Summary: Ms Y complains Emerson Grange Care Home failed to safeguard her mother, Mrs X, and failed to provide the care she needed. Ms Y says this resulted in Mrs X being admitted to hospital. The Ombudsman finds fault with the Care Provider for failing to provide care to Mrs X and failing to safeguard her from harm. The Care Provider has already provided a partial refund of fees, however the Care Provider has agreed to make a further distress payment and carry out service improvements for its complaints handling.

The complaint

1. Ms Y complains the provider has failed in its standards of care when caring for her mother, Mrs X.
2. Ms Y complains the Care Provider:

• failed to suitably dress Mrs X on several occasions,
• failed to correctly manage Mrs X’s continence and hygiene needs,
• failed to properly safeguard Mrs X which resulted in her suffering, unexplained injuries and being found by family members after falling, and
• failed to act on Mrs X’s declining health, which meant she was left unwell and family members had to call an ambulance.

3. Ms Y also complains the Care Provider has failed to properly consider the complaint and has failed to share information about its investigation into the concerns.

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The Ombudsman’s role and powers

4. We investigate complaints about adult social Care Providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
5. If an adult social Care Provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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)

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How I considered this complaint

7. I considered Mrs X’s complaint and the information provided by Mrs X’s family and her representative, Ms Y. I also considered information from the Care Provider, and third-party information from the Local Authority where the care home was located.
8. I considered comments received on a draft of my decision.
9. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of Care Providers that 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.
11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered Care Providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
12. Of relevance to this complaint are:

• Regulation 9 “Person centered care”. This says care and treatment must be appropriate and meet service users needs.
• Regulation 10 “Dignity and respect”. This says Care Providers should ensure service users are always treated with respect and dignity.
• Regulation 12 “Safe care and treatment”. This says care and treatment must be provided in a safe way for service users.
• Regulation 13 “Safeguarding from abuse and improper treatment”. This says the Care Provider should have robust procedures to prevent service users from being abused by staff.
• Regulation 17 “Good governance” says that Care Providers should maintain an accurate, complete and contemporaneous record in respect of each service user.

Safeguarding

13. A Local Authority 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 Local Authority 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 Local Authority 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

14. Mrs X became a resident of the Care Home in February 2022. Shortly after arrival, her family complained to the Care Provider about issues with care delivery and poor record keeping.
15. The Care Provider met with Mrs X’s family in April 2022 and agreed to address some of the ongoing issues.
16. Ms Y visited Mrs X at the care home in May 2022. Ms Y was concerned Mrs X was unwell and called emergency services. Mrs X was taken to hospital, where hospital staff raised a safeguarding concern with the Local Authority about the Care Provider’s failure to act on Mrs X’s worsening health before being admitted.
17. Mrs X was later discharged to a different care home in May 2022 where she died.
18. The Local Authority opened an enquiry into the concerns raised by the Hospital and determined that Mrs X had experienced neglect while living in the Care Home. In particular, the Local Authority were concerned the Care Provider had delayed addressing Mrs X’s health concerns and should have alerted services sooner to her worsening health.
19. The safeguarding enquiry set out service improvements for the Care Provider and directed the Care Provider to meet with Mrs X’s family and representatives.
20. The Care Provider agreed to reinvestigate the concerns raised by Ms Y and met with Ms Y and other family members in May 2023. At this meeting, the Care Provider agreed to refund the fees for the period where Mrs X was in hospital, despite the room still being occupied with her belongings.
21. Following the meeting, the Care Provider agreed to refund the fees for all of May 2022 which totalled £6735.12.
22. The Care Provider told Ms Y in June 2023 that it was continuing to investigate the issues raised by Ms Y.
23. It later told Ms Y that it had completed its investigation and didn’t reveal anything of concern. It also told Ms Y there were new staff in place, and that previous staff did not uphold its values. The regional manager said he would be visiting weekly to observe the delivery of service.

Analysis

Safeguarding and risk of harm

24. The Local Authority carried out safeguarding enquiry into the incident where Mrs X was unwell and needed hospital admission. The Local Authority identified issues with the Care Provider in how it delivered care and decided Mrs X had experienced neglect because of the Care Provider failing to give care and alert services. It also identified that Mrs X had several falls, and the Care Provider delayed completing a falls referral which resulted in bed safety rails being installed which could have prevented further falls.
25. The Local Authority developed an improvement plan with the Care Provider to address the issues. As the Local Authority has already carried out a review into the safeguarding aspect of this complaint it would not be a good use of public resources to reinvestigate the safeguarding concerns.
26. However, the Ombudsman can consider the findings and the injustice caused to Mrs X. It is clear from the Local Authority’s review that the Care Provider delayed addressing Mrs X’s declining health needs which resulted in her hospital admission. It also found the Care Provider delayed completing a falls referral after Mrs X had several falls.
27. Therefore, I am satisfied:

• The care home did not ensure Mrs X received safe care and treatment from staff. This was a potential breach of regulation 12 “Safe care and treatment”.
• Mrs X was left at risk of harm because of the Care Providers actions. This was a potential breach of Regulation 13 “Safeguarding from abuse and improper treatment”.
• The Care Provider did not keep clear and concise records. This was a potential breach of Regulation 17 “Good governance”.

28. This is significant fault by the Care Provider, resulting in injustice to Mrs X.
29. The Care Provider’s complaint response does not directly address the injustice to Mrs X. However, after the complaint response, the Care Provider agreed to refund care fees of £6735.12.
30. The Local Authority agreed the proposed action plan from the Care Provider, which I agree addresses service improvements. I accept it is not the Local Authority’s role to remedy personal injustice. I will therefore consider whether further personal remedies are reasonable after I have considered the other parts of the complaint.

Person centred care

31. Part of Ms Y’s complaint is the Care Provider failed to dress Mrs X in suitable clothing on several occasions. Ms Y raised this with the Care Provider in February 2022, alongside the concerns for the falls. Ms Y raised with the care home that she often found Mrs X in inappropriate clothing, often with clothing only on her top half, resulting in her being cold.
32. I have reviewed the Care Provider’s records for February 2022 and its investigation into the concerns at the time. The care notes only show when staff changed Mrs X, not what clothing they changed her into, so I cannot say whether staff dressed Mrs X in unsuitable clothing.
33. The investigation by the Care Provider did not uphold that Mrs X was dressed inappropriately, but it did uphold there were times when Mrs X was left cold, without proper bedding and heat. The Care Provider put up notices about ensuring Mrs X wore a vest and arranged for a new duvet. It also arranged for the heating in Mrs X’s room to be checked.
34. The Care Provider has not shown it delivered person centred care consistently to Mrs X in this area. This meant Mrs X was sometimes left cold and without items to keep her warm. This was fault by the Care Provider causing Mrs X injustice, and a potential breach of Regulation 9 “Person centred care”.

Hygiene

35. Part of Ms Y’s complaint is the Care Provider did not give reasonable care for Mrs X’s toileting and hygiene needs. She says staff often left Mrs X soiled, which worsened her health conditions.
36. I have reviewed the summary of concerns that Ms Y presented to the Care Provider in February 2022. While Mrs X did not directly raise how often staff were changing Mrs X, it is clear Ms Y raised that staff should take Mrs X out of bed to use the toilet. Ms Y also asked the Care Provider check Mrs X for infections.
37. The Care Provider said it was building up Mrs X’s strength for using the toilet as she could not do this alone. This was because of a physiotherapy assessment which advised Mrs X did not have a safe sitting balance. The Care Provider said it did not use the method’s Ms Y had requested to check for infections but followed the guidance for this from the Local Authority.
38. I reviewed the care notes for Mrs X in the lead up to her hospital admission. There were days where staff only addressed Mrs X’s toileting needs once a day, in the morning, and then did not address her needs again until the next day. There were also entries when staff changed Mrs X noting she was “very wet”. This shows that Mrs X was left for long periods of time without support for her toileting. This was fault by the Care Provider causing Mrs X injustice. It was also a potential breach of regulation 10 “Dignity and respect”.
39. The Care Provider did not show due care to Mrs X and her toileting needs. However, I cannot say that this contributed to Mrs X’s health needs as such conclusions can only be drawn by medical professionals.

Complaint handling

40. Part of Ms Y’s complaint is the Care Provider did not properly address the complaint and failed to tell her of the outcomes of the investigation.
41. I note the communication between the Care Provider and the Local Authority raises some concerns about the Care Provider’s delay in contacting Ms Y and addressing the concerns.
42. The communication to Ms Y by the Care Provider about the June 2023 investigation is vague and contradicting. The Care Provider told Ms Y it had not identified further concerns, but also said staff were no longer with the Care Provider as they did not uphold the values. This implies that things had gone wrong, and concerns were substantiated to the point where the Care Provider removed staff.
43. Additionally, in response to our enquiries, the Care Provider told us several staff were removed from business. It also said that while no new issues had been identified, it accepted the changes that should have been in place had not been fully delivered, and that it had taken further steps to address this.
44. The complaint communications to Ms Y by the Care Provider were misleading and vague. The Care Provider should have sent a full complaint response to Ms Y, setting out how it investigated her complaint, the findings and actions, and signposting her to the Ombudsman if she remained unhappy. Not to do so was fault by the Care Provider, causing Ms Y distress and confusion.

Remedies

45. Where we find fault with Care Providers for failing to provide the care agreed, we will normally recommend a partial refund of a percentage of their care. In this case, the Care Provider has already made a partial refund of Mrs X’s care fee’s which is in line with our guidance on remedies. Therefore, I am not recommending a further refund of fees.
46. While there was direct injustice to Mrs X because of the Care Provider’s actions, Mrs X has since died, and so we cannot remedy the direct injustice to her.
47. However, Ms Y was also caused distress and confusion over the Care Provider’s failure to provide care to Mrs X, and its handling of the concerns and complaint. Therefore, I am recommending the Care Provider make a distress payment to Ms Y.

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Agreed action

48. Within 4 weeks the Care Provider has agreed to

• Write to Ms Y and provide a full apology for all fault identified. The Care Provider should give regard to our guidance on how to make an effective apology.
• Pay Ms Y £500 in recognition of the distress caused to her because of the Care Provider’s actions.
• Review its complaints policy and evidence how it will ensure in future that complainants will receive full complaint responses that signpost complainants to the Ombudsman.

49. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

50. I have completed my investigation. I find fault with the Care Provider for failing to safeguard Mrs X and provide the care she needed. I also find fault with the Care Provider for its complaints handling.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman