Summary: A care home, acting on behalf of the Council, failed to provide an appropriate level of care to Miss Y. The Council failed to properly investigate the complaint, it accepted the word of the care home and failed to give due weight to information from Miss Y’s representative.

The complaint

1. Ms X complains about the quality of care provided to Miss Y during a short stay in Park View Residential Care Home. The care home is owned and operated by Yorkshire Care Homes.

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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 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 submitted by Ms X;
• considered the correspondence between the Council and Ms X, including the Council’s final response to the complaint;
• made enquiries of the Council and considered the responses;
• taken account of relevant legislation;
• offered Ms X and the Council an opportunity to comment on a draft of this document, 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. Regulation 9 Person Centred Care says Care Provider 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.
7. Regulation 12 Safe Care & Treatment says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Care Providers must assess the risks to a person’s health and safety during any care or treatment and make sure care staff have the qualifications, competence, skills and experience to keep people safe.
8. 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.

Key facts

9. Miss Y was discharged from hospital to Park View Care Home on 2 March 2023 for a period of assessment. She was recovering from fractures to her rib, spine, and shoulder. One arm was in a sling, and she was unable to mover her arm and shoulder until she had been reviewed by the fracture clinic. She also had a diagnosis of dementia, and her memory and mobility were reported to have deteriorated. The care records show that due to her limited vocabulary her care needs needed to be anticipated by others.

What Ms X says

10. Ms X says that during the course of Miss Y’s stay at the care home, she became increasingly concerned about her wellbeing. She says Miss Y appeared to be in pain and became increasingly unwell. On the morning of 9 March 2023, Ms X was concerned about a significant deterioration in Miss Y’s health, and that she appeared to be ‘presenting differently’. Ms X says she repeatedly alerted care staff to her concerns and asked that Miss Y be seen by a GP on his routine weekly ‘ward round’ on 9 March 2023. This did not happen.
11. Later that day (9 March) Ms X became was so concerned about Miss Y’s wellbeing she removed her from the care home at approximately 4pm. She was admitted to hospital the next day by ambulance and found to have sepsis, kidney failure, dehydration, and a urinary tract infection.
12. Ms X says Miss Y did not become so poorly overnight, the change in her occurred over a few days. She says care staff should have sought medical attention when she alerted to them to her concerns, and its failure to do so, led to Miss Y becoming seriously unwell.

The Council’s response to my enquiries and the care home’s records

13. Miss Y arrived at the care home at 17.55pm on 2 March 2023 from hospital.
14. The care home registered Miss Y with a local GP practice the following day. The care home say registration can take up to seven days to complete.
15. A clinician from the GP practice visits the care home every Thursday to conduct a ‘ward round’. New residents undergo a health screening check and any concerns or follow up action required by the hospital are addressed.
16. The care home recorded Miss Y engaged with care staff and other residents during her stay and joined in activities, no details about the type of activities were given. The care home said Miss Y appeared to settle and slept well. She was supported with medication administration as prescribed by the GP and on occasions had been reported to be ‘non-compliant’.
17. Ms X escorted Miss Y to the hospital for an outpatient appointment at the fracture clinic on 7 March 2023. They arrived back at the care home at 17.51pm. Ms X told a senior carer on duty that the appointment went well in respect of the fracture. The hospital raised no concerns about the healing of the fracture.
18. At the request of Miss Y’s family, a manager of a different care home visited Miss Y on 8 March 2023, to assess if her needs could be met by that care home. Miss Y’s family were present. Miss Y was accepted by the care home and the transfer was arranged for 10 March 2023.
19. On the same day, a social worker visited Miss Y with the intention of completing a mental capacity assessment. Her family said she was tired and asked the social worker to return the following day.
20. The care home records show Ms X asked a senior carer about the pain relief prescribed for Miss Y, and that she asked that the GP be consulted about Miss Y.
21. A nurse practitioner visited the care home on 9 March 2023 around 11am. Four other residents were seen by the nurse. The care home says Miss Y was not included as she did not appear unwell.
22. Later that day Miss Y’s family removed her from the care home.
23. In its complaint response to Ms X the Council said, “GP ward rounds are on a Thursday; [Miss Y] arrived and left on a Thursday missing these rounds on both occasions”.
24. Ms X submitted a formal complaint to the Council on 30 May 2023. The Council telephoned the registered manager at the care home to discuss the complaint. It conducted a “…desktop review of documentary evidence submitted via email, further clarification was obtained via telephone and further email submissions. These were then triangulated via a site visit undertaken by our Safeguarding Team”.
25. Information from the Council’s safeguarding team shows Since she [Miss Y] was in hospital and not in a position to provide her views, we could not collate first hand her views on the care she received. The views were from [Ms X]. Since the stay was in March for [ Miss Y] and no safeguarding concerns were raised at the time, we could only review documentation provided by the home to evidence the care provided.
26. The safeguarding investigation concluded there “…was no reasonable cause to suspect that multiple adults were at risk of abuse and or neglect and acts of omission and the OSE was closed at stage 2 in line with Multi-Agency Organisational Safeguarding Enquiries Procedures”.
27. I have had sight of the Council’s complaint response letter to Ms X dated 26 June 2023. The letter sets out each point of complaint. Some aspects were upheld, some not and some were found inconclusive. In respect of complaint about Mrs Y’s deteriorating health, the Council said the care home completed observations of Mrs Y and there there had been no cause for concern.
28. The care home says Ms X did not raise any concerns about Miss Y during her stay. It received a complaint via the Council on 31 May 2023.

Analysis

29. When Council’s commission care services for a person they remain liable for the service failures of the service provider. So even though Ms X complains about a care home, it is the Council that is responsible for any failings.
30. There appears to be inconsistency in the information provided by the care home and the Council. The care home says Ms X raised no concerns about Miss Y during her stay at the care home, but the records show a discussion in which Ms X asks about pain relief for Miss Y and that she been seen by a GP, so it can be assumed she was concerned about Miss Y’s wellbeing. Given the injuries Miss Y was recovering from, the care home should have sought medical advice the same day. It is no excuse to say a resident’s registration at the GP surgery can take up to seven days. Any person can be seen by a GP as a temporary resident.
31. There is also inconsistency in the information provided about the ‘ward rounds’ at the care home. The care home says all new residents receive a visit from a GP or nurse practitioner, but Miss Y did not because she did not seem unwell. If all new residents are seen as a matter of course, then it should not have mattered whether Miss Y was well or unwell.
32. In its final complaint response to Ms X the Council said Miss Y was not seen by the visiting nurse practitioner because she left the care home that day. The nurse practitioner arrived at the care home at 11am, Miss Y did not leave until 4pm.
33. In any event, if a family member raises concerns about a residents’ health, then it would be appropriate to request a GP visit as soon as possible.
34. There’s a clear indication from the subsequent admission to hospital that Miss Y needed urgent medical attention. The care home’s failure to act put Miss Y at risk of those problems getting worse, if left untreated. Miss Y was particularly vulnerable and reliant on those caring for her identifying and responding to her needs and the care home did not do so even when alerted by Ms X.
35. It must have been very distressing for Ms X to witness Miss Y’s suffering and to also be aware that Miss Y did not receive an appropriate standard of care.
36. I find the Council failed to properly investigate the complaint. It failed to give due weight to the information Ms X provided and accepted the ‘word’ and the documents from the care home without question. It should have made enquiries of the hospital to establish Miss Y’s condition on admission and then commenced a safeguarding enquiry. Had it not been for the intervention of Ms X, Miss Y could have come to serious harm.
37. The Council’s failure to properly consider the actions of the care home potentially places other vulnerable residents at risk.

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Agreed action

38. The Council should within four weeks of the final decision:

• apologise to Miss Y for the failings above and make a payment of £500 in acknowledgment of her distress;
• apologise to Ms X for the failings set out above and make a payment of £250 in acknowledgement of her time and trouble pursuing the complaint with the Council, the care home, and this office.

39. Within three months:

• discuss the findings with the Council’s monitoring team and establish what action is required to address the failings by the care home and follow up with monitoring visits;
• consider lessons learned in respect of complaint investigation;
• provide evidence of the above to this office.

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Final decision

40. There is evidence of fault in this complaint. The care home failed to provide an appropriate level of care to Miss Y, which placed her at risk of harm. The Council failed to properly investigate the complaint. It accepted the word of the care home and failed to give due weight to information from Ms X.
41. The above recommendations are a suitable way to settle the complaint.
42. It is on this basis; the complaint will be closed.
43. 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.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman