Summary: Mrs X complained about the standard of care received by her husband Mr X while on a respite stay at a care home. We have found fault. There is evidence that the home failed to consider Mr X’s needs fully when he was admitted and did not transfer Mr X’s toiletries with him when he moved rooms. Mrs X says Mr X was very distressed upon leaving the home and that this has in turn caused her distress and uncertainty about the general standard of care he received.

The complaint

1. Mrs X complained that B & M Care, (“the home”):

• Failed to properly assess Mr X’s needs at admission;
• Placed Mr X in the wrong area of the home, an area that was not suitable for someone suffering with dementia;
• Failed to move his clothes and toiletries with him when he moved to another area of the home on the third day of his respite stay;
• Failed to make sure he was shaved and presented on his discharge day; and
• Failed to attend to an eye infection that Mr X suffered from.

2. Mrs X also says that Mr X was very distressed after leaving the home and had lost a significant amount of weight.
3. The above alleged failings caused Ms X to have concerns about the standard of care Mr X received while in the home.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission.
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)

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How I considered this complaint

9. I spoke with Mrs X.
10. I made enquiries of the Home and researched the relevant law.
11. Mrs X and the organisation had an opportunity to comment on my draft decisions. I considered any comments received before making a final decision.

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What I found

Fundamental standards

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
13. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
14. The home’s contract with Mrs X says it applies those standards to its practice.
15. Relevant to this decision is Regulation 10. This sets out that service users must be treated with dignity and respect. They must not be left in undignified situations and must be supported to maintain their autonomy and independence in line with their needs and stated preferences.

What happened

16. Below is an account of the material facts in this case. It is not meant to be a full chronology and does not detail everything that happened. I consider it will be helpful to address each of Mrs X’s complaint points in turn and assess whether I consider there was any fault on behalf of the home for each element, separately. I will then draw my conclusions on the complaint at the end of this report.

Mr X’s initial assessment and placement at the home.

17. In mid-January 2022 Mrs X visited the home to enquire about a possible respite place for Mr X. The home completed an assessment on Mr X. It was noted, among other things, that Mr X:

• Suffered from dementia. He had no challenging behaviours but fluctuated between being severely confused and being lucid.
• Had very poor short term memory.
• Suffered extreme anxiety in new environments and could be emotionally distressed.
• Woke frequently through the night. The possible cause was cited as being dementia or other health related issues.
• Would need prompting to undress. It was noted that Mr X, “Looks smart with trousers and shirt.”
• Mr X’s weight at the time of admission was not noted. Mrs X told me that she thought it was 78.9kg although she was unable to be certain about this. After one week of being in the home, Mr X’s weight was recorded as being 74.5 kg.

18. The home has different communities for residents with different needs. In its response to Mrs X’s complaint and in correspondence with the Ombudsman, it has set out the home’s structure. The information provided is unclear. The home says both that it has three separate communities and that as it is a home registered for people with dementia, it “does not state specific areas.” I have drawn up a table, setting out where Mr X was placed and when:

19. It was agreed that Mr X would take a room and stay at the home for two weeks respite from the beginning of February 2022.
20. The home has apologized to Mrs X if there was some misunderstanding about the levels of care the different communities provided. It says an assessment of a resident’s care needs usually helps the home determine where best to accommodate a resident. However, sometimes residents move within the home when it becomes clear a different area would be more suitable.
21. In response to our draft decision the home said that as part of the assessment undertaken before Mr X began his stay, Mrs X was told that Treetops would be the best place for Mr X; that it was explained to her how the different levels of dementia were catered for. However, it says that Mrs X did not want Mr X to stay in Treetops and instead chose the Squirrels area for Mr X.
22. The home has provided an email thread between the manager at the time and Mrs X which it considers supports the above. In the email thread, the day after Mr X was placed in the Squirrels area, Mrs X wrote to the home’s manager saying that she had “…now [realised]” that Mr X was not with dementia patients, and she was concerned about that. The home replied that Mrs X had specifically asked that Mr X should not be placed in Treetops, “…the dementia floor”.
23. The home also says that another reason Mr X was placed in home’s ‘residential area’ was because the home had not been made aware at the time of assessment that Mr X walked around during the night period.
24. Mrs X says she was concerned that the manager she spoke to at or around the time of admission, did not appear to fully understand some aspects of dementia and how it can affect people.

Analysis

25. On balance, given that Mr X’s initial care assessment did not describe Mr X’s dementia as being mild, and in fact noted that he could be ‘severely confused’, noting that he had very poor term short term memory, the evidence indicates it was more likely than not that Mr X was placed in an area of the home that was not appropriate. I accept that Mrs X asked Mr X to be placed there but I also accept that she was not given clear information about the types of care provided in different areas of the home. The home now says that Mrs X was told Treetops would be the best place for Mr X but Mrs X still wanted to place him in Squirrels. There is no compelling evidence that this happened. There is no evidence in the assessment that this was advised. Further, the home says that another reason Mr X was placed in Squirrels (the residential area), is that it was not aware that he could wander during the night. I consider that the fact the assessment stated that Mr X woke frequently through the night, which was thought could stem from his dementia, counters this.
26. Further, the email from Mrs X the next day after his placement, saying that she had ‘realised’ that Mr X was not in an area that catered for dementia patients, indicates, on balance, that this had not been clearly explained to her at or around the time of assessment, when she chose Squirrels.
27. The home is registered for people with dementia. It says that for that reason it does not state it has specific areas. But at the same extent, in complaint correspondence, it said it does have specific areas to provide care for those with specific needs. It says that some people with mild dementia can be placed in its ‘residential area’. But Mr X’s assessment does not describe him as suffering from mild dementia. I am also persuaded that Mrs X would not have asked Mr X to be moved, (especially as he was described as someone who finds new environments emotionally distressing), if she had not been told by a staff member that he was not in the right community. I consider this was fault. It would have been understandable if Mr X’s assessment was vague about the level of dementia Mr X suffered from. An error of judgment would have been acceptable in those circumstances. I agree with the home that sometimes these things can happen and it can be difficult to fully understand a person’s needs at the outset. But, in this case, on balance, I find that a combination of not being clear with Mrs X about what each area of the home offered and a failure to properly take into account the information in Mr X’s assessment, resulted in fault that caused Mr X (and Mrs X) an injustice. It was necessary to move Mr X as he was not being provided with the type of care he needed for the first three days. I am further persuaded that the home handled Mr X’s initial placement and move poorly because of the home’s failure to move Mr X’s toiletries with him when it moved him to a new room. I discuss this below but it is evidence of the home’s general failure to ensure Mr X was comfortably placed.
28. That is not to say Mr X was not being cared for. The records I have seen show that he was. But I consider a reduction to the respite fees should be accounted for in recognition of the likely distress caused by the home’s approach.

The alleged failure to move Mr X’s clothes and toiletries with him when he moved rooms.

29. When Mrs X came to collect Mr X, she said she found that his belongings were not in his room but had remained in the room he had vacated 11 days prior. This distressed Mrs X as she could not see how Mr X had been able to wash or clean himself or dress in his own clothes while resident at the home. She said all his undergarments were still in the drawers in his old room. They had not been touched.
30. The home says it is sorry that staff failed to check if Mr X’s belongings had moved with him to his new room. It says that all of Mr X’s clothes were taken to his new room but accepts that as staff failed to check the en-suite, his toiletries were not taken.
31. When I spoke with Mrs X after our draft decision, she did not say that his clothes had not been moved but just his undergarments and socks, and toiletries. She said a pile of dirty laundry with his clothes in had been left on the side in Mr X’s new room when she came to collect him. The home has said that it had some laundry issues around that time.
32. It says it has a store of emergency toiletries for when people run out of shampoo, shower gel, toothpaste etc.

Analysis

33. The home has apologised for failing to move Mr X’s toiletries. It has not commented on whether Mr X’s undergarments or socks were moved with him but says his belongings were moved. On the evidence I have, I cannot make a finding on that, and it would not be proportionate for me to make further enquiries. However, on balance, while there may have been some issues with the laundry, I do not consider the evidence is there to say that Mr X was not dressed in his own clothes. I also accept that it is more likely than not that Mr X would have been able to use the home’s store of emergency toiletries. The records indicate that Mr X was regularly washed or helped with self-care. It does not appear that he was neglected. While the home’s failure to transfer Mr X’s toiletries will have understandably given Mrs X some concern, I do not consider this would have caused a significant injustice.

The allegation that Mr X was not properly bathed or presented on his discharge day.

34. Mrs X says that when she came to collect Mr X he was unshaven. She said that when she visited during his stay he was always unshaven.
35. The records show that Mr X was bathed, washed and changed regularly. It does not record that he was shaved. The home says that staff say they assisted Mr X with personal care including shaving and changing into fresh clothing. However, it accepts that whether Mr X was shaved or not was not recorded. It apologies that Mr X was unshaven when Mrs X came to pick him up. It says it has raised this with staff members.

Analysis

36. The home says that Mr X was helped with shaving while staying there. However, it also accepts there is no record of this. It further accepts that Mr X was unshaven when Mrs X collected him. It is likely that Mr X, who liked to be in smart clothes, would have also liked to complement this by being clean-shaven as Mrs X says. The home’s failure to ensure Mr X was helped to present himself in the way he liked is fault. I have made a further recommendation to acknowledge this.

Failed to attend to an eye infection that Mr X suffered from.

37. Mrs X says that the home failed to address an eye infection while he stayed there. She said she had to take Mr X to the doctor upon his return home and he was prescribed antibiotics.
38. The home says that it agreed with Mrs X that she should take Mr X to his own GP upon his return.
39. The home has provided records which show that Mr X’s eye was checked regularly. It also refers to a GP visit. It says this was not about Mr X’s eye as the home had no concerns about Mr X’s eye.
40. The record of the contact with a GP does not show that the GP visited but that he/she was spoken to over the phone as the home raised concerns about Mr X’s anxiety.

Analysis

41. I do not find the home at fault for failing to take Mr X to a GP about his eye. It is clear that it was willing to contact a GP if it had concerns about anything in particular and that is why it contacted the GP about Mr X’s levels of anxiety. It is also clear from the records that regular checks were made of Mr X’s eye and the home had no concerns.

Mr X’s alleged weight loss

42. Mrs X says that Mr X lost so much weight that his pacemaker, which had not previously been visible, was seen to be protruding from under his flesh. She says this has been disturbing for him. If Mrs X’s records are correct, Mr X lost over half a stone while staying at the home.

Analysis

43. The records I have seen show that Mr X enjoyed regular meals, including puddings and drinks. However, Mr X was also clearly anxious while at the home and this could have contributed to any weight loss.
44. I cannot say with any reasonable degree of certainty that Mr X’s stress was directly and wholly related to his experience at the home. No matter what his experience had been like at the home, it was noted that he could be emotionally distressed in new places and therefore, he could have felt distressed with the best of care and that stress could have resulted in weight loss. It is not possible for me to say. Further, I also cannot say that Mr X did in fact lose that amount of weight. (Mrs X can not be sure of his weight either at the beginning of his stay at the home nor when he left, and the home only weighed Mr X after one week of his stay.) I do not have compelling evidence that the home was at fault in this regard.

Conclusions

45. The home says that when a new resident arrives at a home it can take a few weeks to settle in. I accept this, but the home should be prepared, as much as possible, to ensure that a person’s stay is as comfortable as possible during respite stays. Mrs X paid the sum of £2400 for Mr X’s respite. It is a difficult decision to make when placing a loved one in a home and it is understandable that she hoped he would have received the best care and be treated with dignity and respect. I do not consider that the home in any way set out not to treat Mr X in that way. I also note that the records show that, for the most part, he was well attended to. He was provided with regular meals, he was checked on regularly etc. But the evidence is that the home was not fully set-up to care for Mr X in the respectful way it should have.
46. I consider the home should reduce its fees in recognition of how unsettled Mr X’s stay was.

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Agreed action

47. Within a month of my final decision, the home should:

• Apologise again to Mrs X for the fault identified in this decision.
• Reduce the respite fees by the sum of £300 to acknowledge the failure to provide care to the standard it should have done, during Mr X’s stay.
• Remind staff about the importance of keeping proper records.
• Prepare information about the three different areas of the home to be presented to service-users to help make an informed decision about the most suitable area to place residents in.
• If it is necessary for residents to move between areas on occasion, the home should prepare a checklist setting out the reasons for moving and ensuring that a resident is moved with all their belongings in a way that reflects attention to a resident’s personal dignity.

48. The home should provide evidence of completion of the above to the Ombudsman.

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Final decision

49. I have found the home at some fault and made recommendations to address any injustice. I have now completed my investigation.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman