Summary: Mr X complains Southfield Court Care Home failed to provide his wife with the care she should have received, causing avoidable distress and resulting in him moving her to another care home. The care provider accepts Mr & Mrs X’s experience of the Care Home was not what it should have been. It has apologised and has taken steps to improve its performance. The Care Home’s failings resulted in a loss of dignity to Mrs X, avoidable distress and put her at risk of harm. The care provider needs to waive £1,000 of the outstanding fees to remedy that injustice.

The complaint

1. The complainant, whom I shall refer to as Mr X, complains Southfield Court Care Home (the Care Home) failed to provide his wife with the care she should have received, causing avoidable distress and resulting in him moving her to another care home.

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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 an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
3. This complaint partly involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.

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How I considered this complaint

4. I have:
• considered the complaint and the documents provided by Mr X;
• discussed the complaint with Mr X;
• considered the comments and documents the care provider has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mr X and the care provider, and taken account of the comments received.

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What I found

Key facts

5. The Care Home is run by Tamaris Healthcare (England) Limited, which is part of the Four Seasons Healthcare Group (the care provider). Mrs X has dementia and used to live at home with support from personal assistants. Mr X arranged for her to move to the Care Home when it was no longer possible to care for her at home.
6. The Care Home did a pre-admission assessment on 20 January 2023 and decided it could meet Mrs X’s needs.
7. Mrs X went to stay at the Care Home on 27 January. The Care Home kept records of her condition and the support provided for her. The records show she could walk independently. However, due to postural hypertension, she had a series of falls but no significant injuries. The records also show Mrs X was unsettled at times, wandering around the Care Home and sometimes into other people’s rooms.
8. On 12 February another resident pushed Mrs X to the floor. The Care Home told Mr X, who said he was not happy about the incident and asked what would be done to prevent it from happening again. It moved Mrs X to a different room (away from the other resident) and personalised the door in the hope this would help her recognise her own room. Mrs X received a letter from the Adult Community Therapy Team, confirming the hospital had referred her for a falls assessment, for which there was an eight-week waiting list.
9. On 19 February Mrs X remained in bed. Her visitor tested her for COVID-19 and told the Crae Home the result was positive. The visitor also pointed out Mrs X had a fall the previous day, but the Care Home had not told Mr  X. The Care Home then told Mr X about the fall and the positive test for COVID-19. Mr X asked the Care Home to do another test, which was negative, and her temperature was normal. When the Care Home did a further COVID-19 test the next day, Mrs X tested positive again. Its records say she could not isolate as she was walking independently most of the day. She had another fall.
10. Mr X arranged for his wife to leave the Care Home on 9 March, as he had lost confidence in its ability to look after her properly.
11. When the Care Quality Commission (CQC) inspected the Care Home in March, it found it required improvements to make it safe, effective and well-led. It was mostly assured about its infection prevention and control measures, but only somewhat assured about admission procedures and the premises, and not assured about its policies. It noted the premises were not suitable for the needs of people with dementia and there were strong odours throughout. It also noted staffing levels were not adequate.
12. Mr X complained to the care provider in March, saying.
• Despite arriving at 11.00 as arranged, they had to wait 30 minutes for someone to welcome them. None of the people who did her basic tests (bloods, blood pressure etc) introduced themselves or addressed Mrs X by name.
• Despite being told there was a buddy system, this did not work.
• During her stay staff were unresponsive to his wife’s needs. Her visitors had to wash and change her two days in a row after she soiled herself and was left in soiled, wet clothes.
• Mrs X’s visitors had prevented a nurse from giving her the wrong medication at the wrong time and in the wrong dose.
• The Care Home failed to update Mr X after saying it would carry out a full investigation when another resident pushed Mrs X to the floor.
• The care provider had sent him an invoice which did not take account of the payments Mr X had already made.
• The Care Home did not discuss or share Mrs X’s care plans with him.
• Despite being told there was an activity schedule, he was not aware of his wife taking part in any activities.
• Staff had left a used incontinence pad in Mrs X’s bed, despite remaking it. Her visitor discovered this because of a strong smell of urine in the room.
• He learned of the outbreak of COVID-19 at the Care Home from one of Mrs X’s visitors on 18 February. When he asked why Mrs X was being allowed to wander freely round the ground floor, a member of staff told him COVID-19 was “going to go through the whole place anyway”.
13. He asked the care provider to reimburse his wife for the payments she had made.
14. When responding to Mr X’s complaint in April, the care provider said:
• It apologised if they felt the admission experience fell below standards and expectations – The Care Home would reflect on this to ensure processes were explained and people were made to feel welcome when arriving. It would provide further training on completing pre-admission assessments.
• It apologised for not discussing Mrs X’s care plans with them, despite updating the care plans following her admission. It said there should have been a more open channel of communication to address any concerns.
• It apologised if they felt Mrs X had not been treated with dignity and respect by some members of staff but said it could not look into this in detail as they had not provided the names of the staff involved. Nevertheless, staff would reflect on their concerns.
• It could not look into the claim that a nurse tried to give Mrs X the wrong medication as it did not have the date of the alleged incident. However, it would discuss the issue with the clinical team.
• One of Mrs X’s medications (an anti-depressant) had been out of stock at the pharmacy for nine days, but nursing staff failed to record what action they took to follow this up with the GP or the pharmacy. This fell short of expectations, so it would look further into why it had happened.
• The Care Home was going through a period of management change. It was supporting the Care Home to reassure residents and relatives it was working safely and effectively, and fully investigating incidents and making improvements.
• It had reported the incident with another resident (who pushed Mrs X over) to CQC and the local safeguarding authority. Staff had increased observations for Mrs X and the other resident. They had also moved Mrs X to another room (Mr X says this was at her visitor’s suggestion), so she was no longer next door to the other resident and to reduce the risk of further incidents. It apologised for not updating Mr X about the manager’s investigation into the incident.
• Mrs X had taken part in activities on eight days while she was in the Care Home. It was recruiting a full-time activities co-ordinator to take over from the current part-time co-ordinator. It would consider how best to share information about activities with families.
• It accepted the Care Home had not given Mr X the right information when he raised concerns about its handling of an outbreak of COVID-19. It said it could not isolate Mrs X after she tested positive for COVID-19, as she could not understand the need to remain in her room and became distressed.
• It accepted a payment made on 16 February (£2,185) should be offset against the invoice subsequently sent to him.
15. Mr X was not satisfied with the care provider’s response, so contacted it again. When the care provider responded in June, it said:
• Further training on the administration of medication had been provided to prevent a re-occurrence of the problems Mrs X had experienced (being offered the wrong medication on one occasion and being without her anti-depressant for nine days).
• It was a constant challenge to support residents living with dementia who could become distressed when isolated. Information was shared with Public Health England and the Care Home implemented the care provider’s infection prevention and control policy.
• Mrs X had thought another resident was her husband, which caused them both distress and resulted in the other resident pushing her to the floor. It had moved Mrs X to another room away from the resident and nearer the office (Mr X disputes the claim that the room was nearer the office). The local authority’s safeguarding team confirmed no further action was necessary.

The care provider referred to Mrs X as Mr X’s mother throughout its letter.

16. Mr X paid for most of his wife’s stay at the Care Home, but there is an outstanding balance of £1,912.14, which the care provider has put on hold while he pursues his complaint.

Did the care provider’s actions cause injustice?

17. There is no dispute over the fact that Mr & Mrs X’s experience of the Care Home did not meet their expectations. The care provider has changed the management of the Care Home and accepted the need to make improvements. It has also been required to make improvements by CQC. Some of CQC’s findings reflected Mr & Mrs X’s experience of the Care Home, in particular the lack of staff to meet people’s needs safely and effectively.
18. I can see no reason to dispute the claims made by Mrs X’s visitors that:
• she was not always cleaned and changed promptly after experiencing incontinence;
• on one occasion she was offered the wrong medication at the wrong time and in the wrong dose (but received the correct medication when this was pointed out);
• a used continence pad was left in her bed, despite staff having changed the sheets.
19. The care provider accepts staff did not take steps to ensure Mrs X received her anti-depressants, leaving her without the medication for over a week. During the time she was without her medication she was pushed over by another resident. The lack of medication could have been a contributory factor to the incident.
20. These failings caused injustice to Mrs X through a loss of dignity, avoidable distress and put her at risk of harm.
21. The Government guidance (COVID-19 supplement to the infection prevention and control resource for adult social care) in place when Mrs X tested positive for COVID-19 said, when testing positive for COVID-19:
• “The care home manager should inform the resident’s GP and should: support the resident to self-isolate for up to 10 days within their own room with tests available to end the period of self-isolation”.
22. While it is true that it is not always possible to isolate people with dementia who do not understand the need to do so, I would have expected to see a more robust risk assessment than the one contained in Mrs X’s records to justify the decision not to attempt to isolate her in her room.

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Recommended action

23. I recommend the care provider within four weeks writes to Mr X agreeing to waive £1,000 of the outstanding fees.
24. The care provider should provide us with evidence it has complied with the above actions.
25. Under the terms of our Memorandum of Understanding and information sharing agreement with CQC, I will send it a copy of my final decision statement.

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Final decision

26. I have completed my investigation on the basis the care provider’s actions have caused injustice requiring a remedy, which the care provider has agreed to carry out.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman