Summary: Ms C complained about the care her (late) father received at his care home. We found there was fault with regards to some of the aspects of the support Mr F received at the care home. The care home has agreed to apologise for the distress this caused and pay a financial remedy.

The complaint

1. The complainant, whom I shall call Ms C, complained to us on behalf of her (late) father (whom I shall call Mr F) and her sister, whom I shall call Ms S. Ms C complained about the care her father received at his care home. She complained that:
• He suffered a severe burn to his left thigh after staff left him unattended with a hot drink.
• The home failed to organise an appointment with a dentist when his dentures broke.
• The home failed to provide oral care to her father, resulting in oral thrush and the dentist not treating him due to food debris in his mouth.
• The care home failed to prevent her father’s falls.
• Staff did not offer her father regular drinks or stay with him to ensure he would drink it.
• Staff failed to encourage her father to eat more, which resulted in weight loss.
• There were regular technical and logistical problems trying to arrange contact with her father via Skype. This was time consuming and very frustrating.
• Her father’s cupboard was often untidy.
• On the day her father died, the care home failed to alert her sister to come into the home quickly and have an opportunity to say goodbye.
• There was a lack of communication.
2. Ms C complained that, in addition to having an impact on her (late) father, the above faults resulted in distress to her and her sister.

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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 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. I considered the information I received from Ms C and the care provider and carried out an interview with the care home. I shared a copy of my draft decision with both parties and considered any comments I received, before I made my final decision.

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What I found

Background legislation and guidance

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. We consider the 2014 Regulations and the Fundamental Standards, as well as a provider’s policies and procedures, when determining complaints about poor standards of care. The following regulations are relevant to this complaint:
8. Regulation 9 (Person-centred care) says each service user should receive care that is personalised specifically for them, that meets their needs and reflects their preferences.
9. Regulation 12 (Safe care and treatment) is about providing care in a safe way for service users.

The complaint about the burn

10. Mr F suffered a burn on 20 December 2021 to his left thigh. The care provider investigated the incident at the time and acknowledged and apologised that it happened because staff had failed to help him with his hot drink. The records state that:
• The staff on duty at the time of the incident were: a Unit Leader, one of the home’s own experienced staff and two agency care workers.
• Two agency care workers were giving drinks to the residents at around 2pm. Both had done this before and should have been aware who needed support. However, they left Mr F unattended with a hot drink when staff would normally assist him with such a drink.
• When Mr F received personal care at around 4.30pm, a staff member noticed a large mark on his left upper thigh. The care home’s nurse looked at the mark and applied dressing. The night nurse reviewed the mark and contacted the out of hours GP at 7pm. The Out of Hours GP asked the home to send a photo of the wound/scald and subsequently confirmed it looked like a scald.
• Staff completed a wound assessment tool every day, which said Mr F did not express any pain.
11. The care provider took appropriate actions to address any shortcomings, following its investigation.

Analysis

12. The care provider has already acknowledged to Ms C there was fault and has already apologised for this. The staff’s failure to provide the support needed to keep Mr F safe, was not in line with Regulation 12.
13. While this would have been a very unpleasant and distressing experience for Mr F, there is no indication to conclude he was in pain. The incident has caused distress to Ms C and her sister.

The complaint about the delay in dental treatment

14. Ms C said the home failed to organise an appointment with a dentist when her father’s dentures broke in August 2021. She said:
• They only contacted their usual dentist and did not subsequently try to find out if any other options were available. Ms C said she did the logical thing by calling Bristol Dental Hospital, which resulted in an appointment.
• The home sent the form to the hospital mid-September 2021, and it took until February 2022 before the hospital saw him. The care home did not chase the hospital to try and get a quicker appointment.
• This delay resulted in her father not being able to eat the kind of food he liked in the interim. Everything needed to be mashed, which he did not like. As a result, he ate less and lost weight.
15. The care provider told me it contacted four dental practices in September 2021, none of which were able to offer an appointment due to the ongoing Covid-19 pandemic. None of the practices suggested to contact the Dental Hospital.

Analysis

16. The care provider has already acknowledged it did not identify that Bristol Dental Hospital could possibly provide dental treatment to Mr F and apologised for this. This resulted in a delay of several weeks. However, the majority of the delay between August 2021 and February 2022 was due to Mr F being on the dental hospital’s waiting list. It is not possible to determine if it would have made any impact if the care home had chased up its referral to the hospital.

The complaint about Mr F’s oral care

17. Ms C said the home failed to provide the oral care her father needed, as staff was not cleaning his mouth twice a day. She said that:
• When her father finally got an appointment with the dentist, the dentist said it was impossible to get into his mouth as there was a lot of old food and debris that had been allowed to accumulate.
• It was only then when the care home told the family that it had trouble cleaning his mouth. If the home had told them earlier, the family could have tried to support the home with this.
• As a result of the poor oral care, her father had developed thrush in his mouth. This could have been avoided if oral care, or if it had sought external advice how to deal with his oral care. When she spoke about this to a nurse, she identified several methods that staff could have applied to clean his mouth without a toothbrush. The home subsequently successfully applied these.
18. The care provider said it has acknowledged to Mr F’s family there have been shortcomings with regards to this. It said that, as a result:
• Staff now receive daily reminders about oral care via handovers. Staff keep a daily oral health monitoring chart, and a weekly oral health assessment is now in place for all residents.
• The deputy home manager carries out regular full oral hygiene audits of the residents, to identify any need for dental referrals as early as possible.
19. The care provider’s Dementia Care Lead reported in February 2022 that he visited Mr F, who received good oral care that morning. His mouth looked clean and free from any food debris.

Analysis

20. The care home has acknowledged and apologised for failing to provide oral care to Mr F, which resulted in food becoming stuck in his mouth and oral thrush developing. The care Mr F received with regards to this, was not in line with Regulation 9.
21. It has since introduced appropriate steps to address this. I found the care home should refund, to Mr F’s estate, 5% of the care home fees Mr F paid during the period while the care home was not providing (appropriate) oral care.

The complaint about Mr F’s repeated falls

22. Ms C said the care home failed to put the required measures in place to prevent her father from falling regularly. She said that:
• Most falls were unwitnessed by staff.
• The home explained it had put measures in place. However, it was of concern that he kept falling from the bed, from his chair etc. The number of incidents lead the family to believe that the measures in place were not sufficient.
23. Mr F’s falls risk management plan dated June 2021 said that:
• Staff will complete regular checks on Mr F, especially when he is in his room.
• Staff will encourage him to be in the communal area where he can be watched
• When in bed, staff will try to position him facing the wall, so there is less chance him rolling out of bed.
24. The care provider has said that:
• Mr F’s falls risk assessment was updated monthly.
• As Mr F had dementia, it would not have been appropriate to put bed rails in place, as he could try to climb over them and hurt himself. As such, there was no way to prevent Mr F from occasionally rolling out of bed.
• He had a sensor mat in place, a crash mat when he was in bed, and he also had a low profiling bed. Staff carried out hourly visual checks at night.
• Although Mr F was at high risk of falling out of bed, the measures in place greatly reduced the chance he would get injured as a result. Mr F had 13 falls between April 2021 and January 2022, of which ten were him rolling out of bed. The last time that he had an injury from a fall was April 2021.

Analysis

25. Mr F was at high risk of rolling out of bed. I found the care home put the correct measure in place to minimise the risk that Mr F would injure himself. The care he received was in line with Regulation 12.

The complaint about nutrition

26. Mr F had dementia. The care home explained that people with dementia often lose interest in food and drinks and may refuse this, which can result in weight loss and not drinking enough.
27. The care home did not have a care plan in place for Mr F around Nutrition. It said such a plan was not created for him as it was not needed on admission.
28. Ms C said her father was often thirsty and had a dry mouth when she would visit him. She said her father needed encouragement and help to ensure he would drink enough during the day. She said she raised this with staff, but the home:
• Failed to regularly offer him drinks throughout the day.
• Failed to stay with him to try and ensure he would drink it.
29. The care home kept food and fluid charts so it could monitor Mr F’s food and fluid intake throughout the day. I reviewed the fluid charts for August and October 2021, which showed that:
• Staff offered Mr F fluids about 6 to 7 times a day.
• Mr F would drink about one litre of fluids on average per day during August, and 1.3 litre during October 2021.
30. The care provider said Mr F’s usual fluid intake was around 1 litre a day and the above shows staff offered Mr F fluids regularly and throughout the day. It said the actual number of ‘offerings’ would likely have been higher as staff do not always record when they return to a resident to offer a drink but the resident refuses (again). This is something the care home has worked on with its staff. Elderly patients with dementia can often refuse drinks despite the staff’s best efforts.
31. Ms C said that, after her father broke his dentures in September 2021, he lost weight. She said the family had discussions with the home about his weight loss, which resulted in the home getting special nutritional drinks. However, he did not like these. Ms C said that staff failed to encourage her father to eat more. She said there seemed to be no plan in place as to what staff should do to improve this. She said he did not get enough of the food he liked and there was not enough choice at mealtimes. As a result, her father lost weight.
32. Mr F’s weight chart shows that his weight went from 66kg in June 2021 (‘at low risk of malnutrition’), to 63kg in July, and 58kg in August, which meant he was now at ‘medium risk’. When Mr F’s weight reduced further to 54kg in September, the home recorded he was now at ‘high risk’. It discussed this with the GP who referred Mr F to a dietician. Ms C told me the care home did not tell her about this.
33. The home put a ‘Clinical Indicator’ in place in September 2021 following Mr F’s weight loss. It said that:
• Mr F was on a fork mashable diet because he was waiting for new dentures. He was also receiving two fortified drinks a day.
• Staff should offer snacks and high calorie food to enable him to gain weight.
• It worked with the family to identify foods Mr F liked and listed the food he liked to eat.
• This resulted in weight gain. He gained 3.6kg in one month, weighing 57.8 kilo in October 2021.
34. The care provider said that Mr F was at risk of weight loss. It said that, as such:
• The care home put a food chart in place to monitor his food intake, which staff completed.
• Staff was in contact with his GP, who prescribed drinks and puddings fortified with minerals, vitamins and supplements.
• Staff offered food and snacks throughout the day.
• The family acknowledged, after a meeting with the Dementia Care Lead, that staff offered enough fortified food and fluid. Ms C has since told me she denies this.
35. I reviewed Mr F’s food charts from August and October 2021, which showed that:
• Staff offered three meals a day, a fortified drink once or twice a day and snacks once or twice a day.
• He only ate the equivalent of 1 to 2 full meals a day during August, but he had a good appetite during October 2021 and would usually eat all (most) of his three meals.
36. The daily care records from August 2021 regularly state that staff assisted and encouraged Mr F with food and drinks.
37. A record in January 2022 said that Mr F’s weight increased to 59kg. Staff continue to offer fortified drinks and puddings and snacks in between.

Analysis

38. I found that, although there may well have been occasions when Mr F was thirsty when Ms C visited, the records indicate that staff regularly offered Mr F drinks throughout the day and that an appropriate care plan was in place for this.
39. Mr F had a reduced appetite, which the care home said is not uncommon amongst dementia residents. This became even more challenging when he could only eat mashed food when his dentures broke. The records indicate the home took the correct steps in response to this. It had a chart in place, and it regularly offered Mr F food throughout the day, including fortified drinks. It also involved the GP, who was responsible for involving a dietician if needed. As a result, Mr F’s weight did not further decrease after September 2021. As such, I found that the care was in line with Regulation 12.
40. However, the care home failed to put a Nutrition Care Plan in place when Mr F arrived at the home. This was not in line with Regulation 9. The care provider has said it has now asked all Unit Care Leaders to complete one on admission, which will also include information about any likes, dislikes and cultural requirements.

The complaint about setting up Skype meetings

41. Ms C complained there were regular technical and logistical problems trying to arrange contact with her father via Skype, which was time consuming and very frustrating. This included equipment not being available and staff not knowing how to set up the video link.
42. In response, the care provider said there were ongoing internet connection issues, which it has tried to address. It already apologised to the family for this.

Analysis

43. The care provider has already acknowledged there was fault, for which it has apologised. I found this was an appropriate remedy for any injustice caused.

The complaint about his utility cupboard

44. Ms C complained her father’s cupboard was often untidy. She said the cupboard where the family kept things for her father often had black and yellow bags in it with care home equipment etc.
45. In response, the care provider said it was entirely appropriate for the home to store dressings and equipment for Mr F in his wardrobe. At the time, the yellow bags were stored in his wardrobe as part of Covid-19 infection control procedures. Mr F’s clothes were kept in his wardrobe, and his continence products were quarantined in the ensuite bathroom. The home has already apologised that it did not communicate this better to the family.

Analysis

46. I found there was no fault with regards to this aspect of Ms C’s complaint.

The complaint about not alerting family

47. Ms C complained that, on the day her father passed away, the care home failed to alert her sister (who lives very close to the home) of his (sudden) deterioration, and that the family should come into the home. Ms C says this resulted in her father dying without any family present, and her sister not having an opportunity to say goodbye. Ms C said she spoke to staff three times that day, with the third call on the early afternoon. She has said that a staff member has since told her that she could see he had deteriorated and was very poor. As such, she kept telling the care leader to call and get his daughter.
48. The daily record says that staff spoke to the GP at 1.45pm. The record states that:
• Poor diet and only 100ml taken since the morning
• GP said to monitor and nurse practitioner will come tomorrow to assess him
• Spoke to daughter to keep her updated. She will call later today for an update.
• Two hourly observations. If his vital scores go higher contact GP immediately.
49. The daily record says that staff spoke to the GP again at 3.20pm. The record states the home asked the GP to come as staff feel he has deteriorated. Mr F died at 4.10pm.
50. In response, the care provider said that
• Mr F deteriorated very rapidly, so it was not possible for staff to contact the family enabling them to come. We always try to call relatives when we feel someone is reaching the end of their life but sometimes this is not possible when people deteriorate rapidly.
• Mr F deteriorated rapidly and, as such, staff were busy trying to arrange an emergency GP visit and make Mr F comfortable. With hindsight it would have also been appropriate to call the family at that point and get them in.

Analysis

51. The records show that staff was concerned about Mr F’s presentation at 1.45pm, after which he further deteriorated. I found that, although Mr F deteriorated rapidly, staff had identified at 3.20pm that the situation had deteriorated significantly. As such, staff should have told Ms S, who would have been able to come to the home before her father passed away 50 minutes later.
52. The fact that Ms S could not be with her father that day to say goodbye to him, has resulted in significant distress to her. The fact that no family was with Mr F when he passed away, has resulted in significant distress to Ms C and her sister.

The complaint about lack of communication

53. Ms C complained that, overall, there was a lack of communication. She said:
• The family did not receive written information on the care home and its policies at the start. She said she asked for this several times but did not get this.
• Her father did not have a key worker and there were other occasions where it became clear that relatives of other residents also did not know who theirs were.
• Staff failed to keep the next of kin informed and updated when needed.
54. In response, the care provider said that:
• It sends certain policies to the family at the time it sends out the contract on admission. This includes the complaints policy, hospitality and gifts policy etc.
• If the family wanted a copy of other policies, the family could have asked for this at any time.
• Mr F had a key worker, which was clearly documented on the front of his care folder. If the family believed he did not have a key worker, it could have asked the care home for the name at any time. In response, Ms C told me the care folder was not kept in her father’s room.
• Communication records show staff provided regular updates to the family. Family also visited weekly and were updated about general care issues by the staff on the unit.

Analysis

55. According to the available information, I found there was an appropriate level of communication. The care home has already apologised if the family felt the level of communication should have been more. Based on Ms C’s observations, it would be good practice to review how it implements the arrangements in relation to para 54.1 and 54.3.

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Agreed action

56. I recommended that, within four weeks of my decision, the care provider should:
• Provide an apology to Ms C and Ms S for the distress they experienced as a result of the faults identified above, except for the faults it has already apologised for.
• Pay Ms S £500 for the distress she experienced for not being able to be with her father when he died.
• Pay Ms C £300 for the distress she experienced knowing her father died alone, even though a family member could have been with him during his final moments.
• Refund, to Mr F’s estate, 5% of the care home fees he paid during the period while the care home was not providing (appropriate) oral care (brushing). The care provider has confirmed that it will reimburse the 5% care fees for the total time of Mr F’s stay at the home - 39.5 weeks, giving a compensation amount of £2,039.78.
• Share the lessons learned with staff, where this has not already happened.

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Final decision

57. For reasons explained above, I found there was some fault by the care provider, as a result of which I will uphold the complaint.
58. Under our information sharing agreement, I have shared this decision with the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman