Summary: Mr B complained that his mother’s care home failed to keep a proper record of Mrs D’s dental care, failed to provide the dental care in line with the care plan and did not amend the care plan appropriately. The Home also did not properly monitor Mrs D’s hydration towards the end of her stay at the care home and failed to act soon enough when Mrs D’s nutrition intake and her weight declined. We have found fault and the Council has agreed to apologise, pay a financial remedy and remind the care home of its duties.

The complaint

1. Mr B complains on behalf of his mother, Mrs D, who has sadly passed away.
2. He complains about the care provided by the Poplars Nursing Home in Smethwick, in particular, poor dental care, lack of monitoring and action in relation to nutrition and hydration and he said Mrs D was often left in bed all day.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
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 have discussed the complaint with Mr B. I have considered the information that he and the Council have sent, the relevant law, guidance and policies and the comments on the draft decision by Mr B, the Council and the Home.

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What I found

Law, guidance and policies

Safeguarding

7. The Care Act 2014 and the Care and Support Statutory Guidance 2014 (updated 2017) set out the Council’s duties towards adults who require care and support.
8. Section 42 of the Act says the local authority should make safeguarding enquiries, where a local authority has reasonable cause to suspect that an adult in its area:
• has needs for care and support,
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

CQC

9. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that 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 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards. This says that:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• The nutritional and hydration needs of the service user must be met. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment (regulation 14).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service (regulation 17).

What happened

11. Mrs D was an elderly woman with dementia. She was admitted to the nursing home for respite care on 25 April 2022. She was taken to hospital on 17 June 2022 and sadly passed away on 16 July 2023.
12. Mrs D’s care package was funded by the Council.

Mr B’s complaint – 27 June 2022

13. Mr B complained to the Home on 27 June 2022. He said:
• Mrs D’s dentures were lost within two weeks of her move to the Home. Nobody could find them and the Home did not take Mrs D to the dentist. This affected Mrs D’s ability to eat.
• Mr B visited Mrs D on 21 May 2022. He said her dentures were missing, her natural teeth had not been cleaned as they were heavily stained. The bottle of mouthwash was still sealed and none of the denture tablets had been used. The toothpaste was hardly used. Mrs D had lost a lot of weight.
• Mrs D was weighed on 29 May 2022 and her weight was 45 kg. She weighed 52 kg when she moved into the Home on 25 April 2022.
• Mr B says the staff agreed with his concerns on 29 May 2022 and said they would brush Mrs D’s teeth and encourage her to eat. But there were no real improvements.
• The family made an appointment to take Mrs D to the dentist but, when they turned up, Mrs D had not been prepared for the visit and was in bed.
• He did not know whether the Home administered Mrs D’s medications on time as there were times when the family visited at the time Mrs D’s medication should have been administered and staff did not turn up.
• Mr B visited Mrs D on 16 June 2022 and insisted that an ambulance was called. Mrs D was taken to hospital and the doctors said she was dehydrated and undernourished. The occupational health therapist said Mrs D’s joints had seized due to having to stay in bed with all care being provided in bed.’

Safeguarding enquiry

14. The Council decided that the concerns raised met the threshold for a section 42 safeguarding enquiry.
15. Mr B gave more details of his concerns to the Council. In terms of the dentures, he said that, when the family visited, the top dentures had been lost, the bottom were in a container with food debris on it. The family provided 20 tablets to clean the dentures and only 2 were used. The mouthwash provided remained sealed.
16. The Council’s safeguarding enquiry came to the following conclusions:
• In relation to the concerns of malnutrition and dehydration, the report said: ‘An intake of 600-700 ml of fluid per day is not enough to keep someone hydrated. From records, professional input was sought from the Poplars in relation to [Mrs D’s] food and fluid intake, however, there are questions as to why this was not done sooner.’
• In relation to the dentures, the report said: ‘[Mrs D’s] dentures went missing within 2 weeks of her being at the Poplars and the dentist was not contacted – having a missing denture can affect communication and consumption of food, so should have been raised with the appropriate professional, but an appointment was not scheduled (by family) until 6 June.’
• ‘When the Home’s manager was asked why a dentist appointment was not made sooner, she said she didn’t know and explained a community dentist is hard to sought (sic).’
17. In answer to the question: ‘Were the allegations substantiated?’ the report said the outcome was ‘inconclusive’. The report said that, when Mrs D was admitted to hospital, the doctors stated ‘there were no reversible causes for deterioration found and therefore was a general decline’. The report said: ‘Therefore, although [Mrs D] was eating and drinking little at the Poplars – it cannot be proven that this was the cause of her deterioration.’

The Home’s response to Mr B’s complaint – August 2022

18. The Home responded to the complaint on 12 August 2022. The Home said:
• In terms of oral care, oral care was provided twice a day on most days and often three times a day.
• Staff reported to the manager that ‘[Mrs D] was consistently reluctant to remove her dentures to allow them to be soaked in appropriate solutions, so staff cleaned the dentures in situ.’ The Home said the GP had the same problem when he visited on 7 June 2022.
• Mr B alerted the staff to the missing dentures on 3 June 2022 and informed the staff that he had made an appointment with the dentist on 6 June 2022 to have the dentures replaced. The dentures had not been reported missing before that date and, by the time Mr B reported the matter, he had already made the appointment.
• In terms of Mrs D’s nutrition, the Home said its staff would encourage Mrs D to eat, but she would regularly refuse and ‘rarely finish what was offered to her.’ The Home said the family encountered the same problems.
• The Home made a referral to the dietitian on 27 May 2022 and Mrs D was prescribed a shake supplement twice daily. The GP visited Mrs D on 7 June 2022.
• In response to the complaint that Mrs D was kept in her bed for the entirety of the stay, the Home said that the family told the Home that Mrs D could walk short distances, but that was not the case. She could only transfer with handheld support. Mrs D was regularly out in the lounge and then would return to bed.
• In terms of the medication, the Home said Mrs D sometimes refused medication and it was exploring alternative methods of administering the medication.
• Mrs D’s charts showed her fluids intake was decreased during the 24 hours before she went to hospital. It was also not surprised by Mrs D was undernourished when she arrived at hospital ‘considering the amount of external medical professionals already involved in trying to resolve the problem’.
• In terms of the Home’s reluctance to call an ambulance on 17 June 2022, the Home said it would normally refer a person to the hospital avoidance service as they could advise what the best course of action was, but this service was not available after 8 pm. The nurse said Mrs D’s observations were within the normal range, but agreed to call an ambulance for additional observations.
19. The Home said it could not see ‘evidence that negligence or neglect from the service significantly impacted on [Mrs D’s] life expectancy’. It said that placing someone with dementia in a care home could trigger changes in presentation and behaviour and lead to non-compliance compared to what they would do at home. This, combined with Mrs D’s underlying health conditions, affected Mrs D.

The Home’s records

20. I have read the following records from the Home as part of my investigation.

Care plan

21. The Home’s care plan for Mrs D said:
• Eating and drinking. Mrs D was able to eat independently and would eat in the dining room. Staff should encourage her to eat as she could sometimes be reluctant to eat. Staff should offer her snacks between meals.
• Mrs D was able to drink from a normal cup or beaker. Staff should encourage fluids and check Mrs D’s skin elasticity for signs of dehydration.
• If Mrs D refused food or fluids, the staff should inform the nurse and record the food and fluids on the nutritional chart.
• Mobility. Mrs D could mobilise for a short distance with a walking frame or stick. She had to be supervised at all times, as she was at high risk of falls.
22. The care plan on dental hygiene was 2 pages long and said:
• Night staff had to remove Mrs D’s dentures in the evening, brush them with a toothbrush or denture brush and cleanser and then soak them in a denture pot with a cleaning agent overnight.
• The denture cleansing solution delivered extra chemical breakdown of the plaque and disinfection. The cleansing solution should only be used outside of the mouth and ‘denture wearers should strictly follow the manufacturer’s guidelines.’
• Mrs D should not keep her dentures in the mouth overnight unless there were specific reasons for keeping them in.
• If Mrs D refused to wear her dentures or take them out, the nurse had to be informed.
• Staff had to rinse the dentures in the morning and give them to Mrs D so she could put them in.
• Staff should check Mrs D’s dentures following a meal to see if the dentures needed cleaning, ie debris of food on the roof of the dentures as this could cause irritation or infection.
• Staff should check Mrs D’s gums.

Nutrition and fluid chart

23. The Home kept a nutrition and fluid intake chart.
24. The chart detailed every liquid Mrs D drank in ml. The chart also gave the totals each day. The fluid recording from 24 April 2022 to 8 June 2022 showed that, on average, Mrs D drank between 1300 to 1500 ml a day. The Home has not sent me the nutrition and fluid charts from 9 to 12 June 2022.
25. From 13 to 16 June 2022, no fluid totals were calculated. I calculated the totals and Mrs D drank 500 ml, 80 ml, 550 ml and 390 ml on the 4 days from 13 to 16 June 2022.
26. In terms of nutrition, there were days, in the earlier weeks, when Mrs D ate all the meals that she was offered. However, from May onwards, she rarely ate all three meals that she was offered.
27. In June 2022, Mrs D’s nutrition intake declined further. She often refused meals and intake was now measured in spoons. For example, on 6 June 2022, Mrs D did not eat any lunch or dinner, she ate little on 10 and 11 June 2022. On 13 June 2022, Mrs D ate 2 spoons of lunch and no dinner. She ate nothing on 14 June 2022 and spoons of food on 15 and 16 June 2022.
28. Mrs D’s care plan said the nurse should be informed when Mrs D refused food. The records showed the nurse was informed on 20 May 2022, 4 June 2022 and 13 June 2022. The nurse was involved in trying to convince Mrs D to eat on 8 June 2022.

Weight chart

29. Mrs D was weighed twice during her stay. Mrs D weighed 52 kg on 24 April 2022 when she entered the Home and 46 kg on 27 May 2022.

Dental records

30. The Home has a hygiene chart which allows care workers to tick a box when personal care has been delivered. The care workers ticked the box ‘yes’ for ‘clean teeth/oral hygiene’ most mornings and afternoons, but there were occasions when they ticked ‘no’ in the evenings.
31. There were no details of what oral or dental care was provided in the daily records between 25 April and 22 May 2022. After 22 May 2022 the records showed:
• 22 May 2022 – cleaned teeth.
• 31 May 2022 – allowed to brush teeth.
• 3 June 2022 – teeth were thoroughly brushed.
• 5 June 2022 – oral care given, brushed tooth, mouthwash used.
• 9 June 2022 – teeth cleaned.
• 12 June 2022 – teeth were cleaned, Mrs D tried to bite staff when they gave her oral care.
• 13 June 2022 – teeth cleaned.
32. There were no records to show that the nurse was informed when Mrs D refused to allow oral care or refused to take out her dentures. There were no records relating to the dentures going missing or being found.

Moving and handling

33. I found the following entries in the daily records of Mrs D walking. On 27 April 2022, Mrs D was assisted to walk to the dining table and then back to a chair in the lounge. There was a mention of Mrs D ‘participating in an exercise’ on 12 May 2022, but it is not clear what that exercise was. On 13 May 2022, Mrs D walked in the lounge. On 16 May 2022, Mrs D walked to the kitchen table with assistance.
34. Mrs D was taken to the lounge for her meals or relaxation on most days, but this was mostly in her wheelchair. She was then assisted to transfer from her wheelchair to an armchair.

Medication

35. The Home kept medication administration record (MAR) charts and recorded the medication that staff gave to Mrs D. The records were filled in daily at the times when the medication was due to be administered. Most medications did not have a specific time for administration, but said ‘morning’ or ‘evening or ‘three times a day’. One medication had to be administered at 4pm.
36. There were occasions, when Mrs D refused medication and the staff entered ‘R’ for refusal.
37. On 7 June 2022 the Home spoke to the GP about covert medication and the GP signed this off.

Other records

38. On 31 May 2022 the dietitian and advised the Home to give Mrs D 100 ml instead of 200 ml to increase the possibility of Mrs D taking the shake. The dietitian said the Home should ring them again if Mrs D continued to lose weight.
39. The GP visited Mrs D on 7 June 2022. They discussed covert medication. The GP wanted to inspect Mrs D’s mouth for mouth ulcers, but she did not open her mouth. They discussed Mrs D’s eating and drinking. The GP said he would speak to the family about a ‘do not attempt to resuscitate’ form.
40. There were further conversations with the pharmacist on 9 and 16 June 2022 about covert medication.
41. The nurse called on 16 June 2022 to review Mrs D’s health condition as the family had reported that Mrs D was not taking her medication.
42. On 16 June 2022, the family continued to be concerned about Mrs D as she was not eating or drinking and was deteriorating. The Home noted that the Hospital Avoidance Team was not available as it was after 20:00. An ambulance was called at 22:30 and Mrs D was taken to hospital in the early hours of 17 June 2022.

The Home’s comments to the Ombudsman

43. The Home made further comments to the Ombudsman and said:
• Mr B said the upper dentures went missing within 2 weeks of Mrs D’s stay and his sisters raised this with the Home. He raised the missing dentures with the Home on 21 May 2022.
• It could not confirm, from its records, that the Home was alerted to the dentures being missing. It said that, on occasions, Mrs D removed her dentures and then lost them, but care workers would find them again. Nurses and care staff would struggle to replace the dentures in Mrs D's mouth as she had ‘a habit of clamping her jaws.’
• The Home said Mrs D was still able to eat and drink without the upper dentures in place.
• The family raised the issue of the missing dentures on 3 June 2022 and had booked an appointment with the dentist on 6 June 2022.
• In terms of the oral care, the Home said this was ‘challenging since [Mrs D] was often confused and had her jaws clenched and was not always compliant with full oral care’.
• The staff cleaned the teeth in situ where possible.
• Mrs D preferred to leave her lower dentures in her mouth.
• I asked the Home why it did not weigh Mrs D more frequently. The Home said it had a policy to weigh residents once a month.
• In terms of the medication, the Home said it had started the process of covert medication on 30 May 2022 as Mrs D sometimes refused to take medication.
• In terms of the nutrition, the Home said it allocated care workers who spoke Mrs D’s language to encourage her to eat and drink, it offered food in line with Mrs D’s cultural background and the family also brought in familiar foods. The care workers would ensure that Mrs D was in the main lounge so she could eat with other residents.
• The nurse’s records had gone missing, possibly when Mrs D was taken to hospital so this may contain more information about what information was shared with the nurses in terms of dental care and nutrition.

Analysis

44. I have not investigated what the cause was of Mrs D’s decline and her admission to hospital. That would require a specialist medical investigation and analysis and is best left to the courts. The Ombudsman is not a court.
45. I have investigated what the Home should have done and what it has done.
46. These are the actions that would be expected from a care home, in line with the CQC’s guidance. A care home should:
• Write a care plan which meets the needs of the resident.
• Provide the care in line with the care plan.
• If it is not possible to provide the care in line with the care plan, it should address any concerns as soon as they become apparent and amend the care plan, if necessary.
• Keep adequate records.

Mobility

47. In terms of the complaint that Mrs D was left in her bed most days, I have not found the evidence to support that complaint.
48. The records showed that the staff helped Mrs D to get out of bed most days and she had meals with other residents. She was transferred to the lounge and often sat in an armchair in the lounge. It is true that she did not walk very often, but neither was she left in her bed all day very often.

Medication and ambulance

49. In terms of the medication, there was no fault in the record keeping. The Home noted every time Mrs D took her medication or refused the medication and kept a record of this. I note the Home had obtained authorisation for covert medication because Mrs D sometimes refused to take her medication.
50. It is difficult for me to comment on the Home’s alleged reluctance to call an ambulance as this depends on the professional judgement of the nurse which is outside of the Ombudsman’s remit.

Dental care

51. I note that the Home said there were great difficulties in providing oral care to Mrs D, in line with her care plan. The Home said Mrs D would keep her lower dentures in her mouth and the upper dentures were often lost. The care staff then brushed the dentures in situ.
52. The care plan said the dentures should be placed in the cleansing solution overnight as this delivered extra chemical breakdown. The cleansing solution should only be used outside of the mouth and ‘denture wearers should strictly follow the manufacturer’s guidelines.’
53. The Home had a detailed care plan on Mrs D’s oral care and its staff did not follow that care plan.
54. I appreciate that this may be because Mrs D was non-compliant, but the fault lies in the fact that there were no records relating to this. Also, if Mrs D was non-compliant with the care plan, then the Home should have reviewed the care plan and decided how it could amend the care plan to address the problem. Instead staff were not following the care plan and not recording what was happening. This was fault.
55. The Home’s record keeping regarding dental care was poor to non-existent. There should have been a lot more detail considering the problems the Home said it was experiencing with Mrs D’s dental care.
56. In terms of the missing dentures, the family says this happened within two weeks of Mrs D’s arrival. The Home did not deny this, but denied having a record of the family informing them of the dentures going missing. The Home then admitted the dentures went missing, but said it found them. But again, there were no records of any of this and this failure to keep a record was fault.
57. The Home accepts that, by 3 June 2022, the upper dentures were permanently missing as the family had informed them of this. But it should not have been left to the family to alert the Home of the fact that the dentures were missing and that Mrs D needed replacement dentures. Surely the care workers should have noticed this and should have raised this much earlier.

Nutrition and hydration

58. The Home kept good records of Mrs D’s food and liquid intake between 24 April 2022 to 8 June 2022. The Home has not sent me the nutrition and fluid charts from 9 to 12 June 2022.
59. There were concerns about Mrs D’s food intake from May onwards as she was eating very little. And then in June 2022, Mrs D hardly ate at all. Mrs D also lost a lot of weight in a short period of time. The family says the weight loss was noticeable and I accept their evidence. Mrs D only weighed 52 kg when she entered so a loss of 6 kg would have been noticeable quickly.
60. I therefore do not understand why the Home did not weigh Mrs D earlier, especially as the family was raising concerns about this. The Home says it did not do so as they only weigh residents once a month, but surely, if a resident is eating very little and visibly losing weight, the Home should weigh them earlier.
61. I also note that the nurse was informed a few times that Mrs D was refusing food, but certainly not every time, as recommended in the care plan. However, I accept that the nurse’s notes have gone missing so it may be that the nurse was informed more frequently than the documents that I have seen, indicated.
62. I note the dietitian was not contacted until 31 May 2022, but the decline in Mrs D’s eating started in early May 2022.
63. There was further fault in the Home’s failure to properly monitor the fluid intake between 13 and 16 June 2022. The totals were not recorded, so it is not clear whether the Home was monitoring how little Mrs D was drinking at this stage. The Home said, in its complaint response that Mrs D had a decreased intake of fluids 24 hours before leaving the service. However, the decline had been going on since 13 June 2022 and possibly earlier as the records between 9 to 12 June 2022 are missing.
64. Mrs D drank only 500 ml, 80 ml, 550 ml and 390 ml on the 4 days from 13 to 16 June 2022. Considering how quickly dehydration can occur, I would have expected the Home to keep accurate records of hydration and its actions in relation to this.

Injustice and remedy

65. Sadly, Mrs D has passed away so any injustice to her cannot be remedied.
66. However, I do not underestimate the impact that these concerns had on Mr B as he was worried about the care Mrs D received. He will always have the uncertainty whether things could have been different for Mrs D if she had not moved to the Home.
67. When the fault has caused no direct financial injustice, the Ombudsman can sometimes recommend a small symbolic payment to acknowledge the impact of fault on the complainant. I recommend the Council pays Mr B £250.

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Agreed action

68. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Home, I have made recommendations to the Council.
69. Under our information sharing agreement, we will share this decision with the Care Quality Commission. They are best placed to address concerns relating to the Home.
70. The Council has agreed to take the following actions within one month of the final decision:
• Apologise in writing to Mr B for the fault.
• Pay Mr B £250 as a symbolic payment to acknowledge the fault.
• Remind the Home of the importance of appropriate record keeping and the importance of alerting relevant staff if the care plan is not being followed and needs to be amended.

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Final decision

71. I have completed my investigation and found fault. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman