The Ombudsman's final decision
Summary: We have found fault in the way the Home communicated with Ms C’s family and in its record keeping. There were incidents when the care was not delivered in line with the care plan. The Home has agreed to apologise to Ms B and Ms C and pay a financial remedy.
The complaint
Ms B complains on behalf of her aunt, Ms C, who does not have the mental capacity to make the complaint. Ms B complains about Willowcroft Care Home in Salisbury. She complains about the care the Home provided and the Home’s record keeping and communication with the family. Ms B also complains that the Home refused to disclose Ms C’s care records to her.
What I have investigated I have investigated Ms B’s complaints except for the complaint about disclosing information. Paragraph 130 explains why I have not investigated this complaint.
The Ombudsman’s role and powers
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) If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4)) The Information Commissioner's Office considers complaints about freedom of information. Its decision notices may be appealed to the First Tier Tribunal (Information Rights). So where we receive complaints about freedom of information, we normally consider it reasonable to expect the person to refer the matter to the Information Commissioner.
We normally expect someone to refer the matter to the Information Commissioner if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), as amended)
How I considered this complaint
I have discussed the complaint with Ms B. I have considered the documents she and the Home have sent, the relevant guidance and policies and both sides’ comments on the draft decision.
What I found
Law, guidance and policies The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which 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.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve.
The CQC has provided guidance on the regulations. This says that: The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
Service users must be treated with dignity and respect (regulation 10).
The care and treatment must be provided in a safe way for service users. (regulation 12).
Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
The Home must, as far as is reasonably practicable, ensure that service users are able to make decisions about their care or treatment (regulation 11).
The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17) NHS Continuing Healthcare (CHC) The NHS CHC Framework sets out the principles.
NHS Continuing Healthcare (CHC) means a package of ongoing care that is arranged and funded solely by the NHS where the individual has been assessed to have a ‘primary health need’ as set out in the Framework.
The CHC Checklist is the first stage of the assessment to decide whether a person is eligible for CHC. The Frameworks says where there may be a need for CHC, a Checklist should be completed.
An individual cannot complete the Checklist themselves, but they can contact the CCG for someone to complete the Checklist or if they are in a care home, they can ask the care home to contact the CCG on their behalf.
If the outcome of the checklist is positive, then a person requires a full assessment of CHC eligibility.
NHS continuing healthcare can be provided in a variety of settings outside of hospital, such as in a person’s own home or in a care home.
What happened Ms C moved to the Home in September 2018.
Ms B complained to the Home in November 2020 after she attended a CHC checklist assessment meeting. Ms B says she became aware of a lot of problems during this meeting.
The complaint went through the three-stage complaint process and ended in August 2021.
My investigation The Home has sent me the care plans and all the daily records including any incident reports and CQC referrals for the relevant times.
The documents show the following.
Ms C’s initial care plan said Ms C was at high risk of falls. She walked with the aid of a stick or Zimmer frame and one care worker assisting her.
The Home’s care plan had 12 sections including: Mobility and dexterity Fall prevention In addition, the Home also had documents such as: Care plan: evaluation / progress notes Moving and handling risk assessment and review Falls risk assessment tool Risk assessment review All these documents were updated at various times with handwritten notes. For example, the mobility and dexterity plan was updated 23 times between 22 January 2019 and 19 November 2020. There was duplication between the different documents. I have summarised the events insofar as they are relevant to the complaint I am investigating.
Fall – 8 April 2019 The records show that Ms C was found on the floor with her back against the wall in the lounge. A kitchen staff member found Ms C at 12:00. Ms C said she bumped her head when she fell but she felt fine and had no injuries.
The Home put a head chart in place, but did not complete an incident report or risk assessment.
Fall – 11 July 2019 The incident report said Ms C had a witnessed fall at 02:40 while she was walking along the corridor. The night carer walked towards her and Ms C turned and went to hold the handrail but missed and fell. The Home called the paramedics and it was confirmed that Ms C had fractured her wrist.
The report said an alert sensor mat was in place and a wellbeing chart, observation chart and body map were completed. The Home informed Ms C’s next of kin.
The Home made a CQC referral. The Home carried out a risk assessment and said no changes were needed to the care plan. The Home said this was because, at the time it did not know yet what changes would be needed.
The care plan evaluation notes said, on 12 July 2019, that, due to the fractured wrist, Ms C was finding it hard to mobilise and one carer should assist.
Fall – 15 July 2019 The incident report said Ms C had an unwitnessed fall at 04:20 and was found on the floor by her bed when the night carers checked up on her. She had a red mark below her shoulder blade and this was added to the body map. The Home did not inform the next of kin.
Ms C was on a wellbeing chart and a pressure mat was in place.
A falls risk assessment was completed which said there was no need to change the care plan.
The care plan was reviewed on 16 July 2019 and said Ms C had good days when she was still able to mobilise with a stick, but was reluctant to mobilise. Ms C needed more support to mobilise as she had lost her confidence. Ms C was due to be seen by the nurse practitioner on the following day for a review of her medication.
Fall – 19 July 2019 The incident report said Ms C had an unwitnessed fall at 06:30 and was found on the floor by her bed. She had red marks by her knees. The staff had been alerted by the alert mat to go to Ms C’s room. The next of kin was not informed.
The report said staff should ensure the alert mat was placed in front of Ms C. Ms C needed assistance to mobilise at the moment but did not always remember this because of her Alzheimer’s so she may not call for help when she needed it.
Fall – 22 July 2019 The incident report said Ms C had an unwitnessed fall at 01:45 and was found on the floor in front of her bed. She had no injuries. The next of kin was informed.
The report said that the family were told that the Home would be changing the bed to a profiling bed so that the bed could be lowered to the lowest position. The nurse practitioner had visited Ms C on 16 July 2019 and was due to visit her again on 23 July 2019.
The care plan evaluation notes said Ms C had ‘probably slipped off the bed.’
Care plan changes – July to October 2019 The care plan ‘mobility and dexterity’ showed frequent changes to the care plan in the following weeks.
By 25 August 2019, the care plan said Ms C was ‘hoist only’ but at times she could stand to transfer depending on how she felt. She was in a wheelchair if she left her room.
On 12 September 2019, the care plan remained that Ms C should be assessed each time staff moved her. Staff should check the alert mat was plugged in to alert staff if Ms C moved and the crash mat was by the bed.
There were many entries in the care plan evaluation form in October 2019. Most of the time, Ms C was not willing or able to stand so she had to be hoisted. The ‘care plan – evaluation/progress notes’ said that there were instances when Ms C was ‘shouting and screaming’ or was fighting the care workers when they tried to hoist her.
Later entries showed Ms C was ‘hoist only’.
By 19 November 2019 the care plan stated that Ms C’s mobility had declined and that she needed two carers at all times for moving and handling.
Fall – 9 August 2020 Incident report: Ms C had an unwitnessed fall at 05:30. She had a skin tear to the left shoulder and a swollen left cheek. The paramedics were called and their assessment concluded that Ms C did not need to go to hospital. The incident report stated: ‘According to the carers on the floor on the night of 09.08.20, [Ms C] declined to go to bed. [Ms C] spent the night in her chair with her legs on the foot stool.’
The report said residents should be put to bed at night and care workers should not leave residents in a chair throughout the night. If a resident refused to go to bed, carers should note this in the care plan. Carers should carry out two-hourly checks and reposition them.
The next of kin was informed and the CQC was notified of the incident. The CQC report said Ms C ‘had declined to go to bed, and had fallen asleep in the chair, with her legs up on a stool.’
The daily records showed that the last record for 8 August 2020, was recorded at 20:00 and said Ms C ‘appeared happy and settled, good diet and fluids encouraged. Full assistance given with wash and dress.’ The next record related to 9 August 2020 at 13:50 and said Ms C ‘appears well and content today. Good diet a mealtimes.’
A 72-hour head chart was put in place and a body map completed.
The daily records for the first ten days of August 2020 showed that there were other times when Ms C refused to go to bed and staff would leave her in her armchair or she would wake up during the night and request to be moved to the armchair.
Request for CHC checklist The contact records for 4 November 2020 said: ‘[Ms B] has contacted [the manager] several times with the request of asking for a referral for continuing healthcare. [The manager] has explained we don’t but we could ask GP.’
Ms B rang again that day to check whether the referral had been done and the Home told her that the GP was due to visit tomorrow.
The CHC team rang to say they had been contacted by the Doctor regarding a referral for a CHC checklist. The CHC team said Ms C’s relatives needed to contact the CHC and ask for a CHC checklist assessment. The Home passed on the message to Ms B.
The CHC checklist meeting took place on 16 November 2020 and the outcome was that Ms C would have a full CHC assessment.
The care plan was re-written on 19 November 2020.
The Home carried out a ‘Wiltshire Dependency Assessment’ on 19 November 2020 and said Ms C did not require nursing care.
A full CHC assessment was carried out in December 2020.
Ms C moved to a nursing home on 2 June 2021. The CCG approved CHC funding for Ms C on 11 June 2021, which was backdated to December 2020.
Further information The ‘care plan – evaluation / progress notes’ showed Ms C had three further unwitnessed falls on 3 January 2021, 31 January 2021 and 18 February 2021. The Home filled in an incident report for the fall on 3 January 2021, but not for the other two dates.
One of Ms B’s complaints related to the use of a pressure cushion so I have checked the document to find any information regarding the pressure cushion.
The ‘care plan – tissue viability’ document showed that Ms C bruised easily and had frequent problems with skin tears which were being treated by the district nursing team.
The ‘multi-disciplinary liaison document’ said on 9 September 2020: ‘GP called, refer [Ms C] to district nurse for pro-pad cushion.’ The Home said, in its response to the Ombudsman’s draft decision that it had no further evidence of this referral or outcome.
The ‘multi-disciplinary liaison document’ had the following entries in response to a complaint by Ms B that she found Ms C sitting on a black bin liner without her pressure cushion: 10 May 2021: The Home admitted it had put black bin liners to protect the cushion foam while the cover was being washed. It removed the bin liners and replaced the cushion cover.
10 May 2021: ‘[Ms B] also asked where [Ms C’s] purple cushion is for pressure relief. Informed that it had been taken off due to [Ms C] sliding off the chair. Call put [Ms C] onto ward round on 11/5 for referral to district nurse for a different pressure relieving equipment.’
11 May 2021: ‘Ward round with GP. Spoke about different cushion for chair. GP will do a referral to get different cushion.’
The care plan said on 20 May 2021 that a chair cushion was put in place.
Ms B’s complaint I have summarised the complaint under complaint headings: Complaint 1: Falls, communication and involving the family members in care planning Ms B said: She was shocked, at the CHC checklist meeting in November 2020, to see how much Ms C had deteriorated. She said the Home had failed to inform her when Ms C’s needs deteriorated and did not involve her in the changes to Ms C’s care plan.
Ms C had suffered falls and the Home had not informed her of the falls, nor had it kept an adequate record of the falls.
The Home said: Response – May 2021 It invited Ms B to a review of Ms C’s care plan in January 2020, but received no response. The Home admitted it had slipped in its care plan reviews because of the Covid pandemic.
The Home had re-written sections on Ms C’s care plan on 19 and 27 November 2020. The Home manager apologised to Ms B for not including her in initial care plan reviews.
There had been occasions when Ms C ‘had unwitnessed slips and has been found on her crash mat by the bed’. The Home said admitted it could not ‘find any evidence that an incident log was completed and that you were advised of these slips’.
Response – June 2021 Ms C had fallen 5 times that were witnessed and 5 ‘slips’ that were unwitnessed but recorded in the daily notes but not the incident logs.
Analysis The records showed that Ms C had a fall on 8 April 2019, 31 January 2021 and 18 February 2021. The Home did not fill in an incident report, nor did it contact the family. The Home has admitted that there were at least five slips/falls where it did not fill in an incident report and did not contact the family. This was fault.
I have further investigated the falls where the Home kept a full record. The records show Ms C suffered four falls between 11 and 22 July 2019. Ms C broke her wrist during the first fall and this affected her mobility as she was less able to use her stick or Zimmer frame.
There was fault as the Home failed to notify the family of the falls on 15 and 19 July 2019.
It was difficult, from the paperwork to determine what changes the Home made to the care plan and why. As there were so many different overlapping sections, it was difficult to determine what the care plan was at any given stage.
I could not find much analysis on what the causes were of the falls and any checks on whether the measures in the care plan to reduce the risks of falls were working. For example, I note that the Home put in an alert sensor mat, although it was difficult to say when this happened. I presume the purpose of the alert mat was to ensure that, if Ms C was attempting to get up, a care worker would be alerted and go to her room and help her as it was unsafe for her to walk unaided.
However, there was no proper analysis of whether this plan was working. I note that the alert mat worked on 19 July 2019 but there is no explanation why Ms C was able to get out of bed without triggering the mat on the other occasions.
If the alert mat was not activated on the other dates, then the Home should find out why this was. If the alert mat was activated, then the Home should check how quickly the care worker attended. This information was not recorded.
I uphold Ms B’s complaint that the Home failed to involve her in changes in the care plan. Ms C’s needs changed significantly following the falls in July 2019. Previously she was still relatively mobile, but, in the following months, she was mostly hoisted from bed to chair, doubly incontinent and often resistant to the care.
The Home addressed these changes in Ms C’s needs by changes to the care plans, but it should have involved Ms C’s family in the reviews/changes of the care plan and failed to do so.
Complaint 2: Incident on 9 August 2020 Ms C suffered a fall during the night on 9 August 2020. Ms C fell out of her chair at 5:30 am and was fully dressed when she was found by the ambulance crew.
Ms B said: It took the Home three days to find out why Ms C was fully dressed in her chair at 5:30 am when she had her fall because the Home had not properly recorded the fall.
The records about the incident and the referral to the CQC did not clarify that Ms C was in a swivel chair when she fell.
The Home did not carry out an appropriate risk assessment of Ms C sleeping in the swivel chair.
Sleeping in the swivel chair increased the risk of falls. The sides of the chair were low and, if Ms C sat on her pressure cushion, she would be at even higher risk of falls. It also meant that, when Ms C fell, the Home was not alerted to the fall because Ms C did not fall on the alert mat.
Ms B removed the swivel chair, on the advice of the district nurse who agreed with her that the swivel chair was not appropriate.
The Home said: Response – May 2021: The fall was unwitnessed and ‘Therefore, no one is able to evidence that [Ms C] had swivelled in her chair before falling.’
The Home had noted that ‘[Ms C] had declined to go to bed that night and fell asleep in her chair with her feet up on a stool.’ The Home could not comment further due to the lack of records, which it had addressed with the manager.
The Home was ‘unable to recall’ whether it had been asked to provide a pressure mat for [Ms C].
The Home’s manager was ‘unable to confirm’ what happened in relation to the swivel chair as she was on leave at the time.
Response - June 2021: ‘Ms C was put in her night clothes at 8 pm the previous night after personal care and was in bed.’
‘[Ms C] was in bed at 8 pm and at 12 midnight was cared for in her chair, her repositioning was at 3am and she was found on the floor at 5 am.’
There was no risk assessment for the chair which was described as a fixed base with tilt back. ‘As the chair was not on site, I was unable to view it but the staff inform me that it was recliner that tilted but did not swivel.’
Response - July 2021: The daily record shows Ms C was in bed at 20:00. The repositioning chart shows she was in her armchair at 23:00 and she remained there until her fall at 05:30.
Analysis The record keeping for the day of the incident was poor and therefore it was difficult to say what exactly happened. There was hardly any detail in the daily record and there were no daily records from 20:00 on 8 August 2020 until 13:50 on 9 August 2020. The Home had a duty to properly record the care it was giving and failed to do so.
I am also concerned about the different complaint responses the Home has provided to the family. The incident report and the referral to the CQC both said that Ms C declined to go to bed and spent the night in her chair. This was also the response the Home initially provided to the family in May 2021. In this response the Home also admitted there was a lack of records so it could not comment further.
However, in the Home’s later responses dated June and July 2021, the Home said Ms C had gone to bed at 20:00 and was put in her night-clothes, but then got up at 23:00 and was put in her chair. As Ms C was found fully dressed in her chair at 05:30, this would suggest that the care staff changed Ms C into her day-clothes at 23:00 which would be odd.
The underlying issue is that the record keeping was poor and the further communication with the family was contradictory which increased the family’s concerns that the Home was trying to hide something.
In terms of the swivel chair, I am, again, concerned that in the initial complaint response dated May 2021, the Home admitted it could not say whether Ms C had swivelled before falling, which suggested that Ms C had been sitting in a swivel chair. However, in later responses, the Home said the chair had a fixed base.
I can make a decision on the balance of probabilities and I accept Ms B’s evidence that Ms C brought her swivel chair with her when she moved to the Home. Ms B removed the chair after the fall in August which is why the chair was no longer present when Ms C made her complaint.
There is no mention that the alert mat was activated when Ms C was found after her fall. I am concerned, as mentioned before, why the Home did not question this. The care plan said the alert mat should be put in front of Ms C’s chair if she was in her chair. So, either the mat was not put in front of the chair, or the mat malfunctioned or the chair swivelled. Unfortunately, as this was not checked or recorded, the Home was unable to draw lessons from the incident to ensure it did not happen again.
I agree with Ms B that the Home should have carried out a risk assessment of Ms C sleeping in a swivel chair as the records showed that Ms C frequently slept in the chair and this increased the risks of falls.
Complaint 3 - CHC assessment Ms B said: The Home failed to recognise that Ms C’s needs had changed and that she needed nursing care instead of residential care. Ms B asked the manager if she thought Ms C may be eligible for CHC funding and the manager said the Home was not a nursing home and did not do CHC assessments. She thought maybe Ms C’s GP may be able to help.
The Home said: May 2021 response: Ms C was assessed in November 2020 using the Wiltshire Dependency Tool and the outcome was that she needed ‘residential enhanced’ care, but not nursing care. The Home manager was confident that the Home could fully meet Ms C’s needs.
June 2021 response: The Home did not carry out CHC assessments as they were carried out by the local authority. The manager said Ms C was ‘borderline residential/nursing’.
I asked the Home why it had not made the referral in November 2020 and the Home said ‘this is not something that Willowcroft would do and at this time it was not deemed, in accordance with the Wiltshire dependence result, that [Ms C] needed nursing care.’
Analysis I accept that the Home would not carry out the full CHC assessment, but I am surprised by its unwillingness to make a referral for a CHC checklist assessment. The Home advised Ms C that the request had to be made by a GP and this was not the correct advice. Both the Home and a family member could have made the request.
The Home should have made that clearer to Ms C. The threshold for a CHC checklist is low and the Home said, in its letter dated June 2021 that Ms C was ‘borderline residential/nursing’ so a referral was appropriate at that stage.
However, I cannot say that Ms C suffered substantial injustice as a result of this as the request for CHC checklist was made soon after it was raised by Ms B. I also note that CHC funding can be received in any setting, care home or nursing home so an approval for CHC funding does not mean that a person has to move to a different setting.
Complaint 4: Cuts and bruises in December 2020 Ms B said: Ms C was covered in cuts and bruises during a video call in December 2020 and had a bandaged wrist. The Home was unable to explain how the injuries happened or why the wrist was bandaged.
The Home said: ‘I have not found any documentation pertaining to a bandage applied to [Ms C’s] right wrist in December 2020.’ The Home made a referral to the district nurse regarding a tear to Ms C’s left arm on 30 December 2020. It could not say what caused the skin tear and speculated it could relate to the fall in August 2020 and had re-opened.
Analysis The Home should have kept a proper record of cuts and bruises when they first occurred. It should have documented the causes of the cuts and bruises so that I could assess how to avoid further cuts and bruises. Its failure to do so was fault.
Complaint 5 - Inappropriate lifting – 7 May 2021 Staff attempted to move Ms C without a hoist on 7 May 2021. This only came to light because the specialist dementia nurse witnessed it. The matter was reported to the council’s safeguarding team and the CQC.
The Home has upheld this complaint and I agree this was fault. The Home should have followed the ‘moving and handling’ care plan at all times and failed to do so. This put Ms C and staff at risk of injury.
Complaint 6 - 10 May 2021 incident (bin liner and pressure cushion) Ms B said: She visited Ms C on 10 May 2021 and Ms C was sitting on a black bin liner. When she asked why this was, she was told the covers of the chair were being washed.
The staff also removed the pressure cushion as she kept slipping off the cushion or the cushion kept slipping from the chair. Ms C was informed it had been removed a month earlier.
The Home said: May 2021 response: The Home said, in relation to the fall on 9 August 2021 that the ‘Home Manager was unable to recall having been asked to provide a pressure mat for [Ms C].’
June 2021 response. The Home apologised for Ms C sitting on a bin liner on 10 May 2021. The Home said staff had been reminded that this should not happen again.
June 2021 response. There was no pressure cushion on the chair as Ms C did not need one. Ms C’s skin was in good condition and there was no tissue viability damage through pressure.
Analysis Clearly, Ms C should not have been sitting on a bin liner. The Home has already upheld this complaint and I agree this was fault.
I have first considered what the records said about Ms C needing a pressure cushion. The ‘multi-disciplinary liaison document’ said Ms C had a pressure cushion before 10 May 2021, but it had been removed because Ms C was sliding off the cushion. The Home was going to find a replacement via the district nursing team or the GP but then obtained a replacement via the GP, on the following day.
Therefore, the records showed Ms C needed the pressure cushion and this was not provided. If the cushion needed to be replaced, the Home should have sought a replacement earlier and it appears this did not happen until Ms C raised the problem.
I am also concerned that the Home changed its complaint response in June 2021 to suggest that Ms C did not need a pressure cushion, when this was not correct. I am also concerned about its statement that Ms C’s skin was in good condition which contradicted the 11-page ‘tissue viability – care plan’ which had been written to address all the concerns about Ms C’s skin.
Complaint 7 – record keeping and communication Ms B said: The Home’s overall record keeping was poor. The Home said at the CHC meeting in November 2020 that it did not keep a record of continence pad changes, nutrition or fluid intake. Written records were not kept and information was passed on verbally.
The Home was asked, at the CHC review meeting, how often Ms C was given laxatives and how often she opened her bowels. The Home said ‘as and when’, but said it did not keep records, only told the next shift verbally.
In its response to the draft decision, the Home explained that it would start a bowel record chart if there was an individual need to do so and it has sent me a copy of the chart.
Analysis I do not uphold the complaint that the Home kept insufficient records regarding the bowel movements. The Home has provided evidence that it kept a record of the bowel movements when this was required.
I uphold Ms B’s complaint that the Home’s record keeping was poor. I have already touched upon this in the other complaints, but to summarise, I note the following: The daily records did not provide enough detail of the care that had been provided. Often, there would only be one or two entries for an entire day.
As an example, the records of 8 and 9 August 2020 were too sparse to allow the Home to explain what happened and why Ms C fell.
The recording of the care planning was confusing as it was difficult to say, at any given point what the care plan was. I note the Home summarised the care plan in November 2020, presumably because of the CHC checklist assessment.
The Home admitted that it could not say whether Ms C needed a pressure mat or whether she had a swivel chair because it could not remember. These matters should have been recorded.
The Home admitted it did not fill in incident reports or properly record five occasions when Ms C had slips/falls.
The failure to properly record the cuts and bruises in December 2020.
The Home’s communications with Ms C’s family was also poor. As described above, the Home did not always fully involve the family in the care planning for Ms C. When the Home responded to the complaints, there were changes in the responses and a lack of clarity.
Injustice Ms C suffered the main injustice as there was poor care on a number of occasions. There was poor record keeping which raised the uncertainty whether the care was properly delivered and whether the Home properly reviewed Ms C’s care plan. The Home then failed to involve the family in the changes to Ms C’s care plan which exacerbated the problem.
In its final complaint response to the family dated July 2021, the Home apologised to the family and said it would deduct four weeks of care costs to reflect ‘the disruption this inevitably caused’.
As this is more than the financial remedy the Ombudsman would recommend to remedy the injustice to Ms C, we do not recommend a further financial remedy for Ms C.
I also do not underestimate the distress Ms B has suffered in worrying about Ms C and what happened. The poor record keeping and the contradictory complaint responses made matters worse. Ms B spent a considerable time pursuing the complaint as she was not satisfied with the responses she received. I therefore also recommend a remedy to reflect Ms B’s distress and time and trouble in pursuing the complaint.
Agreed action
The Home has already deducted four weeks of fees from Ms C’s invoice.
The Home has agreed to take the following actions within one month of the final decision. It will: Apologise in writing to Ms B and Ms C for the fault.
Pay £250 to Ms B.
Review its recording practices and remind staff of the importance of keeping good records.
The CQC is best placed to address some of the concerns I have identified in this decision. Under our information sharing agreement, we will share this decision with the Care Quality Commission.
Final decision
I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has already remedied part of the injustice and has agreed a further remedy to address the injustice.
Parts of the complaint that I did not investigate I have not investigated Ms B’s complaint about the Home’s refusal to disclose Ms C’s care records to her. The ICO is far better placed to investigate this complaint and I understand Ms B has raised this complaint with the ICO.
Investigator's decision on behalf of the Ombudsman