Hertfordshire and West Essex Integrated Care Board

4. Ms K complains about the Organisation. She complains it:

• did not oversee and respond appropriately to the concerns she raised on 27 September 2022 about the care being provided to her father whilst he was a resident in a care home between March 2022 and January 2023 and did not recognise and act on the poor care he was receiving by inexperienced/untrained agency carers through 1:1 care.

5. Ms K says the lack of response or action from the Organisation resulted in ongoing inadequate care, distress, and anxiety for her father until his death in January 2023 because no changes were made despite her raising concerns. She says the lack of action from the Organisation also impacted greatly on her emotional and mental wellbeing. She experienced stress, fatigue, and flashbacks.

6. Ms K wants the Organisation to accept responsibility and accountability. She wants to understand why the Organisation did not take her concerns seriously whilst her father was a resident in the care home and why it took no action.

7. Mr K had severe dementia which included frequent hallucinations. He became a resident in a care home on 14 March 2022. His care was funded by Continuing Healthcare (CHC) via the then West Essex Clinical Commissioning Group. This organisation is now Hertfordshire and Essex Integrated Care Board. It provided funding for 1:1 support due to Mr K’s complex needs.

8. Ms K says staff in the care home provided inadequate care to her father. They carried out unsafe transfers, lacked skill in personal care, did not refer to his care plan, did not adhere to risk assessments or keep adequate records. She says staff were not appropriately trained in dementia care or the use of essential equipment.

9. On 27 September Mr K fell from his bed, sustaining injury and resulting in a hospital admittance. Ms K made a complaint to the home and alerted the Organisation.

10. Mr K died on 4 January 2023. Ms K says the inadequate care continued until the time of his death.

Did not oversee and respond appropriately to concerns and did not recognise and act on the poor care Mr K was receiving

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

14. Ms K says she witnessed staff at the care home providing inadequate care to her father throughout his stay there. This culminated in Mr K having a serious fall from his bed on 27 September 2022 whilst his 1:1 carer was in attendance. This resulted in injury and a hospital admission.

15. At this time Ms K contacted the Organisation to express her concerns about the care her father was receiving. She raised concerns about his risk assessed needs not being met, inadequately trained staff, and the neglectful care that had led to his fall.

16. We can see Ms K informed the Organisation’s Continuing Healthcare (CHC) service manager of her concerns on 27 September 2022. On 29 September the CHC service manager visited the care home and conducted a welfare check. They did not identify any concerns regarding Mr K’s care and care package.

17. We also note the Organisation had a discussion with Ms K about the possibility of Mr K moving to a different home. This indicates the Organisation considered Mr K’s care package and how risks could be mitigated. Unfortunately, a move could not be facilitated due to Mr K’s frailty, so he remained at the care home.

18. On 28 September 2023 the Organisation tried to arrange a meeting with Ms K but she turned this down. Ms K says this was because she had already raised her concerns in writing. Records indicate it was agreed the care home would investigate the concerns raised.

19. The NHS complaint Regulations (section 7) say when a commissioner (such as the Organisation) receives a complaint about a provider (such as the care home), if the commissioner considers it is more appropriate for the provider to deal with the complaint, and the complainant consents, the commissioner must notify the provider of the complaint, and the provider will then handle the complaint. In this situation the complaint is deemed as having been made to the provider. This is what happened to Ms K’s complaint.

20. The care home carried out an initial investigation and records indicate a response was sent to Ms K on 6 December 2023. Ms K says she did not receive an adequate response at this time. She made a further complaint to the care home in February 2024. The care home sent a final response on 17 April 2024.

21. This is a detailed response acknowledging all her concerns. It accepts Mr K did not receive adequate care on a number of occasions. It acknowledges the issues concerning agency staff and the related shortfall in care. It apologises for the experience Ms K and Mr K had with the care home. It says the care home has learned lessons from the complaint, identified failures and continues to work to improve its service.

22. The Organisation says Ms K’s concerns have been investigated by the care home and a response has been provided to Ms K, and it will not duplicate this work.

23. Ms K consented to the care home carrying out an investigation into her concerns about the care provided to her father. The Organisation acted in line with the NHS complaints regulations when it decided not to investigate Ms K’s complaint thereafter. Therefore, we cannot see indications of failings in this area.

24. The Department of Health safeguarding guidance says commissioners (like the Organisation) have a responsibility to address failures in care with providers, in line with multi agency procedures. It says commissioners must work collaboratively with local safeguarding adults board partners such as the local authority. Safeguarding adults boards have a legal duty as set out in the Care Act 2014 to protect adults who are experiencing (or are at risk) of abuse and neglect. The guidance also sets out that the Care Quality Commission has responsibility for ensuring that healthcare providers comply with essential standards of quality and safety.

25. We can see the Organisation’s CHC manager discussed Ms K’s concerns with the ICB Adult Safeguarding Team at this time and referred their concerns to Essex County Council (the Local Authority). The Organisation followed its statutory duties and acted in line with local multiagency procedures by making a referral to the Local Authority when it was made aware of concerns about Mr K’s care. We can see the CQC was also aware of the situation and passed information to the Local Authority.

26. The Local Authority completed a safeguarding assessment and provided a report on 30 June 2023. It concluded on the balance of probability the allegations of neglect and acts of omission were substantiated. It found evidence the care home neglected Mr K and the fall could have been prevented if his care plan was adequately met. It provided a safeguarding management plan which recommended actions to mitigate the risk of reoccurrence. It advised Ms K the Organisation would have the responsibility for reviewing any recommendations following the end of its enquiry.

27. Ms K questions why the Organisation did not follow up the recommendations made by the Local Authority to ensure safer care was being provided. She made a formal complaint to the Organisation on 22 April 2024. She complained the Organisation did not ensure the appropriate care was being provided to Mr K despite her raising concerns at the time. She says the neglectful care continued up until his death. Ms K considers the Organisation neglected its duty of care as the funding body.

28. We recognise Ms K’s view that as the commissioners the Organisation had a responsibility for ensuring Mr K’s needs were being met through the CHC funded care.

29. The National Framework for Continuing Healthcare (paragraph 195) says commissioners have overall responsibility for monitoring quality, access, and patient experience within the context of provider performance. It also says commissioners should take into account the role of the Care Quality Commission (CQC) and Local Authority to avoid duplication.

30. We can see from the records both the CQC and Local Authority were investigating the issues relating to Mr K’s care. Given this, it was in line with National Framework for the Organisation to not take any further action, to avoid duplicating work that was being done by other agencies.

31. We can see the CQC assessed the home in August-September 2023. We can understand Ms K’s concern that the CQC assessed that the home ‘requires improvement’ as it was not meeting the essential standards for a safe, effective and well led service. The CQC was aware of the concerns raised by Ms K, and it is its role as the regulator to monitor the overall care being provided and whether any improvements are needed.

32. We realise this process has caused Ms K stress and anxiety. Ms K has told us her upset at not being able to care for her father at home, especially when she was so aware of the inadequate care he was receiving. We understand why it is important for her that his poor care is acknowledged by all involved. We hope she can understand why we cannot take her complaint further. Our decision does not take away from the poor experience Mr and Ms K had. We thank Ms K for bringing her complaint to us and wish her all the best for the future.

1. We have carefully considered Ms K’s complaint about Hertfordshire and West Essex Integrated Care Board (the Organisation). We understand how distressing it was for Ms K to witness her father experiencing inadequate care in the care home. We understand she feels the Organisation should accept some responsibility for this as the funding body. We are sorry to hear how this experience impacted on her. We also offer our condolences for the death of her father.

2. Taking into account the evidence we have seen, we consider the Organisation acted appropriately when Ms K told staff about her concerns. We have seen the Organisation acted within relevant policy and guidance.

3. We want to thank Ms K for the time she has taken to bring her complaint to us. We hope our explanation below will explain why we will not be taking her complaint further.