Summary: Mrs X complains about the care provided to Mr X during his two month stay for respite. She says the Care Provider did not change his catheter, provide exercise as planned or clean his teeth. The Ombudsman finds the Care Provider caused an increased risk of harm to Mr X and significant stress to Mrs X. He recommended it reimburse a total of £4,992 to Mr and Mrs X to remedy the injustice it caused and take action to prevent similar problems in future. It has agreed to do this.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains on behalf of her husband, Mr X, that Richmond Villages Operations Limited:
• Did not provide adequate catheter care.
• Did not support Mr X’s fluid intake adequately.
• Used a hoist for transfers when Mr X did not need it and it caused him pain.
• Did not support him to mobilise adequately.
• Did not use the pressure relief cushion as needed.
• Failed to provide the support he needed to clean his teeth for several weeks.
• Did not ensure Mr X could always access his call bell.
2. Mrs X says this caused Mr X to need remedial dental treatment and physiotherapy. He could not return home because he lost his ability to mobilise, and developed a pressure sore, due to not standing or walking for eight weeks. Despite the physiotherapy Mr X did not recover this ability and moved to a permanent care home placement elsewhere. Mrs X says she was supposed to be resting after an operation and was under significant stress waiting for test results. She was unable to rest and felt she was still looking after Mr X which caused her considerable additional stress and upset. Mrs X says they should not have to raise these issues and should be able to depend on an adequate quality of care, especially as they were paying a premium rate.

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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 an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. If we are satisfied with a care provider’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)
6. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended) Mr X gave consent for Mrs X to bring this complaint on his behalf.
7. 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

8. I considered information from the Complainant and from the Council.
9. I will send both parties a copy of my draft decision for comment and will take account of the comments I receive in response.

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What I found

Background

The Care Quality Commission

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
11. Regulation 9 is about personalised care. The CQC’s guidance on the regulations says:
• “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
12. Regulation 12 is about safe care and treatment. The guidance says:
• “Providers must do all that is reasonably practicable to mitigate risks”.
• “Staff must follow plans and pathways”.
13. Regulation 17 is about good governance. 17(2)(c) says care providers should “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”.

What happened

14. Richmond Village Witney, is a care home run by Richmond Villages Operations Limited (the Care Provider).
15. Mr X had various health conditions which affected his mobility and ability to complete daily living tasks. Mrs X was his main carer. She says Mr X walked to the bathroom and lounge every day with a walking frame and used a rotating stand aid to help with transfers.
16. In May 2019, Mrs X had an operation and could not continue to care for Mr X while she recovered; she was also under significant stress waiting for test results. The Care Provider visited Mr and Mrs X at home to assess Mr X’s needs in preparation for his stay at Richmond Village Witney. The Care Provider asked Mr X to bring his rotating stand aid and belt with him, which he did. Mr X stayed for almost eight weeks. Mr X paid a total of £11,100 for his stay.
17. Mrs X was unhappy about the care Mr X received and complained to the Care Provider.
18. Mr X’s pre admission assessment, care plans and risk assessments include the following information:
• “Band 4 care – nursing care, frail and dementia”.
• “High or more complex needs”.
• “Requires assistance with most activities of living with a focus on the essentials of care”.
• “Leg exercises – needs fitness instructor”
• “fitness instructor to see”.
• “encourage exercises”.
• “Leg bag to be changed weekly on Sunday”.
• “Encourage fluids”.
• “No support to drink”.
• “Staff to brush [PA’s] teeth twice a day”.
• Night time routine includes cleaning teeth.
19. The Care Provider accepts there is “no documented evidence that the catheter bag was changed every 7 days”. It also accepts that when it was changed in mid June, it was put on upside down which it said was “unacceptable”.
20. The Care Provider also noted in its response to Mrs X, that, as Mr X had an indwelling catheter, he should have been on a fluid chart. It also said he should have had “fluids pushed throughout the day”. Mr X’s fluid chart ended after two weeks.
21. I saw no evidence of exercises being completed or of the fitness instructor being involved. The safe handling plan says to use the stand aid for transfers in and out of bed but the records show that a hoist was used on occasions. There are several notes that Mr X did not want to be hoisted. There was also a short period of notes that Mr X complained the stand aid was hurting but numerous notes that he used this without a problem. On 29 May, the Care Provider advised Mrs X they would use the stand aid 3000 not a hoist. Four days later, the records note that Mr X “was reluctant to be hoisted to bed”. Following this the notes say he did not want to get up in the morning as he did not want to be hoisted.
22. The records note Mr X was to use a pressure relief cushion and the Care Provider says the Head of Care says it was always in use. However, a pressure relief cushion checklist covering two weeks of his stay was completed with N/A throughout.
23. I did not see any significant evidence with regards to the accessibility of the call bell.
24. A few weeks into Mr X’s stay, Mrs X complained that hardly any toothpaste had been used and she doubted that Mr X had cleaned his teeth since he arrived. Records show limited and conflicting information about this however the Care Provider accepts that Mr X’s teeth were not cleaned twice a day as planned. It said, in its response to Mrs X, it was “unacceptable that this was only fully actioned after you had complained”.
25. In early July, Mr X moved to another care home. Mrs X says he was a different man after his stay at Richmond Village Witney. She says he was unable to walk and all his muscles had seized through lack of use and therefore could not return home. Mrs X arranged a course of physiotherapy for him but he was unable to regain his mobility and eventually had to stop. Mrs X also says he needed a crown replaced because his dental hygiene had been neglected.
26. The Care Provider wrote to Mrs X and apologised. It said:

“The investigation confirms that there were gaps in the documentation of daily notes and that some staff were unfamiliar with [Mr X’s] care needs. This suggests that the required level of care and support was not consistently provided to [Mr X]. This falls short of our expectations in terms of the quality of care that we aim to provide to all residents and is unacceptable. I am sorry that you were unhappy with the care that we provided to [Mr X] and I also acknowledge the impact that this had upon you, as [Mr X] was admitted to the care home for a period of respite to give you a break whilst you had treatment of your own”.

27. The Care Provider thanked Mrs X for her feedback. It noted that the baseline care in the home was valued at £1,100 and Mr X had paid £1,365 per week. It offered £2,120 gesture of goodwill. It said it had taken the following action to prevent similar problems in future however I saw no evidence of this:
• Provided additional training for nurses and carers to refresh their knowledge and competence with catheter care.
• “Put an action in place” to remind staff to check residents have their call bells within reach whenever they leave the resident’s room.
• Increased oversight from the central care and quality support team to review compliance with documentation and care plans as well as additional audits and visits from the operations manager.
28. Mrs X was unhappy with this as she felt it did not recognise the impact on them. She said they had paid for a premium service but had not got a basic service. She also felt she should not need to give feedback like this as it should not happen.
29. Mrs X has provided evidence that Mr X paid £312.50 for dental treatment in July 2019 and £3,195 for physiotherapy between early August 2019 and late February 2020.

Did the Care Provider’s actions cause injustice?

30. It is clear, by the Care Provider’s own admission, it caused both Mr and Mrs X significant injustice. However, the response to Mrs X’s complaint did not adequately consider the injustice caused.
31. In respect of the fluid intake and pressure relief, the evidence is that the Care Provider did not take adequate precautions to ensure Mr X received care as planned. The records which should have evidenced this were not completed and therefore I have no reason to doubt Mrs X’s view that Mr X did not receive care as planned. This caused an increased risk of harm to Mr X.
32. Mr X was flagged as having a high level of needs which required a “focus on the essentials of care”. His teeth were not cleaned adequately, his catheter was not changed and he did not receive the support he needed with his mobility. These were essentials of care and this caused Mr X an avoidable, increased risk of harm. I have concluded that Mr X should not pay more than the baseline fees which would total £8800 for 8 weeks. He paid a total of £1100 so the Care Provider should reimburse him with £2,300 as a starting point. The care Mr X received still did not come up to this baseline level and did not meet the standards expected of any care home. I have therefore also recommended a further reimbursement equivalent to a 10% reduction. Also, £500 each for Mr X and Mrs X to recognise the stress and risk of harm.
33. Additionally, I am satisfied, on the balance of probability, that the dental treatment was needed because of the inadequate dental hygiene. Therefore, the Care Provider should reimburse Mr X with the £312.50 that he paid for this.
34. The mobility issues are less clear. We cannot be sure that Mr X would not have experienced a reduction in mobility had he been at home. However, the Care Provider’s failure to provide care as planned, put him at an increased risk of this. It should have taken professional advice when his safe handling needs changed and he could no longer use his own stand aid. It should also have been clear under what circumstances staff should use a hoist and how. This is aside from the exercises and fitness instructor which were part of the planned care from the start of his stay, but which never happened. This caused Mr X a lost opportunity to maintain his mobility. I have therefore recommended a further reimbursement of £500 to recognise the lost opportunity. The total reimbursement of fees I have recommended therefore totals £4,680
35. I have not seen any evidence to support either Mrs X’s view that the call bell was not in Mr X’s reach or that it was. I am therefore unable to uphold this part of her complaint.
36. Mrs X was particularly vulnerable at the time of these events and already under significant stress. The whole purpose of the care was to give her a break from caring but the Care Provider caused her more stress as she tried to get the care it had agreed to provide. The Care Provider did apologise adequately but did not take sufficient action to reflect this.
37. As I have identified potential breaches of regulations 9, 12 and 17, I will send a copy of the final decision to the CQC.

Agreed action

38. To remedy the injustice identified above, I recommended the Care Provider:
• Refund £4,680 of fees paid.
• Reimburse Mr X with £312.50 for the dental treatment.
• Complete these two recommendations within one month of the final decision and provide confirmation to the Ombudsman.

The Care Provider has agreed to complete these actions.

39. The Care Provider has also agreed to provide evidence, within three months, of the following actions which it told Mrs X it had completed:
• Provide additional training for nurses and carers to refresh their knowledge and competence with catheter care.
• Remind staff to check residents have their call bells within reach whenever they leave the resident’s room.
• Increased oversight from the central care and quality support team to review compliance with documentation and care plans as well as additional audits and visits from the operations manager.

Suitable evidence would include a list of staff who have undertaken training and a copy of the reminder to staff.

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Final decision

40. I have completed my investigation and uphold Mrs X’s complaints that the Care Provider:
• Did not provide adequate catheter care.
• Did not support Mr X’s fluid intake adequately.
• Used a hoist for transfers when Mr X did not need it and it caused him pain.
• Did not support him to mobilise adequately.
• Did not use the pressure relief cushion as needed.
• Failed to provide the support he needed to clean his teeth for several weeks.
41. I do not uphold Mrs X’s complaint that the Care Provider did not ensure Mr X could always access his call bell.
42. I am satisfied that, in completing the agreed actions, the Care Provider, will remedy the injustice as far as possible.

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Investigator's decision on behalf of the Ombudsman