The Ombudsman's final decision
Summary: Mr and Mrs X complained on behalf of their relative, Mr Y, about poor service and poor care whilst Mr Y lived in a Council-commissioned care home. They say poor care led to Mr Y being admitted to hospital where he later died. The Council was at fault. There was poor record keeping and poor communication from both the Council and the care provider which caused Mr and Mrs X uncertainty and distress. However, the evidence does not show Mr Y received poor care. The Council has already apologised to Mr and Mrs X, written off some advanced care charges and acted to improve its service. It will now pay Mr and Mrs X £200 to acknowledge the distress and uncertainty caused by poor record keeping and poor communication.
The complaint
Mr and Mrs X complained on behalf of their relative, Mr Y, about poor service from adult social services and poor care whilst Mr Y lived in a Council-commissioned care home. They said the poor service and poor care led to Mr Y being admitted to hospital, where he later died.
They want the Council to accept there was poor service and poor care, write off the outstanding care fees and act to improve services.
The Ombudsman’s role and powers
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) When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
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)
How I considered this complaint
I read Mr and Mrs X’s complaint and spoke with Mr X about it on the phone.
I made enquiries of the Council and considered information it sent me.
Mr and Mrs X and the Council had the opportunity to comment on the draft decision. I considered comments received and discussed Mr X’s comments with him on the phone before making a final decision.
What I found
Background information 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 fundamental standards include minimum standards for: Person-centred care Maintaining accurate and complete records Ensuring people are treated with dignity and respect Safe care and treatment When investigating complaints about the standards of care in a care home, we consider if the 2014 regulations and the fundamental standards have been met. If they have not, we consider whether any identified faults have resulted in injustice.
Continuing healthcare (CHC) is a package of NHS funding awarded to people whose primary need is a health need. There are strict eligibility criteria, but if a person is deemed eligible following assessment, the NHS will then pay for the care required to meet the person’s needs.
What happened In 2020, Mr and Mrs X’s relative, Mr Y, had dementia and other health conditions. Mr Y lived alone in his own home with support from home carers four times a day. The carers applied cream to Mr Y’s legs daily and applied leg wraps to help control swelling.
He also had regular visits from a podiatrist to dress a wound on his heel.
Mr X says during this time the podiatrist had no concerns. Mr and Mrs X did not live close to Mr Y but visited regularly to provide support and were in frequent contact over the phone.
In September 2020 Mr Y was struggling to cope at home. Mr X contacted the Council to request a review of his care needs and ongoing support.
The Council assessed Mr Y’s needs. It gathered Mr Y’s views and those of Mr and Mrs X. Mr Y and Mr and Mrs X all said they felt Mr Y needed residential care. They told the Council their preferred care home was care home B. The Council completed its assessment and agreed that residential care would meet Mr Y’s needs.
The Council contacted care home B who agreed it could meet his needs and had a bed available. Mrs X told the Council she would take Mr Y to care home B the following week. The Council told her it would review Mr Y after two weeks, to ensure that he was happy with care home B and wanted to stay. It also said it would ask care home B to arrange an occupational therapy assessment to assess Mr Y for any equipment needs, including whether it could provide a riser recliner chair. However, the records do not show the Council did this.
Mr Y moved to care home B at the end of September 2020.
Two days later, a nurse visited to teach care home staff how to apply Mr Y’s leg wraps. They told care home B he should wear the leg wraps for 12 hours a day. The district nurses agreed to visit twice a week initially to change the leg wraps, with care home staff completing them on other days. The podiatrist also visited the same day to dress the wound on Mr Y’s heel.
Over the next week, the care notes show Mr Y was settled and was eating and drinking well.
On 9 October 2020, the district nurse visited Mr Y to re-dress his heel and review how care staff were managing. The district nurse and care home agreed their nurse would take over the dressings from this point on and that care staff would apply the daily leg wraps.
Mr X asked the Council to arrange for Mr Y to have a CHC assessment, to assess if Mr Y was eligible for CHC funding. The Council rang care home B and asked it to arrange an assessment.
Records show Mr X also asked the care home to do this.
On 14 October 2020, Mr Y became unwell and was admitted to hospital.
Mr Y remained in hospital and passed away four weeks later.
In December 2020, Mr and Mrs X complained to the Council and the NHS. They complained about the care he received at care home B and during his hospital admission. The complaint against care home B included that: Care home B had not ensured Mr Y had all the equipment he needed, which included a riser recliner chair, a footstool, bedrails and a waterproof covering for his leg dressing for use when showering or bathing.
Bed rails were requested and not completed, and the care home fitted a ‘falls mat’ for Mr Y without communication to Mr X as his legal representative.
His leg wraps were not applied daily.
His heel dressing was not changed regularly.
Staff had allowed his heel dressing to get wet as they did not use appropriate equipment to keep his dressings dry whilst using the shower.
Care home B responded to the complaint and said it: Apologised it had not clearly explained prior to admission that it could not provide a riser recliner chair, and this would have to be assessed for by an occupational therapist. The home did have footstools and it is unclear why they were told otherwise. A decision to fit bed rails would need a risk assessment by staff, and would not be fitted just because family requested them.
Accepted there were errors and omissions it its documentation. It said there were some days where it was not recorded whether or not staff applied Mr Y’s leg wraps and one day where there was no record of whether the nurse changed Mr Y’s heel dressing.
Accepted staff should have been more proactive in contacting district nurses to obtain a waterproof covering for Mr Y’s leg dressings but said there was no evidence staff had allowed the dressings to get wet.
It apologised to Mr and Mrs X for the errors in documentation and poor communication on admission. It said it would ensure lessons were learnt from the complaint and it would conduct further staff training as needed.
Mr and Mrs X remained dissatisfied and complained to the Council. In addition to their previous complaints, they said the Council had not put a contract in place and the care home had sent Mr Y a bill for the whole of October and November, despite him being admitted to hospital part way through October. They alleged there were systematic failures of process due to poor training, based on the replies received from the care home.
The Council reviewed Mr and Mrs X ‘s complaint and the responses provided by care home B. The Council provided three further complaint responses. In summary these said: Its records showed Mrs X had asked the social worker about whether Mr Y would have a riser recliner chair. The social worker said she would contact care home B to discuss this and request an occupational therapist assessment. Although the social worker said she did this, it was not documented in Council records.
It accepted Mr and Mrs X had requested a CHC assessment for Mr Y but this was not completed.
It acknowledged there was no contract in place between Mr Y and care home B, as neither the care home manager nor the social worker had issued this. It acknowledged they had been sent a bill for the whole of October and November.
It apologised to Mr and Mrs X for the poor record keeping, the lack of care contract and the fact the care home did not complete the CHC assessment as they had requested. It agreed to refund the care fees for November for the period after Mr Y had passed away. It said it would share details of the complaint with its commissioning team, who would consider the points raised in the complaint and continue to monitor and improve the standards of care at care home B.
Mr and Mrs X remained dissatisfied and brought their complaint to us.
In its response to our enquiries, the Council said that since November 2020, it has continued to work with care home B to monitor and improve the service. It provided evidence of this ongoing work to us.
It said it only became aware of Mr and Mrs X’s complaint in October 2021 when they brought it to the Council. It then reviewed the care providers responses and provided further responses to ensure all points of complaint were responded to. It said it had accepted some fault and since reviewed its response to Mr and Mrs X’s complaints. It said it wished to offer them its apologies and £200 in recognition of the upset and distress caused.
It said it had credited Mr Y’s account to refund the care fees for after he was admitted to hospital. It confirmed there was still fees outstanding for Mr Y’s care during September and mid-November 2020.
Analysis Where a care provider is providing a service on behalf of a council, we consider the council to be responsible. Although I have considered the care home’s actions as part of this investigation, as the Council commissioned Mr Y’s care I have made findings against the Council.
In their complaint responses, the Council and care provider accepted there was poor record keeping. I have reviewed the records and agree with this finding because: There were no specific care plans for Mr Y’s leg wraps or heel dressing.
It was not clearly documented when care staff changed the leg wraps and how long Mr Y had them in place each day.
It was not documented whether the care home nurse changed Mr Y’s heel dressing between 9 and 14 October 2020.
Some of Mr Y’s care plans contained contradictory information, particularly related to his mental capacity.
There was no record of what happened when Mr Y was admitted to hospital.
The poor record keeping is fault and has caused uncertainty as to whether or not the care home was meeting Mr Y’s needs.
The Council has also accepted there was poor communication. I agree with this finding because: The care home has accepted it did not contact Mr and Mrs X prior to Mr Y’s admission to gather information and discuss his ongoing care needs.
The Council and Mr X asked the care home to complete a CHC assessment, but the care home did not do this.
Council records do not show that the social worker asked the care home to request an occupational therapist assessment, as agreed during the phone call with Mrs X.
Care home B did not explain to Mr and Mrs X prior to admission that it could not provide a riser recliner chair, and that this would either have to be provided following an occupational therapist assessment or Mr and Mrs X would need to bring in Mr Y’s riser recliner chair from home.
The poor communication is fault and added to the distress and uncertainty felt by Mr and Mrs X.
Despite the poor record keeping and poor communication, I cannot say this is evidence there was poor care. This is because: The district nurses were completing Mr Y’s heel dressing and monitoring the leg wraps prior to 9 October 2020. When they reviewed Mr Y on 9 October, they were satisfied care home B was competent to take over the management of these. Because of this decision and on the balance of probabilities, I consider it more likely than not that the care home was applying the leg wraps before this time. Between 9 and 14 October there are four days where the records show the leg wraps were applied and two days where it is not documented. I cannot know whether they were applied on these days, only that the lack of documentation makes it unclear as to whether they were completed.
Although the Council has accepted the care home should have been more proactive to request a specialist waterproof covering for Mr Y’s dressing from the district nurses, the records show the care provider did improvise to ensure it was covered during bathing. There is no evidence the dressing got wet or that the lack of specialist covering caused Mr Y any harm.
Although there was poor communication related to Mr Y’s need for a riser recliner chair and use of footstool, the notes show the care provider encouraged him to lie on the bed to raise his legs during the afternoon, to help reduce any swelling. This is an appropriate way to reduce the risk of lower limb swelling and there is no evidence the lack of a riser recliner chair or footstool caused Mr Y harm.
The records are at times poor, but I cannot say this is evidence of poor care or that poor care led to Mr Y being admitted to hospital. However, the poor record keeping and poor communication have caused Mr and Mrs X uncertainty and frustration.
The Council and care provider have already apologised to Mr and Mrs X in their complaint responses for the upheld points of complaint. The Council has now offered Mr and Mrs X £200 as an acknowledgement of the distress and uncertainty caused by the identified faults. This is an appropriate offer and is in line with our guidance on remedies.
Mr and Mrs X told us they wanted the Council to act to improve the care provided. I have seen evidence of Council actions since November 2020 to monitor and improve the standard of care provided at care home B. I am satisfied the Council has taken appropriate action to improve the service and ensure a satisfactory standard of care for residents.
Agreed action
Within one month of the final decision, the Council will pay Mr and Mrs X £200 in recognition of the distress and uncertainty caused.
Final decision
I have completed my investigation. I have found fault and the Council has agreed action to remedy the injustice caused.
Investigator's decision on behalf of the Ombudsman