Summary: Mrs X complained about the short-term respite care her father, Mr Z, received at Farthings Residential Care Home which is owned by Ashall Care Ltd. The care provider has already found it failed to properly check Mr Z’s room when he moved in and did not explain how to keep his valuables safe. It has explained what service improvements it will make. The care provider was also at fault for not providing written details of the terms of Mr Z’s stay although this did not cause a significant injustice. It also acted with fault when it failed to take appropriate steps when Mrs X reported money belonging to Mr Z had gone missing. It has agreed to make service changes to prevent a reoccurrence. There was no fault in Mr Z’s pre-admission assessment, his care plan or the care he received.

The complaint

1. Mrs X complains Farthings Residential Care Home:
1. failed to carry out a comprehensive assessment of her late father, Mr Z’s, care needs and did not provide a written contract;
2. failed to follow government guidance when it allowed Mr Z to be admitted to the care home without receiving the results of his COVID-19 PCR test;
3. failed to check Mr Z’s room before he was admitted which meant it was cold and a bag of clothes belonging to a former resident was found in the wardrobe;
4. did not appear to have any hand gel, wipes or masks in the home;
5. failed to take the correct precautions which led to Mr Z having a fall, failed to carry out a risk assessment or put measures in place to help prevent further falls, allowed Mr Z to leave the care home when he was clearly unwell and failed to notify her of Mr Z’s falls; and
6. failed to adequately protect Mr Z’s money and acted with a lack of respect when it put Mr Z’s possessions into plastic bags after he was admitted to hospital.
2. Mrs X says that she has been left feeling guilty for allowing her father to go into the care home and grieving over his death.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider.
6. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
7. In this case, Mr Z arranged and paid for his care. This means the complaint is against the care provider.
8. 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)
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

10. I spoke to Mrs X and considered her view of her complaint.
11. I made enquiries of the care provider and considered the information it provided.
12. I wrote to Mrs X and the care provider with my draft decision and considered their comments before I made my final decision.

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What I found

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 13

13. Regulation 13 is designed to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment.
14. Providers must have robust procedures and processes to prevent people using the service from being abused by staff or other people with whom they may have contact.
15. Where any form of abuse is suspected, the provider must take appropriate action without delay. This action must include investigation and referral to relevant external bodies.

Care Quality Commission (Registration) Regulations 2009: Regulation 18

16. Regulation 18 specifies a range of events or occurrences that must be notified to the CQC so that, where needed, it can take follow-up action.
17. Providers must notify the CQC of all incidents that affect the health, safety and welfare of people who use services. The list of incidents set out in the regulation includes “theft, misuse or misappropriation of money or property”.

Care home policies

COVID-19 testing

18. The procedures at the care home at the time Mr Z was admitted required all admissions to have a negative COVID-19 PCR test within 72 hours of admission. A swab would be taken on the day of admission and again on day seven, with lateral flow tests (LFTs) taken daily.

Falls procedures

19. The care home’s falls procedures state that in the event of a fall, where there may be a head injury, 999 or 111 should be called, first aid action should be taken and an assessment carried out to try to assess the extent of the injury. If the resident was responsive, the procedures said they should be kept lying down if they were on the floor.

What happened

20. Mr Z lived alone in his own property. Mrs X supported him by helping with his personal care, doing his cooking and carrying out other chores. Mr Z had full capacity.
21. On 2 February 2022, the care home manager met with Mrs X and Mr Z to discuss a respite placement whilst Mrs X went on holiday. On 4 February, the manager returned and gave Mr Z a PCR test. Mr Z subsequently went into the care home on 6 February. Mr Z had two falls on 7 February. On 8 February he had another fall and also tested positive for COVID-19. He was admitted to hospital where he was diagnosed with a broken vertebrae. He died later that month from COVID-19 and other conditions.
22. Mrs X complained later that month.
23. The care home manager carried out an investigation. As part of this, she interviewed eleven members of staff, checked the staffing levels on the days Mr Z was in the care home and read his case notes and accident forms. The care provider said it did not charge for Mr Z’s stay because it considered Mrs X was under enough pressure with Mr Z being in hospital and she had to cut her holiday short.
24. The information below details Mrs X’s complaints and the outcome on each from the manager’s investigation.

Pre-admission assessment and contract

Mrs X’s complaint

25. Mrs X complained the pre-admission assessment was too brief and she provided more support than the assessment and Mr Z’s care plan specified.
26. As part of her later complaint to the Ombudsman, she said neither she nor Mr Z received a written contract or agreement from the care home.

Care home’s response

27. The manager said she discussed Mr Z’s care needs and it was agreed he needed the assistance of one care worker to get out of and into the shower, but he was able to wash and dress independently, although a member of staff would stay with him initially.
28. The manager found the information gathered before Mr Z was admitted was appropriate to Mr Z’s care needs. She also stated Mr Z was aware he could use his call bell if required.
29. During my investigation I asked the care provider to send me a copy of Mr Z’s agreement. The care provider did not do so.

COVID-19 status prior to admission to the care home

Mrs X’s complaint

30. Mrs X said she did not know that Mr Z’s results had not come back when he was admitted to the care home. She was very upset that he tested positive and put the lives of the care home staff and residents at risk.

Care home’s response

31. On 4 February, the manager carried out Mr Z’s pre-admission PCR test. The manager sent this by courier the same day to the NHS testing facilities. During my investigation, the care provider sent proof from NHS testing facility that it received the test on 4 February.
32. The results of the test were not available before the date Mr Z was due to move in. Therefore, the manager exercised her discretion to admit Mr Z. She based this on several reasons including the fact Mrs X was about to go on holiday which meant Mr Z would not have his usual support and the PCR results would probably be available soon after Mr Z had arrived at the care home.
33. Mr Z arrived at the care home on 7 February with Mrs X who confirmed they had both tested negative for COVID-19 after taking a LFT that day. The care home carried out another LFT the same day with Mr Z which was negative.
34. The care provider stated although Mr Z’s status was not known when he was admitted, it was decided any risks could be mitigated to allow Mrs X to go on holiday. Any test delays were not the responsibility of the care home.

Bag of clothes belonging to a former resident and temperature of the room

Mrs X’s complaint

35. Mrs X said there were someone else’s clothes in the wardrobe which were not removed straightaway, and this indicated a deep clean had not been carried out. Mrs X also complained Mr Z’s room was cold.

Care home’s response

36. The manager said someone else’s bag should never be left in the room. It was possible the radiator had been turned down because the room had been decorated the week before Mr Z arrived. A final check of the room should have been carried out by the senior carer, but this did not take place.
37. The care home said it would develop a pre-admission checklist to prevent a reoccurrence. It confirmed as part of my investigation that had taken place.
38. The manager said the heating system worked on a smart thermostat and was set to a minimum of 22 degrees at night increasing to a minimum of 23 degrees during the day. On colder or warmer days, the heating could be manually adjusted at the request of residents or staff.

Hand gel, wipes and masks

Mrs X’s complaint

39. Mrs X said there appeared to be no hand gel, wipes and masks when she dropped Mr Z off at the care home.
40. Mrs X did not complain about this to the care provider. However, I have considered it below as part of my investigation.

Mr Z’s falls, Mr Z was allowed to leave the care home when unwell and notification to Mrs X of the falls

Mrs X’s complaint

41. Mrs X raised concerns that Mr Z, who had only had one previous fall, fell three times in two days and medical help was only sought after the third one. Mrs X said Mr Z would not have been able to get up from the floor with little support, as claimed by the care home. She complained no crash mats or cot sides were installed.
42. Mrs X also complained that Mr Z felt sluggish and unwell on the morning of 8 February, yet the care home failed to take any action. She felt the care home should not have allowed him to go out that day with his friend. Mr Z’s final fall happened after his return to the care home.
43. When Mr Z fell, the care home said he told staff he was not in any pain. Mrs X said this could not be true because several days later, he was still in pain despite taking painkillers. Mrs X also said the care home should not have moved him. The paramedics immediately immobilised his neck and he was later found to have broken his vertebrae.

Care home’s response

44. Mr Z’s pre-admission assessment and care plan recorded he was able to walk over the threshold of his room and the wheelchair was manoeuvred into the room behind him. The notes also recorded Mr Z was able to use his wheelchair to get to the bathroom and then take a few steps independently to use the toilet and walk back to his wheelchair. Mrs X was present at the time and the notes state she said Mr Z could manage independently when the care worker offered support.
45. On the morning of 7 February, care workers found Mr Z on the floor lying on his quilt. Mr Z said he had slipped out of bed but was not in any pain. The care records stated he was able to get up with little support and was assisted into his wheelchair. Mr Z was recorded as saying he might have fallen because he was used to a double bed.
46. Mr Z was placed on two hourly observations. Just before midnight on the same day, the records note he was found on the floor. Although he had a small cut on his foot, the records noted he said he had no pain and it was recorded that he was in good spirits. Care workers carried out checks every 15-20 minutes and he slept until the following morning.
47. When Mr Z fell the first two times, staff carried out top to toe assessments and he was considered to have no significant injuries.
48. On the morning of 8 February, the district nurse visited and dressed Mr Z’s cut. Mr Z at first said he wished to stay in bed for the day. A care worker reminded him a friend was coming to take him out and so he got washed and dressed with the help of a care worker. It was recorded that he needed a lot of help. Mr Z initially refused breakfast but was persuaded to eat something.
49. His lateral flow test was negative and his temperature was normal.
50. When Mr Z returned, staff noticed his mobility was poor, he was unable to get out of his friend’s car and he appeared exhausted. His friend said she had struggled to cope with Mr Z’s mobility whilst out. She said Mr Z had not eaten or drunk anything.
51. Care home staff used mobility equipment to get Mr Z out of the car and into a wheelchair. Staff suggested he lie down in bed, but Mr Z said he wanted to sit in his chair.
52. The care worker went to speak to another resident after seeing Mr Z’s friend off, and then went to check again on Mr Z. She found him on the floor and called for help. He was examined by a senior care worker who rolled him over to assess his injuries. Mr Z said he was not in pain or distressed but had hit his head so staff called 999. Staff said they chatted whilst they waited for an ambulance to arrive.
53. At 15:41, the care home manager received a positive result from the PCR test taken on 7 February. Around 15 minutes later, they received a positive test result from the PCR test taken on 4 February. The manager called the care home to inform staff Mr Z had tested positive for COVID-19. By this stage, Mr Z had left in the ambulance, but one of the first responders was still there. They radioed to the ambulance and staff reported the first responder said “that would likely explain [Mr Z’s] change in behaviour and recent falls being unusual”.
54. Staff assisted Mr Z appropriately for his trip out with his friend. On his return staff suggested he lie on his bed, but Mr Z declined. He was found within minutes by a care worker and there was no delay in calling the emergency services. The fall was reported to the Care Quality Commission and the Health and Safety Executive, in line with the relevant guidance.
55. In relation to notifying Mrs X of the falls, the care provider stated in its response to me that because the first two falls were minor and Mrs X was on holiday, the care home did not inform her. Following the third, more serious fall, staff notified her immediately.

Mr Z’s belongings and missing money

Mrs X’s complaint

56. Mrs X said she was deeply upset that all of Mr Z’s possessions “had been thrown into a plastic bag… like a bag of rubbish”. She also discovered over £300 was missing from his wallet. She said she was not informed there was a safe for valuables.

Care home’s response

57. Staff cleaned Mr Z’s room. His soiled clothes, some of which had blood on them, were placed in a clinical waste bag. Other items were placed in his suitcase or a carrier bag. Staff noticed there was quite a lot of money in Mr Z’s wallet, packed it in the bottom of the carrier bag and reported the amount of money to the senior care worker. They decided not to put it in the safe because Mrs X was coming shortly to collect Mr Z’s belongings.
58. When Mrs X reported some of the money had gone missing, the care home said it searched Mr Z’s bedroom, but nothing was found.
59. The family would normally pack a relative’s belongings. However, because the home was in lockdown, staff offered to pack them up. The manager said staff should have prewarned Mrs X that Mr Z’s clothes had not been laundered. Ms Z’s cards must have fallen out of his wallet when it was in the carrier bag as staff would not have removed them.
60. The care home had a safe and Mr Z also had a bedside cabinet with a lockable top drawer in his room, but it was not clear that staff had told him or Mrs X about these. The manager said that in future, new admissions would be asked if they had money or valuables which needed locking away. The care provider confirmed during my investigation that this had now been added to the pre-admission checklist.

My findings

61. During my investigation I received copies of Mr Z’s pre-assessment, his care plan, his contract with the care home, risk assessments, his daily records and details of contact with medical staff.

Pre-admission assessment and lack of a contract or written agreement

62. Mr Z’s care plan is comprehensive, particularly in relation to his mobility, its impact on how he carries out personal care and risk of falls. There was no fault in how this was drawn up by the care home.
63. The care provider has not provided a signed copy of Mr Z’s signed contract. This is fault. However, Mr Z and Mrs X were aware of the period of care and the costs, so this did not cause a significant injustice.

COVID-19 status on admission to the care home

64. The procedures at the care home at the time Mr Z was admitted required all admissions to have a negative COVID-19 PCR test within 72 hours of admission.
65. The care home acted in line with its procedures when it carried out a PCR with Mr X two days before he was admitted. The timing was such that the result should have been back before he was admitted. This was not the case, but that was not the fault of the care home. The manager then took the decision, based on Mr Z’s and Mrs X’s circumstances, to admit him. She was entitled to exercise her discretion to do so, and she did so based on appropriate information. Although a subsequent test came back positive, there was no fault in the care home’s actions or the way it made the decision to admit Mr Z.

Bag of clothes belonging to a former resident and heating in Mr Z’s room

66. Under normal circumstances, I would be unlikely to investigate the matter if a bag of clothes was left in a resident’s room because any fault and injustice would not be sufficiently significant to warrant comment.
67. However, at the time, COVID-19 remained prevalent in the country, with care homes required to be particularly vigilant because of the vulnerability of its residents. Under these circumstances the failure of the care home to properly ensure the previous resident’s possessions were removed from Mr Z’s bedroom is fault. However, any injustice would stem from the risk of infection Mr Z was exposed to and because he was already positive for COVID-19, albeit unknown at the time, it did not cause him an injustice.
68. In relation to the temperature of Mr Z’s room on his arrival, I will not investigate this matter further. This is because there is not enough evidence of fault to justify investigating and in any case, it did not cause Mr Z a significant injustice.

Mr Z’s falls, allowed Mr Z to leave the care home when unwell and notification to Mrs X of the falls

69. Mrs X feels the care home should have used aids such as cot sides or sensor mats to manage Mr Z’s risk of falls.
70. Restrictions and restraints must be proportionate to the harm the care giver is seeking to prevent.
71. Mr Z fell shortly after arriving at the care home. His explanation that he was unused to a single bed was logical and he was unhurt. Staff increased monitoring which is reflected in his daily case notes. His second fall a few hours later was unexplained, but again he was unhurt, other than a small cut on his foot. Staff monitored him frequently during the night. The district nurse visited the following day and saw Mr Z and dressed his cut. All of these were appropriate actions to take.
72. On 8 February, Mr Z went out with his friend although he was feeling unwell. Mr Z had capacity to make his own decisions. Therefore, the care home was not at fault for abiding by his wishes.
73. Staff advised Mr Z to have a lie down on his return, but he did not wish to. Again, that was his decision to make. Even if the care home had introduced sensor mats, bed rails or other equipment, these would not have prevented the fall from his chair.
74. The daily case notes record Mr Z was left for seven minutes. During that time, he fell forward out of his chair. He remained conscious. The care home said staff made Mr Z comfortable and checked him for injuries. This was in line with its policy. There was no fault in the care provider’s actions.

Mr Z’s belongings and missing money

75. When Mr Z’s stay at the care home ended in his admission to hospital, care home staff packed his dirty laundry in clinical waste bags, and his possessions in his suitcase and a carrier bag. Mrs X found this insensitive; however, I do not find fault in the care home’s actions.
76. The care home has already said has no record of whether Mr Z was shown the lockable top drawer in his bedside table or the safe was explained to him. This is fault.
77. It is not my role to decide what happened to Mr Z’s money and I cannot establish liability for the missing cash. This is a matter which can only be properly decided by a court.
78. However, I can consider whether the care provider acted properly when Mrs X reported the money missing.
79. The law and guidance set out earlier in this statement requires certain things of care providers in these situations. It requires that a proper investigation is undertaken (including getting statements from witnesses), and the Police and the CQC are informed. If the investigation identifies that a member of staff is responsible, further action must be taken.
80. There is no evidence the care provider carried out an investigation in line with the regulations. This is fault. Instead, it informed Mrs X that Mr Z should not have brought so much money with him or, if he did so, should have kept it locked away.
81. I cannot determine with any certainty if an injustice was caused because I cannot determine what happened to the money. However, even if I was able to conclude there was an injustice, the care home did not charge Mr Z for his respite stay when it was within its rights to do so. I would not recommend any further personal remedy.

Agreed actions

82. Within one month of the date of the final decision, the care home has agreed to:
• ensure its procedures are amended to reflect all new residents must be provided with a contract or other written confirmation of the details of their stay;
• ensure staff are reminded of the requirements of CQC Regulations 13 and 18 so that appropriate actions can be carried out if valuables and money go missing; and
• provide evidence it has carried out the actions agreed as part of its investigation.

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Final decision

83. I have completed my investigation. There was fault but it is either not possible to determine injustice or no injustice was caused.

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Investigator's decision on behalf of the Ombudsman