Summary: Mr X complains about the care provided by Broad Oak Manor Nursing Home towards his mother, Mrs Y. Mr X says the Care Provider failed to provide a reasonable standard of care and keep his mother safe. The Ombudsman intends to find fault with the Care Provider for the handling of an incident involving Mrs Y. The Ombudsman does not intend to find fault with the rest of the care provided. The Ombudsman recommends a financial payment in recognition of distress.

The complaint

1. Mr X complains the Care Provider did not provide a reasonable standard of care to his mother, Mrs Y, during her stay. Mr X says the care provider did not do enough to ensure his mother’s safety.
2. Mr X complains the Care Provider did not arrange for suitable care and facilities upon arrival and did not treat Mrs Y with dignity.
3. Mr X also complains about how the Care Provider considered and responded to an incident with another resident which caused Mrs Y’s distress.

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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. 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)
7. 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

8. I considered Mr X’s complaint and information he provided. I also considered information from the Care Provider.
9. I invited Mr X and the Care Provider to comment on my draft decision and considered comments I received.

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What I found

Legal and Administrative Background

10. 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.

Fundamental Standards of Care

11. 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. The standards include:

• Regulation 9: This regulation describes the action providers must take to make sure that each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences.
• Regulation 10: Providers must make sure that they provide care and treatment in a way that ensures people’s dignity and treats them with respect at all times.
• Regulation 17: Providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. The systems and processes must also assess, monitor and mitigate any risks relating to the health, safety and welfare of people using services and others. Providers must continually evaluate and seek to improve their governance and auditing practice.

What happened

12. Mrs Y required some physical respite after experiencing issues with her back. Her son, Mr X, contacted the Care Provider to ask if it could meet Mrs Y’s needs as part of a residential placement whilst she recovered.
13. On 6th September 2023, the Care Provider carried out an initial assessment with Mr X about Mrs Y’s needs over the phone. The initial assessment recorded that Mrs Y needed physical support due to her back issues, but that other than that she remained independent and had capacity to make decision about her care. It agreed it could meet Mrs Y’s needs and that she could start a short residential stay from 7th September 2023.
14. Mr X and Mrs Y arrived the next day to start her stay. When Mrs Y arrived, staff spoke to Mr X instead of Mrs Y about her and her needs. Mrs Y moved into a room in the care home and began her stay.
15. Mr X contacted the care provider and highlighted that staff should have spoken to Mrs Y about her needs, as she had full capacity to make her own decisions. The Care Provider acknowledged that staff should have directly to Mrs Y and not made assumptions about her. It said it reminded staff to not make assumptions about capacity in future.
16. Mrs Y told the care home she did not like the room she was in. The Care Provider arranged for Mrs Y to be moved to a different room.
17. At the end of the first week, Mr X contacted the Care Provider to say Mrs Y wanted to extend it for a further week and Mrs Y was complimentary about the staff. The Care provider agreed as there had been no concerns.
18. On the 15th September 2023, staff supported Mrs Y to bed and went downstairs to complete the staff handover. Another resident entered Mrs Y’s room and attempted to attack her. As Mrs Y was unable to move herself, she could not leave the room. She pressed the call bell to alert staff, but managed to de-escalate the situation and the other resident had calmed down by the time staff arrived. Staff returned the other resident to their room.
19. On 17th September, Mrs Y ended her stay at the care home. Mr X also complained about the attempted attack that had taken place, and was told he would receive a response once an investigation had taken place.
20. In January 2024, Mr X complained to the Care Provider on behalf of Mrs Y. In his complaint he said he was unhappy about the level of care his mother had received. he said the Care Provider had not properly considered his mothers needs and had not provided care that she needed. He also complained about the incident where Mrs Y was attacked in her room.
21. The Care provided responded to Mr X’s complaint. In the response it said

• Staff should not have made assumptions about Mrs Y’s needs when she arrived, but this had been addressed with staff.
• It explained the assessment process was to gather information about residents needs and this will continue to be developed throughout a residents stay.
• It had moved Mrs Y to a different room.
• It could not disclose information about other residents but accepted that the attack on Mrs Y was unforeseen and had caused her stress. It had taken steps to assess the risk and prevent it happening again.
• It had no reason to believe Mrs Y was unhappy during her stay, as the only issues raised were that of staff not speaking to Mrs Y when she arrived, and the attack in her room.
• Mr X had told the care provider Mrs Y wanted to extend her stay and was complimentary about the home.

22. Mr X remained unhappy and asked the care provider to consider the issues further. He said;

• It was hard to find someone to raise issues and complain to.
• No-one seemed to be managing the care of the residents.
• Mrs Y was ignored by staff and left on her own for long periods of time.
• The resident that attacked Mrs Y was left wandering around on their own for long periods without supervision.
• Staff weren’t communicating with each other, and Mrs Y had to call the management line to get staff to respond to her.
• Mrs Y had not been provided with the physical support to walk outside.
• He had not received a meaningful response about the attack on Mrs Y.
• He didn’t feel Mrs Y should have to pay the full outstanding care fees due to the poor care provided.

23. The Care provider’s final response it said

• Management are located at the home during the week, and there is a nurse in charge for each shift. Additionally, Mr X and Mrs Y had the contact details of the management phone which was attended to 24 hours a day. Furthermore, Mr X had remained in contact via email with management throughout Mrs Y’s stay. Therefore, it did not uphold the allegation that there was no-one to complain to.
• It had acknowledged that staff should have spoken directly to Mrs Y when she arrived and addressed this with staff. It believed the issue was resolved because Mr Y asked to extend Mrs Y’s stay and said Mrs Y was happy.
• It disputed Mrs Y or any other resident was left alone for long periods, as care records show they checked at least every hour, including safety and wellbeing checks.
• Sometimes there is a delay in staff responding to alarms or call bells because they are helping other residents.
• Mrs Y had two physio sessions to take her on aided walks outside.
• It apologised for not providing a direct response about the attack on Mrs Y.
• The outstanding care fees remained valid and payable.

24. Mr X remained unhappy and complained to the Ombudsman.

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Analysis

Assessment and delivery of care

25. Part of Mr X’s complaint is that the care provider failed to properly assess Mrs Y’s care needs and deliver care that met her needs.
26. The Care provider has provided records to show it carried out a detailed initial assessment of Mrs Y’s care needs prior to her arrival. This was used to develop a care plan on how best to meet Mrs Y’s needs.
27. The Care Provider’s daily records show that care was delivered in line with Mrs Y’s care plan daily. The records are detailed, and included prompts for staff to check for risk, or non-delivery of care. Where concerns were raised, such as levels of food and fluid below expectation, this is flagged to management for review.
28. I am satisfied the records show the Care Provider assessed Mrs Y’s needs and developed a care plan to reflect the information it collected. The daily records also show Mrs Y received care in line with the care plan. I have seen no evidence to suggest Mrs Y’s care needs were not met, or that she went for long periods without being checked.
29. The Care Provider’s records show that other than staff not speaking to Mrs Y when she arrived, she raised no concerns about her care until the attempted attack. I am satisfied that if Mrs Y or Mr X had significant concerns about the care being received, it was reasonable to raise this with the home to give the opportunity to rectify or respond. Mr X was aware of how to raise these concerns as he had been in contact with the management to discuss the issue of staff initially not speaking to Mrs Y.
30. In response to my draft decision, Mr X said the Care Provider should have recognised calls from other family members as them raising concerns. These calls Mr X says were made to staff to ask and remind them to carry out certain care to Mrs Y. I do not find fault with the Care Provider in this regard. Calls to ask staff to carry out care would not have been automatically considered as a concern. Mr X knew how to raise concerns, had previously done so, and if Mrs Y or Mr X were unhappy with the care, they would not have requested to extend the stay and been complimentary about the staff.
31. I find no fault by the Care Provider in how it assessed and delivered Mrs Y’s care.

Safety of Mrs Y

32. Part of Mr X’s complaint is that the Care Provider did not do enough to ensure Mrs Y’s safety. This is in relation to the attempted attack on Mrs Y which Mr X feels the Care Provider could have avoided.
33. I am satisfied with the evidence provided by the Care Provider that it had no reason to foresee such an event and took action to ensure it would not happen again. The Care Provider has acknowledged it would have been distressing for Mrs Y to experience this.
34. Part of the complaint is that staff delayed responding to Mrs Y’s alarm bell when Mrs Y tried to alert staff of the attempted attack. The Care Provider has said at the time of the attempted attack, staff were engaged in a handover, and so didn’t immediately respond. As part of my enquiries, I asked the Care Provider for records of how long it took staff to respond. The Care Provider said its current system didn’t record such information, but it would upgrade this in the future.
35. There is no dispute that the attempted attack happened, and I accept that Mrs Y’s physical care needs meant that she was unable to remove herself from the risk being posed to her. Whilst I accept the Care Provider could not have foreseen the attempted attack, the delay in staff responding to the call bell heightened the distress caused to Mrs Y. This was fault by the Care Provider, which caused Mrs Y injustice.
36. The Care Provider has accepted it did not provide a response to Mr X’s concerns about the attack when it should have done. This was fault causing Mrs Y further distress.
37. Considering the fault upheld already by the Care Provider, I am recommending a financial remedy for distress for Mrs Y. I am not recommending any service improvements as the Care Provider has already demonstrated it took appropriate action.

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Agreed action

38. Within four weeks of the final decision, the Care Provider has agreed to

• Write to Mrs Y and Mr X and apologise for the fault identified.
• Pay Mrs Y £250. This is in recognition of the distress caused by the fault initially identified by the Care Provider, and further fault found by the Ombudsman.

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

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Final decision

40. I have completed my investigation. I find fault with the Care Provider for the distress caused to Mrs Y by its actions.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman