Summary: Ms X complained staff at the care home where Mr Y was a resident neglected him and were racist. There is no evidence of fault or a racist approach in the care and support the care home provided to Mr Y.

The complaint

1. The complainant, whom I shall refer to as Ms X complained staff at the care home neglected Mr Y and were racist. She complains the care home’s treatment of Mr Y led to his death.

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The Ombudsman’s role and powers

2. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended).
3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended).
4. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them.
5. 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

6. As part of the investigation, I have:
• considered the complaint and the documents provided by Ms X;
• made enquiries of the Council and considered the comments and documents the Council provided;
• Ms X and the Council 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

7. Mr Y moved to Care Home 1 in September 2022. The Council commissioned this placement on Mr Y’s behalf, following a best interest decision as Mr Y did not have capacity to make decisions about his care. Mr Y was supported by Independent Mental Capacity Advocate (IMCA). Mr Y had a number of medical conditions, including a diagnosis of Alzheimer’s Dementia. The Council’s records say Mr Y’s needs had increased in recent months and he now needed nursing care, particularly in relation to mobility, skin integrity, nutrition and his medication regime. Mr Y received two to one support for all his personal care.
8. When Mr Y arrived at Care Home 1, staff noted he had a grade 3 pressure sore on his ankle, and he was at very high risk of developing pressure damage.
9. Shortly after Mr Y moved to Care Home 1 he was admitted to hospital for almost a week. While he was there the Speech and Language Therapy (SALT) team placed him on a pureed diet. Mr Y’s medication was also changed to a liquid form.
10. A medical review in October 2022 noted Mr Y’s dementia had progressed and his care needs were high. Mr Y was bedbound and as he was at a high risk of choking he had a mostly pureed diet. The doctor wrote to Mr Y’s GP suggesting they assess Mr Y’s pain levels and introduce appropriate analgesia.
11. In November 2022 Ms X raised concerns about the care Mr Y was receiving at Care Home 1. In a telephone call with a Council officer she said he was never given any water and his personal care was not adequate. Ms X asserted he was being left in bed for too long in the same position, which was causing him to develop bedsores. She also felt there was a racist element to the poor care. The Council’s records state Ms X did not believe Mr Y had dementia and that he was presenting in the way he was due to neglect and racial abuse he experienced at the hospital and the care homes he had been in.
12. Ms X believed Care Home 1 was preventing Mr Y from walking and preventing him from eating food and drinking. According to the Council’s records the officer tried to explain Mr Y’s condition had deteriorated and he now needed a full-time nursing placement, but Ms X disagreed and ended the call.
13. Care Home 1 informed the Council in early December 2022 Mr Y’s medical condition had deteriorated and he was receiving end of life care. Care Home 1 said Mr Y had a pressure ulcer and explained the action taken, including a referral to the Tissue Viability Nurse. Mr Y was repositioned regularly and there was an air mattress in place. It also confirmed the GP had reviewed Mr Y’s condition.
14. Mr Y died a couple of days later.
15. In February 2023 Ms X made a formal complaint to the Council about the care Mr Y received at Care Home 1. The Council’s response noted that Mr Y had not had capacity to consent to Ms X acting as his representative. And that Ms X did not have authority to make decisions or act on Mr Y’s behalf. In the circumstances, the Council was unable to share Mr Y’s personal information with Ms X.
16. It did however confirm it had carefully considered Ms X’s concerns in conjunction with Mr Y’s care plan. The evidence demonstrated Care Home 1 followed the advice provided by SALT and the Occupational Therapist (OT) in relation to Mr Y’s nutrition and positioning. The Council told Ms X it had found no evidence to substantiate her allegations of neglect or racism.
17. Ms X then complained directly to Care Home 1 in May 2023. The Care Provider responded in detail to Ms X’s concerns about Mr Y’s nutrition and hydration; personal care; weight, skin care and pressure damage; medication; and comfort. The Care Provider noted Mr Y was very poorly when he arrived at Care Home 1 and his prognosis was such that he was receiving End of Life care from the start of his stay.
18. The Care Provider was satisfied Mr Y received appropriate and personalised care which met his support needs. It confirmed it had found nothing to substantiate Ms X’s concerns and there was no indication of a culture of racism in the home. It could find no substance to Ms X’s allegation of racism from staff towards Mr Y.
19. Ms X remains dissatisfied and has asked the Ombudsman to investigate her concerns. Ms X maintains racism and neglect at Care Home 1 led to Mr Y’s death. She says this has affected her own and her son’s health and would like an apology, compensation, and a change in Care Home 1’s policies and procedures.

Analysis

20. The Council contracted with the Care Home to provide Mr Y’s care under powers and duties in the Care Act 2014. We can investigate the Care Home’s service. Any fault we find is a failing by the Council.
21. As Ms X was not Mr Y’s representative and did not hold power of attorney to manage his health and welfare or his finances the Council has only shared limited information with Ms X. The Care Provider has provider greater details of Mr Y’s condition and care but Ms X was not involved in decisions regarding Mr Y’s care. It is therefore likely Ms X was not fully aware of the extent of the deterioration in Mr Y’s health or the professional advice regarding his care.
22. I have carefully considered the information provided by the Council but am unable to share this with Ms X as it is Mr Y’s personal information. Based on the documentation available there is no evidence of fault in the care and support Care Home 1 provided to Mr Y. Mr Y was receiving End of Life care. He was cared for in bed and received a pureed diet based on medical advice.
23. Ms X alleges there was a racist approach to Mr Y’s care at Care Home 1 but has not provided specific examples or details of any racist action. There is no evidence of racism towards Mr Y in the documentation available.

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Final decision

24. There is no evidence of fault or a racist approach in the care and support Care Home 1 provided to Mr Y.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman