• The complaint
• What I have investigated
• The Ombudsman’s role and powers
• How I considered this complaint
• What I found
• Recommended action
• Final decision
• Parts of the complaint that I did not investigate

The Ombudsman's final decision:

Summary: There was fault in the way the Home communicated with the family of a resident and its failure to respond to the family’s complaints. There was also fault in the Home’s record keeping. This has caused the family distress and we recommend that the Home apologises to the family and pays £150.

The complaint

1. Ms B complains on behalf of her grandfather, Mr C, who has sadly passed away. Mr C’s daughter and his wife, Mrs C, support Ms B in the complaint.
2. The complaint relates to Royal Manor Nursing Home when it was managed and owned by Pine View Care Homes Ltd. The Home has been sold to a different owner since the complaint was made. When I refer to ‘the Home’ in my complaint, I am referring to the Home when it was managed by Pine View Care Homes Ltd, not the current owners.
3. Ms B complains about the care that Mr C received, the dressings on Mr C’s legs, the communications from the Home and its refusal to respond to her complaint.

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What I have investigated

4. I have investigated Ms B’s complaints except for the complaint about the dressings. Paragraph 55 explains why I have not investigated that complaint.

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The Ombudsman’s role and powers

5. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
6. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
7. 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

8. I have discussed the complaint with Ms B and I have considered the documents that she and the Home have sent.

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What I found

Care Quality Commission

9. 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.
10. The CQC’s Fundamental Standards gives guidance to care homes (among others) on complying with the requirements of the Health and Social Care Act 2008 in carrying out regulated activities. This says that:
    • The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
    • The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)
11. Regulation 16 says that:
    • Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation.
    • The registered person must establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and other persons in relation to the carrying on of the regulated activity.
12. The more detailed guidance on regulation 16 says:
    • Complainants must not be discriminated against or victimised.
    • Information must be available to a complainant about how to take action if they are not satisfied with how the provider manages and/or responds to their complaint. Information should include the internal procedures that the provider must follow and should explain when complaints should/will be escalated to other appropriate bodies.
    • Providers must have effective systems to make sure that all complaints are investigated without delay. This includes making sure appropriate investigations are carried out to identify what might have caused the complaint and the actions required to prevent similar complaints.

Further guidance on complaint handling

13. The Competition and Markets Authority has advice on consumer law for care homes which sets out what should be included in a complaints procedure.
14. The advice includes examples of policies and practices that the CMA says are likely to be unfair:
    • Fail to respond adequately to complaints by ignoring or failing to investigate the complaint.
    • Mislead residents about how they can exercise their rights, by failing to tell them they can escalate their complaint to an external body such as an Ombudsman
15. The CMA says care homes should make every effort to welcome feedback from residents and their relatives, to ensure that you do not create psychological barriers to complaining, which may amount to an unfair aggressive practice under consumer law.

The Home’s complaint policy

16. The Home’s complaint policy says complainants can speak to a manager or a senior on shift if they have a complaint. The complaint is then forwarded to the care home’s manager who will investigate the circumstances and ‘inform you within 7 working days’. It signposts complainants to the CQC if they are not satisfied with the outcome of their complaint.

What happened

17. Mr C was an elderly man who was diagnosed with Vascular Dementia. Mr C moved into the Home on 26 December 2021 and moved out of the Home on 23 March 2022.

Mr C’s care plan

18. Mr C’s careplan said:
    • Mr C was able to walk but used a walker trolley for safety.
    • He was able to wash and shower himself.
    • Staff need to provide ‘encouragement to shower and shave on a daily basis’. Mr C preferred to shower later in the day depending on his mood.
    • Staff needed to supervise and prompt Mr C for his hygiene.
    • Mr C was continent and used the toilet but he also had a incontinence pad, day and night, for occasional accidents and some incontinence of urine. He was able to know and ask to use the toilet to move his bowels. He had a history of constipation.
    • His bowel movements had to be monitored through a bowel chart (from 16 February 2022).
    • There were instructions for staff to manage Mr C’s behaviour as he could be aggressive towards staff and other residents.

Ms B’s complaint – 31 March 2022

19. Ms B made a formal complaint to the Home on 31 March 2022 and said:
    • The Home did not take care of Mr C’s hygiene and when the family visited him, Mr C was often filthy and ‘stunk of body odour.’ The family found faeces on his hands and his walker twice.
    • Mr C was sent home without incontinence pads.
    • Mr C lost a lot of items including his teeth and his glasses.
    • The Home sent threatening letters to Mr C’s wife, Mrs C and it was highly concerning that the Home was targeting vulnerable people in this way.
20. Ms B attached a copy of the email that the Home sent to Mrs C on 30 March 2022. The email said:
    • ‘I have just spoken to your rude daughter, I have politely explained that two invoices remain outstanding, and as per usual she tried to mug me off. Why people do this is beyond me.’
    • ‘Please ensure this is paid by return or from Monday, I will transfer the debt to my debt collectors who will visit your home to get this paid and every visit costs £150.’

The Home’s response – 31 March 2022

21. The Home responded to Ms B’s complaint on the same day it received the complaint and said:
    • ‘… I am going to get to the point, families like yours disgust me, as soon as there is an invoice to pay, all the complaints come out, no complaints were made when [Mr C] was a resident but as soon as he leaves and I ask for the invoices to be paid, this is what we get. Disgusting.’
    • ‘…you people disgust me when you try to rip off my residents because you do not want to pay what is legally owed to the home.’
    • ‘So I am dismissing your complaint…Fortunately 99% of families appreciate what the care team does, I only had to come across families like yours a few times who would do anything to get away with paying their debts.’
    • ‘If you feel the items you listed are missing because of the Home’s fault, then deduct this from the care fees you owe.’
    • ‘So I repeat you have until end of day 1st April to pay your debt, if this is not paid the debt will be sent to our debt collectors to collect what is legally owed, We are not gangsters…’
    • ‘I will no longer have any communication with you.’
22. Ms B reported the matter to the CQC and came to the Ombudsman.

Home’s email – 5 May 2022

23. The Ombudsman informed the Home on 29 April 2022 that the matter had been referred to its Investigation team. The Home sent these emails to Ms B on 5 May 2022:
    • ‘I am not interested in excuses, get the invoice paid. You have 7 days. With regard to complaining, you can complain to whoever you want, does not bother me in the slightest…I will send collectors in if this is not paid.’
24. The Ombudsman sent its letter of enquiries to the Home on 9 August 2022. The Home sent two emails to Ms B on the same evening:
    • ‘Let’s not play your silly games. Pay up or I will seize goods from your mother’s property with an extra £800 costs. Do the correct thing and pay. And before you say my mother did not sign. She did and I only have to prove it was sent.’
    • ‘The matter has been referred to debt collectors, they will be in touch.’

Documents sent by the Home

25. I have considered the following information as part of the investigation.

Daily records

26. The nurse’s progress notes said staff should start bowel charts for Mr C from 16 February 2022. Mr C’s bowel movements had not been documented since January 2022 although it was noted that Mr C went to the toilet independently so staff may not witness his bowel movements. However, it was agreed that, from 16 February 2022 staff should ask Mr C about his bowel movements every day and record this.
27. The bowel charts show that there were eight entries which all related to the month of March. The nurse’s progress notes commented on Mr C’s bowel movements on 26 and 28 February 2022 and Mr C was given medication.
28. The Home had daily charts for Mr C. These showed when Mr C went to the toilet or was supported to go to the toilet, when his continence pad was checked and changed, when he washed and when he showered. The charts also showed when Mr C was encouraged or offered support but refused the support.
29. I asked Ms B whether she could provide me with the dates when she said the family had noticed that Mr C’s hygiene was lacking.
30. Ms B said this happened at the start of February and on 26 February 2022. The final date was 23 March 2022 when he left the Home.
31. I have looked through all the notes for February and have focussed on the days when Mr C met his family.
    • Mr C went out for a meal with his family on 13 February 2022. The records say that Mr C showered, had a full wash, hair and shave on 13 February 2022 at 05:23. He refused the toilet at 12:42. His continence pad was checked and was dry. He went out with the family at 14:30 and returned at 18:30.
    • Mr C’s daughter visited him on 15 February 2022. Mr C washed on 14 February 2022 at 22:30. He was offered personal care on 15 February 2022 at 04:30 but refused it as he was in pain.
    • Mrs C visited Mr C on 17 February 2022. He had a bed bath/wash at 22:00 on 16 February 2022 and at 05:30 on 18 February 2022.
    • Mr C went out for a meal with his family on 20 February 2022. The notes say his pad was checked at 06:00. He had a shower, washed his hair and shaved at 09:31. He went out with his family at 12:30 and returned at 17:00.
    • On 21 February 2021, Mr C washed at 10:20 and his pad was changed.
    • Mr C’s daughter visited him 22 February 2022. The notes show that Mr C got up at 06:00 and ‘assisted himself to the lounge’. He was assisted to the toilet at 10:30, his pad was checked and dry. He refused the toilet at 12:28. There was no reference to Mr C washing or showering that day. He saw his daughter at 15:51. It does not say when the visit ended but Mr C went into the dining room for tea at 16:45.
    • Mr C’s wife visited him on 24 February 2022. There was no reference to Mr C washing or showering that day. The most recent reference to showering or washing dated back to 21 February 2021 when he washed at 10:20.
    • Mr C washed on 25 February 2022 at 10:00.
32. I have also checked the records for 23 March 2022, the day when Mr C left the Home. The records showed Mr C got up at 04:30, washed and dressed and his pad was changed. He was assisted to the toilet and his clothes were changed at 12:23. The last entry was at 13:43 when he was assisted into an armchair in the lounge.
33. The nurses’ progress notes for 23 March 2022 said that all Mr C’s belongings were gathered as per the list that had been provided. The relevant documents were photocopied and all his medications were packed up.

Further information

34. I asked Ms B whether the family ever raised their concerns with the Home before Mr C moved out. Ms B said the family had raised the concerns verbally with the staff.
35. I asked whether the family had paid the invoices and Ms B said the invoices had been paid and Mrs C deducted £570 for the missing items, as agreed by the Home.

Analysis

Complaint about care

36. I note that Mr C was mobile and able to wash himself, have a shower and use the toilet, although he also used an incontinence pad. The Home’s role was to encourage and assist Mr C in his personal care. I also note that Mr C sometimes would refuse care. I have taken all those factors into consideration.
37. I have read through the care records for February in detail because Ms B said that this is when the incidents of poor hygiene occurred.
38. I have set out the dates when the family visited in February. Mr C went out with his family on 13 and 20 February 2022, but the records said he showered on both those days. His continence pad was checked about two hours before he met the family on 13 February 2020 and there was a three-hour gap between the shower and Mr C going about with his family on 20 February 2022. Therefore, I cannot say that there was evidence of poor hygiene on those days.
39. Mr C had visits on 15 and 17 February 2022 and the records showed Mr C had washed on the evenings before the visits.
40. Mr C washed on 21 February 2021 and the family visited him on that day. There was no record that Mr C washed or showered after 21 February until 25 February 2022. I have also not seen any record that the Home encouraged Mr C to wash or that Mr C refused during this time period. The family visited Mr C on 24 February 2022 so it may be that they noticed a decline in his hygiene during this visit.
41. Therefore, there was a failure to record any actions relating to the washing/showering between 21 and 25 February 2022.
42. Outside of the dates between 21 and 25 February 2022, the record keeping was adequate and indicated that Mr C received a wash or a shower on most days.
43. I have also considered the care provided on the day that Mr C went home, 23 March 2022. There was evidence that Mr C washed in the morning and his pad was changed. He went to the toilet later in the day before he left the Home. I cannot say therefore, that there was fault in the care provided on that day.
44. I note that there were no bowel charts between 16 February 2022 and 3 March 2022 which was not in line with the care plan which was fault.
45. Mr C’s family has suffered an injustice as a result of the poor record keeping as there will always be uncertainty about the care provided to Mr C on the days when the records did not meet the required standard.

Lost belongings

46. I have not further investigated the complaint that the Home lost some of Mr C’s belongings. The Home accepted this may have happened and said Ms B could deduct the cost of the belongings from the outstanding invoice. The family deducted £570 from the payment of the final invoice. That was an appropriate remedy.

Communications and response to complaint

47. There was clear fault in the Home’s response to Ms B’s complaint. Ms B had made a complaint about the care Mr C had received and the Home should have investigated the complaint and responded. However, the Home refused to investigate her complaint and dismissed it without explanation or reference to any investigation.
48. Instead the Home sent a rude and threatening response to Ms B, said her family was ‘disgusting’, and that her family tried to ‘rip off’ the Home’s residents. The Home also immediately threatened punitive bailiff action. That was fault.
49. After Ms B came to the Ombudsman, the Home’s emails to Ms B seemed to be linked to the fact that Ms B was pursuing her complaint to the Ombudsman. The Home said Ms B could ‘complain to whoever you want, does not bother me in the slightest’ and accused Ms B of playing ‘silly games’. The Home escalated its threats and said it would seize goods from Ms B’s mother’s property and charge her an extra £800. This was further fault.
50. I also note that the Home’s complaints procedure is brief, gives little detail and consists of five short lines. The policy should have signposted complainants who are not satisfied with the outcome of the complaint, to the Ombudsman but failed to do so which was fault.
51. Ms B and her family have suffered an injustice because of this fault. Ms B felt the language the Home used was ‘intimidating and aggressive’. This should never happen but, as Ms B explained, some of the Home’s communication was directed at elderly vulnerable people which made matters worse.

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Recommended action

52. The CQC is best placed to address any concerns about the Home’s lack of response to the complaint and the way it communicated. Under our information sharing agreement, we will share this decision with the CQC.
53. I recommend that the Home takes the following action within one month of the final decision. It should:
    • Apologise in writing to Mr C’s family for the fault.
    • Pay Ms B £150 to reflect the distress caused by the fault.

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Final decision

54. I have completed my investigation and have found that the Home’s actions have caused an injustice. I have recommended a remedy to address the injustice.

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Parts of the complaint that I did not investigate

55. I have not investigated the complaint regarding the actions of the nurses who changed the dressings on Mr C’s legs. The nurses were funded by NHS funded nursing care. The actions of nurses are therefore outside of the Local Government and Social Care Ombudsman’s jurisdiction. The Parliamentary and Health Service Ombudsman investigates complaints about the NHS and nurses.

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Investigator's decision on behalf of the Ombudsman

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