sustained injuries; and
• did not consider associated risks with his father’s food and nutrition.
2. Mr X said this caused him and his family significant distress and frustration. He wants the Care Provider to recognise its faults and make service improvements to prevent a recurrence of fault. He also wants the Care Provider to apologise to him and his family and offer them a financial remedy for the injustice caused.

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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. If they have caused a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(3 and 4) as amended)
4. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide further investigation would not lead to a different outcome. (Local Government Act 1974, section 24A(6), as amended, section 34(B))

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. 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)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I spoke with Mr X and considered information he provided.
9. I considered information from the Care Provider.
10. Mr X and the Care Provider had the opportunity to comment on the draft version of this decision. I considered their comments before making a final decision.

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What I found

Legislation and guidance

The Care Quality Commission (CQC)

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out fundamental standards of care which registered care providers must achieve. The Care Quality Commission (CQC) is the statutory regulator of care services and has guidance for care providers which they must comply with to meet the fundamental standards of care. The guidance includes several regulations.
12. Regulation 12, “Safe Care and Treatment”, states care providers:
• must assess the risk of infection and prevent and control the spread of it;
• should use risk assessments about the health, safety and welfare of people using their service to make necessary adjustments. This includes adjustments to the premises and equipment which can affect any aspect of care and treatment; and
• must assess the risks to the health and safety of people receiving care and treatment. This includes assessing risks related to food and nutrition.
13. Regulation 17, “Good Governance”, states care providers must securely maintain accurate, complete and detailed records in respect of each person using the service.

Safeguarding adults

14. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. 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)

What happened

15. Mr Y had health problems. He had been residing at the Care Home for several years.
16. Between July and August 2022, Mr X complained to the Care Provider about the care and treatment the Care Home had been providing to Mr Y. He said when he had visited his father he noted:
• his father’s clothes did not fit him well or were unclean;
• his room was untidy. There was also unclean laundry and soiled items left in his room;
• during hot weather conditions, staff did not close the curtains in Mr Y’s room and did not provide him with a fan;
• Mr Y had developed a pressure sore. Mr X and his family noticed this and made staff aware. A few days later, Mr Y complained of pain in his back area. Upon inspecting Mr Y’s pain, staff noticed Mr Y had a pressure sore. Mr X said staff failed to document the pressure sore when he initially raised it with staff. Mr Y also had unexplained bruising which staff had failed to document too; and
• staff had given Mr Y an ice-pop which was inappropriate as Mr Y required thickened fluids. Staff had also left food in front of Mr Y which was not appropriate as he required supervision during meals due to the risk of him choking.
17. Mr X also raised a safeguarding alert to the Council’s Safeguarding Team.

The Care Provider’s investigation

18. The Care Provider completed an internal investigation into Mr X’s concerns. In its investigation, the Care Provider said:
• on one occasion, staff had assisted Mr Y and then left his room without removing the soiled items. It accepted it was an oversight by staff. The Care Provider had explained to staff the importance of keeping bedrooms tidy and removing soiled items. It had also arranged supervision and a meeting with all staff members to discuss the expected standards of keeping bedrooms tidy;
• it did not routinely provide fans to people to use in their bedrooms however, after receiving Mr X’s complaint, it provided Mr Y with a fan. The Care Provider also reminded staff to close curtains during hot weather conditions to help keep the heat out of the bedrooms;
• staff had documented Mr Y had a pressure sore when Mr X and his family had raised it and staff had treated it appropriately. Staff had also recorded the bruising on a body map. However, the Care Provider said it would discuss with staff the importance of accurately recording such information and promptly reporting matters to the nurses in charge. Mr Y’s General Practitioner (GP) had visited Mr Y a few days later and had no further concerns in relation to the bruising. The GP said Mr Y had fragile skin and so was prone to bruising; and
• until recently, Mr Y was able to independently eat and drink. His care plan also stated this but at times, required prompting. However, after receiving Mr X’s complaint, it had reviewed Mr Y’s care plan and updated it to show Mr Y required support from staff with his food and drink.
19. The Care Provider updated the Council of its internal investigation and the actions it had proposed to take or had taken.

The Council’s safeguarding investigation

20. Between August and October 2022, the Council investigated Mr X's concerns.
21. At the beginning of October 2022, the Council held a meeting to discuss the outcome of its investigation. The Care Provider, clinicians and Mr X were present at the meeting.
22. The Council’s record states it was clear there had been inconsistencies with the care and treatment the Care Home had provided to Mr Y. This included:
• Mr Y’s bedroom being untidy and unclean;
• staff not following CQC and Government guidance in relation to heatwave management;
• inconsistencies with accurate record keeping in relation to the pressure sore and bruising, despite the Care Provider disputing this; and
• staff not following Mr Y’s care plan and risk assessment in relation to eating and drinking.
23. Since Mr X had complained, the Council had visited Mr Y and observed his care and treatment had improved. The Council considered:
• Mr Y’s family had seen an improvement in relation to his bedroom being clean;
• the Care Provider had discussed with staff heatwave management;
• the Care Home had updated Mr Y’s care plan and risk assessment in relation to pressure sore management. Staff had also completed training in pressure sore management; and
• a Speech and Language Therapist had visited Mr Y at the Care Home and provided advice to staff. Mr Y’s GP had also discussed with staff Mr Y’s eating and drinking and what support he required.
24. The Council also considered the actions listed in the internal investigation the Care Provider had taken.
25. As a result, the Council closed its safeguarding investigation. However, Mr X remained unhappy and complained to us.

My enquiries

26. In response to my enquiries, the Care Provider provided evidence to show it had taken action in relation to:
• keeping bedrooms clean and tidy;
• managing hot weather. This included staff regularly monitoring temperatures of bedrooms;
• recording and reporting accidents and incidents;
• the process to follow in relation to infection and wound management. The Care Provider had also updated its daily handover documents to ensure staff communicated with each other about wounds; and
• reviewing risk assessments in general to ensure they are suited to current needs.
27. I asked the Care Provider if it had written to Mr X or the family following the outcome of the Council’s safeguarding investigation. The Care Provider said it did not write to Mr X or the family as Mr X was present during the Council’s outcome meeting.
28. Upon reviewing the information I had received from the Care Provider which included its internal investigation and the Council’s safeguarding document, I could not see Mr X’s complaint about his father’s personal care had been looked into.

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Findings

29. The Care Home left Mr Y’s bedroom untidy. It also left soiled items in his room. This was fault and not in line with CQC regulations. The Care Provider has since addressed the matter with staff to prevent a recurrence of fault. This was appropriate.
30. The Care Home failed to properly ventilate Mr Y’s bedroom during hot weather conditions. This was fault and not in line with CQC regulations. Since Mr X’s complaint, the Care Provider has reviewed with staff its heatwave management policy and has begun regularly monitoring residents’ bedrooms. This was appropriate.
31. Mr X said the Care Home did not document Mr Y’s pressure sore and bruising. The Care Provider said it did. The Council’s safeguarding document states there were inconsistencies with accurate record keeping. I cannot say whether the Care Provider was at fault however, since Mr X’s complaint, it has reviewed with staff the importance of reporting and recording accidents and wounds. This was appropriate.
32. The Care Home did not follow Mr Y’s risk assessment in relation to food and drink. This was fault and not in line with CQC regulations. Since Mr X’s complaint, a Speech and Language Therapist and Mr Y’s GP had provided advice to staff at the Care Home. This was appropriate.
33. The above faults of the Care Provider caused Mr X distress and frustration.
34. Since the Council’s safeguarding investigation, the Care Provider has not contacted Mr X to conclude his complaint. I recognise Mr X was present at the Council’s safeguarding meeting however, it would have been appropriate for the Care Provider to write to Mr X following this and provide him with an apology. This was fault and caused Mr X further distress and frustration.
35. I note Mr X also said in his complaint Mr Y was not presented well at times as his clothes were not fitting or clean. I have no supporting evidence this was explored further as part of Mr X’s complaint with the Care Provider or as part of the Council’s safeguarding investigation. I do not dispute this happened however, I have decided not to investigate this further as it would be difficult for me to achieve anything more.
36. I have not been able to recommend a remedy for any injustice caused to Mr Y from all the faults identified in this section as he has since died. I have recommended a remedy for Mr X for the distress and frustration the faults identified in paragraphs 29-34 have caused him.

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Agreed actions

37. Within one month of the final decision, the Care Provider has agreed it will:
• provide Mr X with a written apology for the distress and frustration it caused him by the care and treatment his late father received. It will also apologise to Mr X for not writing to him after the Council’s safeguarding investigation; and
• pay Mr X a symbolic payment of £300 for the distress and frustration the matter caused him.
38. Within one month of the final decision, the Care Provider will also remind staff to contact the person complaining following a safeguarding investigation. This is to prevent any further distress, frustration and uncertainty to the person complaining.
39. The Care Provider will provide us with evidence it has complied with the above actions.

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Final decision

40. I have now completed my investigation. The Care Provider was at fault. It has made service improvements which were appropriate. The Care Provider will also provide a remedy to Mr X for the injustice caused and remind staff to contact complainants following a safeguarding investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman