A CARE home near Henley has been criticised and ordered to apologise for failing to properly look after a woman who subsequently died
A CARE home near Henley has been criticised and ordered to apologise for failing to properly look after a woman who subsequently died.
Huntercombe Hall, near Nuffield, has also been told to waive the full fee for the elderly woman’s week-long stay.
Oxfordshire County Council has already apologised to the woman’s husband for failing to properly investigate his complaint against the home.
It has also been told to pay him £250 for his time and trouble in pursuing the complaint and £500 for the distress caused.
The Local Government Ombudsman Jane Martin investigated after the man complained that his wife was left severely dehydrated and suffering from oral thrush after a respite stay at Huntercombe Hall, which is operated by the Caring Homes Healthcare Group. In a statement, the Ombudsman said: “The woman, who had advanced dementia, required full assistance in all areas of daily living and could not say when she was hungry or thirsty.
“She struggled to swallow and needed a thickening agent added to her drinks.
“The woman’s husband privately arranged and funded the stay at the home and spoke to the carers there about her special circumstances.
“When the husband returned to pick her up, he described her as ‘less responsive and limp’ and her mouth had a coating of white spots.”
He contacted the care home’s GP and the woman was taken to hospital with paramedics administering intravenous fluids through a drip.
The woman was kept in in hospital for three weeks and her records showed she suffered dehydration and problems with her kidneys. She died just a week after being discharged.
During her stay in hospital, staff made a safeguarding referral to the county council, which investigated but did not involve the woman’s husband.
Meanwhile, he complained to the nursing home about his wife’s care. The home responded but found no shortfalls in its treatment of the woman.
The Ombudsman said: “The council did not conduct a strategy meeting but asked for a report from the provider.
“It did not chase that report swiftly when the provider was slow to respond, potentially putting other vulnerable residents at risk.
“The council’s report into the situation appeared to accept the provider’s version of events but also recorded a finding of ‘neglect — partially substantiated’.
“The council did not recognise the inconsistency in the care provider’s records for the woman and an account given by the GP who saw her on the day she left the home.
“The council closed the initial assessment, taking no further action. It was not clear if it told the provider it had come to a finding of partial neglect, or told the regulator, the Care Quality Commission, or its own contract department about the findings.”
The Ombudsman also found the council did not act in accordance with the law and relevant government guidance on safeguarding adults and failed to follow its own policy and procedure relating to a safeguarding investigation.
It upheld the man’s complaint against the home about the quality of care his wife received and found issues with the way it completed records about her care.
It also found fault in the way the home dealt with the man’s subsequent complaint.
Dr Martin said: “While nothing can make up for the loss of a loved one, I hope my investigation will give this woman’s family some reassurance that lessons have been learnt and other vulnerable adults will not have the same experience.
“Neither the care provider nor council’s investigations were up to the standard that I expect and failed to give the family proper answers as to what went wrong.
“Organisations can only learn from events like these if they conduct thorough and searching investigations.
“I welcome the significant steps Oxfordshire County Council has already taken to improve its policies, procedures and staff training in this area and am pleased it has agreed to my further recommendations.
“I now call on the care provider to reflect upon my report and implement the remedies I have recommended.”
The Ombudsman said the home should provide a full written apology to the man for its failure to provide adequate care to his wife and to apologise for its failure to deal with his complaint properly. It should also waive the full fee for her stay in the home.
John Jackson, the county council’s director of adult social services, said: “We pride ourselves on very high standards in our management of adult social care in Oxfordshire.
“Our satisfaction ratings from service users are always very high and we were recently ranked sixth out of 152 councils nationally for delivering outcomes for service users.
“I have never before or since seen a case in Oxfordshire in which actions dropped below those high standards in this way. The way we handled this case was very disappointing.
“We have not hesitated to apologise to the woman’s husband. As the ombudsman has acknowledged, we have implemented robust and extensive improvements to procedures, even though even at the time this was an isolated case of poor practice and in no way systemic or representative of the general standards to which we operated in 2014 or now.”
A spokesman for Huntercombe Hall said: “We are deeply disappointed by this report and apologise unreservedly to the family for falling short in this instance of the high standards we set ourselves and that residents rightly deserve.
“When concerns were first brought to our attention, we worked closely with the local authority and took their guidance on addressing these issues.
“We have subsequently implemented a range of measures at the home to further strengthen our monitoring and record-keeping processes.
“Following the Ombudsman’s report, a full written apology will be sent to the family in the coming days and we will also waive all associated fees.
“The health and wellbeing of residents remains our number one priority. The home has a strong reputation for providing high quality care, so we are doubly disappointed not to have lived up to our own very high standards in this case.
“We will continue working closely with all partners and we are confident the care being provided at the home is of a consistently high standard.”