Summary: The care provider did not always give a good standard of care and treatment to Mr X. There is evidence of an inappropriate diet, late response to the development of a pressure sore, and some poor practice in relation to medication administration. The care provider has already apologised for some matters but should offer a partial fee refund to Mr X in recognition of the poor care and take steps to review its practices.

The complaint

1. Mr A (as I shall call him) complains about the poor standard of care and treatment provided to his father Mr X during a two week stay at the home. He complains about poor admission procedures, failure to administer medication properly sometimes, other residents wandering into his father’s room, missing clothes, poor hygiene practices and poor nutrition. He also says Mr X developed a pressure sore during his stay.

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The Ombudsman’s role and powers

2. 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)
3. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

5. I considered all the information provided by the care provider and by Mr A. Both parties had the opportunity to comment on an earlier draft of this statement before I reached a final decision.

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What I found

Relevant law and guidance

6. 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.
7. Regulation 10 says “service users must be treated with dignity and respect”.
8. Regulation 12 says care and treatment must be provided in a safe way for service users, including the proper and safe management of medicines.
9. Regulation 14 says “The nutritional and hydration needs of service users must be met.”
10. The care provider’s complaints procedure says, “Depending on the nature of the complaint, we aim to provide a full response and resolution within 28 working days of your initial communication. …” If you do not feel your complaint has been satisfactorily dealt with by the Home Manager or you do not wish to raise the complaint with them directly for any reason, please contact the Regional Director”.

What happened

11. Mr X went into the care home in October 2022 for a two-week respite stay. There was a pre-admission assessment visit undertaken the previous week. Mr A says at the assessment Mr X’s daughter told the home manager what her father’s dietary requirements were (Mr X is edentulous, only wears a top denture, and cannot easily manage to eat toast, crusts or bacon). The nutrition care plan for Mr X says he “likes to have a soft option for meals”; “he likes to have a softer option this is a preference and not a medically assessed need”. It says his diet should include something like “stew, scrambled eggs, pie with soft crust and plenty of gravy”.
12. Mr A says the bedroom was not ready for Mr X when he went into the home. He says a member of care staff was struggling to fit the wrong size sheet to the bed. That was still not resolved two days later and the pump from the airflow mattress was buzzing frequently and keeping Mr X awake. The manager told him the airflow mattress should not have a fitted sheet in any case.
13. Mr A says the initial call bell given to Mr X did not work and the replacement was often left at the bottom of his bed out of reach, so he had to shout for staff to attend and waited as much as half an hour.
14. Mr A says despite the pre-admission assessment, the staff at the care home gave his father inappropriate foods he couldn’t eat instead of the pureed or mashed diet they had requested. He says cold food was given and often Mr X just did not eat. He says on one occasion Mr X was given cold sausage and mashed potato which was too dry to eat. Mr A says he asked staff for gravy but was told there wasn’t any and they could only offer soup to put on his food. Mr A says the diet Mr X was being offered made him constipated and instead of the usual cereal and prunes he was given “thick lumpy” porridge for breakfast.
15. Mr A says one morning the carer missed Mr X’s 6.30am medication but denied this had happened. The senior carer instructed her to give the medication at 8am but again it was missed and not given until 10am. His medication was also missed that evening, Mr A says.
16. Mr A says there were problems with other residents coming into his father’s room uninvited and on one occasion wetting the bed.
17. Mr A developed a pressure sore in the home. The GP arranged for him to be admitted to hospital after 12 days because of concerns about his constipation. Mr A says his father was so weak by the time he went into hospital that after 6 nights in hospital, he was admitted to a rehabilitation unit for another 13 days to regain his strength.
18. Mr A says when Mr X’s room at the care home was cleared, some clothes were found which were not his – he had been seen on occasion wearing other residents’ clothes – and some of his own clothes were missing.

The complaint

19. Mr A complained to the care provider on 13 November. He said the care provider should at least apologise and refund the fees paid for Mr X’s stay.
20. On 5 December the manager responded. He apologised that the room had not been properly ready for Mr X’s admission. He said the medication had not been missed on the day Mr A said but had been given late on Mr X’s return from a hospital appointment. He apologised that on another day medication had been missed, and a requested laxative delayed.
21. The manager said the pre-admission assessment had stated a preference for softer foods, not a pureed or mashed diet (it says “softer consistency – stews etc “ and notes that help should be given to cut up food if necessary - but most of the note is illegible). He attached the meal charts which showed Mr X had sometimes declined food but often had eaten most or all of the food offered. Toast and sandwiches were offered. Towards the end of Mr X’s stay, the records show blended food was offered which was mostly eaten.
22. The manager said the home catered for a range of residents and apologised that there had been a negative effect on Mr X from other residents coming into his room. He apologised for the poor state of cleanliness of Mr X’s bathroom on one occasion. He apologised for the missing items of clothing and offered to reimburse for those which could not be found.
23. In respect of the pressure sore, the manager apologised that this had happened. He said he was discussing this matter with the local safeguarding team and would contact Mr A again when he knew the outcome.
24. Mr A emailed the manager again on 18 January 2023 to escalate his complaint but did not receive a response. He complained again in March to the Regional Director. She responded in April. She said, “The outcome of (the manager’s) findings is that he partly upheld some aspects of the complaint as per his letter sent on 5th December 2022. From that point , if there is no further correspondence in relation to the outcome within 28 days of (his) response then the complaint is closed and as your dad was discharged from the home, the correspondence then stopped.”
25. The director offered again to reimburse for the missing clothing. In terms of a refund for fees, she said, “as the time frame has exceeded our complaints procedure then I am sorry, but I cannot offer you a refund at this stage.”
26. Mr A complained to the Ombudsman.
27. The care provider says staff noticed on 12 October (8 days after admission to the home) that there was a red sore patch round Mr X’s sacrum (the care provider points out that Mr X was largely self-caring in respect of his personal hygiene). She says he was given a pressure cushion and advised to mobilise more, and 2- hourly checks were put in place. She says two days later the skin was seen to have broken and so staff contacted the District Nursing team. As Mr X did not like the noise from the (pressure) airflow mattress, a foam mattress was used instead. She says Mr X was not mobilising well because of discomfort in his stomach.
28. The director says the District Nursing team did not attend the following day and care staff had to contact them again. The District Nursing team told care staff to dress the wound until they could visit. Mr X was admitted to hospital on 16 October before he was seen by the District Nurses. The director says she was unaware of the safeguarding concern raised until November. She says a safeguarding officer visited the home to discuss the alert, but no further action was taken.
29. The director says it is inaccurate to say complaints made after 28 days do not receive a response. She says “If a complaint is raised, investigated and the response is sent to the family and there is no response for 28 days, then we would close the complaint”. She says “When (Mr A) was emailing (the manager) for a lack of response, (the manager) had responded within the timeframe. (Mr A)’s further emails were after 28 days in which I noted that, but still reviewed the complaints made by (Mr A) and I was satisfied that (the manager) had handled the complaint response as per our policy and procedure. The email received from (Mr A) was asking the same questions that had already been answered and most of the complaint was upheld.”

Analysis

30. There is evidence that Mr X was not always treated with dignity and respect – his bathroom was left in an unhygienic state, his bed was initially unsuitable, and he was unable always to call appropriately for assistance. That was fault which caused him injustice and was a potential breach of the regulations.
31. There is also evidence Mr X was not always offered the appropriate diet. The care provider has emphasised that Mr X’s choice of a softer diet was a preference not a medical need, but as it had been included in the pre-admission assessment, it was obvious that Mr X struggled with some of the foods offered and it was possible (as the charts for the later days show) to offer blended food, it is unclear to me why the care provider was unable to offer the chosen diet all along. That was fault on the part of the care provider which caused Mr X injustice and was also a potential breach of the regulations.
32. Mr X’s medication was missed on occasion. He developed a pressure sore which was not treated with the appropriate urgency by care staff who did not contact the District Nursing team until two days after it was noticed, despite their awareness that Mr X was not mobilising well enough at that point to avoid its worsening.
33. The care home manager upheld and apologised for the majority of Mr A’s complaints. No further acknowledgement or contact was made despite Mr A’s wish to escalate the complaint until the regional director belatedly responded some months later. In contrast to her response to the Ombudsman, her response to Mr A clearly said the complaint had been closed as Mr A had not written again within 28 days.

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Recommended action

34. Within one month of my final decision, the care provider should review its approach to dietary requests and let me know how it will ensure residents’ preferences are met to avoid the situation which arose here, where Mr X was offered food he could not eat;
35. Within one month of my final decision the care provider should review its approach to obtaining care for pressure sores;
36. Within one month of my final decision the care provider should take steps to ensure its practice in terms of its complaints responses accords with its procedure.
37. Within one month of my final decision the care provider should offer Mr X a sum equivalent to one week’s fees in recognition that care was not provided as it should have been.
38. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

39. I have completed this investigation. I find the actions of the care provider caused injustice to Mr X which can be remedied by the completion of the recommendations at paragraphs 34- 37 above.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman