Summary: Mrs X complained about the care received by her mother, Mrs Y, at Chiltern View Care Home, which is run by Benslow Management Company Limited (BMCL). We found, on the balance of probabilities, that Mrs Y did not always receive care of an acceptable standard prior to the introduction of service improvements by BMCL. BMCL agreed to apologise, reduce the outstanding balance of Mrs Y’s care fees and make Mrs X a symbolic payment in recognition of the injustice caused.

The complaint

1. Mrs X complained about the care provided to her mother, Mrs Y, at Chiltern View Care Home during her stay. She says:

1. The level of care was below the industry standard.
2. There was lack of cleanliness and maintenance at the home.
3. There were staff shortages and a reluctance to recruit and train new staff.
4. Mrs Y did not receive adequate personal hygiene.
5. Mrs Y was found in soiled clothing and bedding.
6. Mrs Y was left on her own most of the time and did not receive stimulation through tv, radio or staff interaction.

2. Mrs X says the above resulted in her mother being deprived of care she paid for. She also says it caused her distress and put her to the time and trouble of pursuing a complaint.

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The Ombudsman’s role and powers

3.  
4. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
5. 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)
6. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
7. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended.
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).
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

How I considered this complaint

10. I have:
• considered Mrs X’s complaint and discussed it with her;
• considered information from Mrs X and the Care Provider;
• considered the relevant legislation;
• considered our guidance on remedies;
• set out my initial thoughts on the complaint in a draft decision statement and considered Mrs X’s comments in response.

What I found

Relevant legislation

11. 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.
12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.

What happened

13. Mrs Y has a diagnosis of dementia. She became resident at Chiltern View Care Home in December 2021.
14. The Care Provider drew up a care plan for Mrs Y on admission. It said Mrs Y needed:
• a full body wash/ bed bath each morning and her hair and teeth brushed twice a day.
• to have her hands washed and lotion applied and massaged into her hands and wrists afterwards.
• to be repositioned every two hours when sleeping and to be checked regularly during the night and offered fluids when she is awake.
• to eat a fortified diet and an intake of 1500ml of fluids per day.
• to use incontinence pads and to have barrier creams applied.
• staff to use short sentences and to provide support to encourage her to communicate her needs and wishes. Staff should check on her regularly to check she is ok.

The care plan also states that Mrs Y likes to spend time with staff and to listen to music. It said she can sit for four hours a day but no longer because she is at risk of developing pressure sores.

15. The Care Provider recorded the care given to Mrs Y in daily logs.
16. In August 2022 and September 2022, the care home was inspected by the Care Quality Commission (CQC). Its inspection found the care home was inadequate in all areas. It said:
• At busy times of day there was not enough staff to meet the basic needs of the people living there. There was also not enough skilled and experienced staff and the home relied on agency workers to cover gaps in the rota.
• Residents requiring repositioning every two hours did not always receive this care.
• Residents were not supported to manage their continence needs. It said people were left in wet clothing and often had to wait a long time for continence support.
• The standard of cleanliness in the home was poor and there was a malodour throughout.
• People with care plans that required additional high calorie snacks and drinks did not always receive them. Additionally, the fluid intake amounts identified in people’s care plans were not always met.
• Some staff on shift during the inspection did not have the skills to deliver person centred care.
• People had nothing to do and were not kept occupied or stimulated.
17. In response to the findings of its inspection the CQC took enforcement action against the Care Provider which included restricting admissions to the care home. A service improvement plan was also put in place.
18. In March 2023 Mrs Y moved to a different care home.
19. In May Mrs X complained to the Care Provider about the care Mrs Y received at the care home. In June Mrs X made further contact with the Care Provider asking it to reduce the balance Mrs Y owed for her care because of the issues raised in her complaint.
20. In July the Care Provider responded to both matters. It said:
• It apologised for any distress caused by the findings of the CQC inspection and said it had implemented a service improvement plan to improve its service.
• It noted there were concerns in the CQC report about cleanliness but its records showed it had completed deep cleans, kept to its cleaning schedule and replaced seals where urine had penetrated them in the toilets.
• Care records for Mrs Y show she received daily personal care.
• Mrs Y’s care records also show Mrs Y received regular continence checks. However, it apologised if Mrs X found Mrs Y in soiled clothing and bed linen when she visited. It noted Mrs X did not make any complaints about this matter while Mrs Y was resident at the home.
• Care records show Mrs Y listened to TV and music in both her room and the communal conservatory. It said that Mrs Y did not commission one-to one time with staff.
• It had staff levels over and above those required to adequately care for residents. It also used external and online training to equip staff with the skills they needed.
• Accounts for the care home show it spent money on maintenance including equipment servicing and made purchases to make repairs to the building.

It did not consider there were grounds to reduce the outstanding balance for Mrs Y’s care.

21. Mrs X remained unhappy and approached the Ombudsman.
22. As part of our enquiries, we asked the Care Provider for Mrs Y’s care plan and care records. The care records it provided covered the period from December 2022 to March 2023. The records show that Mrs Y received personal care that was broadly in line with her care plan including that she received regular personal care including hair brushing, washing and eye care.
23. The care home is no longer operational.

Finding

24. The evidence in Mrs Y’s care records shows that she received care in line with her care plan from December 2022 onwards.
25. However, the care records provided are for the period following the inspections by CQC and so reflect the improvements the Care Provider introduced following the inspection by CQC.
26. The CQC inspection report found the care home was inadequate in all areas. I cannot discount the findings of the report. I accept its findings mean, on the balance of probabilities, that Mrs Y’s care at times fell below the expected standards prior to the improvement plan being introduced. This caused Mrs Y injustice.
27. Furthermore, the report highlights staff shortages, inadequately trained staff and poor cleanliness. Mrs X’s concerns about these matters are, on the balance of probabilities, valid prior to the improvement plan being introduced by the Care Provider. This caused Mrs Y an injustice. It also caused distress and upset to Mrs X. This is also injustice.

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Agreed action

28. I consider there has been fault by the Care Provider causing Mrs X and Mrs Y an injustice. In recognition the Care Provider has agreed to:
• apologise to Mrs X and Mrs Y in writing for the distress caused to them;
• reduce the outstanding balance for Mrs Y’s care by £1000 and confirm this in writing to Mrs X; and
• make Mrs X a symbolic payment of £200 in recognition of the distress and time and trouble caused to her.

The Care Provider should carry out the recommended actions within one month of my final decision.

29. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

30. I have completed my investigation and found the Care Provider’s actions caused an injustice. The Care Provider has agreed to my recommendations to address that injustice.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman