Summary: Ms X complained about issues with the service and care provided by Avery Homes Limited. We find Avery Homes Limited at fault for providing insufficient care which caused distress to Ms X and her family. Avery Homes Limited has apologised to Ms X, refunded care homes fees and made a payment to recognise injustice.

The complaint

1. Ms X complains the service and care provided by Avery Homes Limited was insufficient, as identified in a Section 42 enquiry. Ms X says the issues identified caused distress to both her and her family. She also feels she has paid for a service that was not provided.

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The Ombudsman’s role and powers

2. 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)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
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)
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I have and have not investigated

7. A Section 42 enquiry has already been undertaken. This investigation has not reinvestigated the issues identified in that enquiry. However, the findings of the enquiry were considered during our investigation.

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How I considered this complaint

8. I spoke to Ms X’s representative about their complaint and considered information they provided.
9. I also considered information received from Avery Homes Limited.
10. Ms X’s representative and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant legislation

11. 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

12. Ms X was a resident at Avery Homes Limited for 10 months. Whilst living there, she paid weekly fees of £1,180.
13. Ms X’s family complained to Avery Homes Limited about the care that she had received. As a result, a Section 42 investigation was undertaken. This enquiry identified a number of issues with the care and service provided to Ms X. These included:
• Not providing Ms X with pain relief as advised by her GP, or taking her family’s concerns about this seriously.
• Not proactively investigating bleeding, or taking her family’s concerns about this seriously.
• A failure to encourage personal care.
• Bedding not changed for 12 days, as well as evidence of blood and faeces stains in Ms X’s room.
• Not providing creams, ointments and treatments as often as prescribed.
• Failing to investigate the cause of bruising.
14. The Section 42 report set out service improvements for the Care Provider, to prevent the same issues reoccurring. Ms X’s family came to the Ombudsman as they felt, alongside service improvements, Ms X should receive a personal remedy.
15. Ms X’s family say these issues were extremely stressful for them and Ms X. They say that they had to contact the Care Provider on a number of occasions to ask for care to be provided. This is confirmed by the Section 42 investigation, which found the family’s concerns were not always taken seriously by the Care Provider. It also highlights that the family had to step in and take action on some occasions, when the Care Provider should have been responsible for doing this.
16. The Care Provider apologised to Ms X and her family, and wrote to them to explain how the service improvements detailed in the Section 42 enquiry had been implemented. It has confirmed to the Ombudsman that there are £595 of outstanding fees.

Analysis

17. The Section 42 enquiry identified that the care provided to Ms X fell short in a number of areas. I have not detailed these findings, as they are set within the Section 42 enquiry. However, the issues identified included a lack of personal care, safeguarding issues, inadequate pain relief and delays in obtaining medical advice. The Section 42 enquiry identified the lack of care and delays in accessing medical support could have impacted Ms X’s health.
18. This is fault. This caused Ms X significant injustice as she did not receive the care that she was paying for or that she was entitled to expect and, at times, her health conditions were not properly managed.
19. It is clear that during the time Ms X was living at Avery Homes Limited she did not receive the standard of care she was paying for. On a number of documented occasions, her family had to take action, for example contacting her GP, despite this being the Care Provider’s responsibility. This is fault. This is injustice as these events would have been distressing to both Ms X and her family.
20. To address the injustice identified above, I asked the Care Provider to:
• Provide Ms X with a written apology for the injustice identified above.
• Write off the outstanding fees of £595.
• Refund Ms X £3,000 in care home fees. This is calculated at £300 per month that she lived in the home.
• Pay Ms X £500 as a symbolic payment to recognise the distress caused to her and her family.
21. It has now provided evidence it has done this and I do not require it to take further action.

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Final decision

22. I find Avery Homes Limited at fault for failing to provide Ms X with sufficient care. I will share this decision with the Care Quality Commission and complete my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman