Summary: Mrs L complained about issues with the care provided by Warmest Welcome Limited. Warmest Welcome Ltd were at fault for providing inadequate care which caused distress, uncertainty and risk of harm. Warmest Welcome Ltd have agreed to apologise to Mrs L, make a reduction to Mrs M’s care fees invoice and take action to improve services in the future.

The complaint

1. The complainant, whom I shall refer to as Mrs L, complains on behalf of her mother, Mrs M. She complains that the Care Home owned by Warmest Welcome Ltd:

• wrongly assured the family the home could meet Mrs M’s care needs;
• failed to provide a proper standard of care during Mrs M’s 3-week stay at Westfield House;
• lost Mrs M’s dentures; and
• has billed Mrs M the full amount for the planned stay despite not providing the promised care.

2. Mrs L says this has affected Mrs M, whose mental capacity has sharply declined because of this experience. Mrs L says it has also caused her family extreme anxiety, distress and disillusion. Mrs L said the family were also required to find alternative care at short notice which had financial implications.

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The Ombudsman’s role and powers

3. 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)
4. Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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 a significant injustice or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(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. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

How I considered this complaint

9. I considered the information Mrs L provided. I also considered the information given by the Care Provider in response to my enquiries.
10. Mrs L and the Care Provider had the opportunity to comment on my draft decision. I considered these comments before making a final decision.

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What I found

Legislation and Guidance

Fundamental standards

11. 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.
12. 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. Of relevance to this complaint are:

• Regulation 9: Person-centered care. The resident must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Regulation 10: Dignity and respect. Residents must be treated with dignity and respect and in a caring and compassionate way.
• Regulation 12: Safe care and treatment. Providers must do all that is reasonably practicable to mitigate risks to the resident’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Regulation 14: Meeting nutritional and hydration needs. Residents must have enough to eat and drink to keep them in good health while they receive care and treatment.
• Regulation 17: Good governance. Providers must maintain securely an accurate, complete and contemporaneous record in respect of each resident.

Care Provider contractual terms

13. The Care Provider’s resident agreement says that insurance is provided by the company up to £500 for personal effects. The home manager should be informed if the sum insured on general items is insufficient or if any item is worth more than £200. If this is the case, the resident may pay for their own insurance.

Background information

14. Mrs M became a resident of the Care Home on 2 June 2023 after receiving 1:1 care in her own home. Mrs M had dementia.
15. Shortly after her arrival, her family complained to the Care Provider about poor care. The Care Provider met with Mrs M’s family in a care review meeting and agreed to address some ongoing issues. This included providing staff with timings for taking Mrs M to the toilet and ensuring that she had her denture and glasses.
16. After three weeks, Mrs M’s family decided to take her home to find alternative care as they were unhappy with the care provided.
17. In July, the family made a complaint to the Care Provider raising concerns that Mrs M had lost 3.2kg of weight in her three week stay with the Care Provider and had not had a bowel movement for 12 days. They also said that Mrs M was severely dehydrated.
18. The family also complained that the Care Provider had lost Mrs M’s denture and only offered £200 towards a replacement. The family refused to pay the outstanding care fees as they felt the care was severely lacking.
19. In November, the family contacted CQC and the local authority’s Adult Social Care Safeguarding Team raising the same concerns about the Care Provider. Both asked the Care Provider to complete a full investigation into the allegations.
20. In the Care Provider’s responses, it accepted there were some parts of the complaint that it had upheld and it had put in some service improvements.
21. The Care Provider stated that it did not receive any information about the outcomes of the complaints. It said the Safeguarding Team did contact the home manager by telephone and stated it was happy with the actions the Care Provider had taken and did not have any other concerns.

What happened

The Care Provider wrongly assured the family the home could meet Mrs M’s care needs

22. The Care Provider met with Mrs M’s family prior to her admission. I was not provided with evidence of the discussions held during this meeting, apart from the pre-admission assessment.

The Care Provider failed to provide a proper standard of care during Mrs M’s 3-week stay at Westfield House

Mrs M was often left with food and drinks near her but unable to access them

23. The pre-admission assessment referred to Mrs M needing encouragement to drink water during the day and that she had recently had a loss of appetite.
24. The Care Provider completed a nutritional risk assessment on 2 June. This said, “monitor to ensure resident is coping”. It also stated Mrs M would need a member of staff to monitor her at all mealtimes and prompt/encourage her to eat and drink. The care plan recorded the same information.
25. I reviewed the daily care records for Mrs M. There was a variation in the content of these. On some occasions it stated that Mrs M ate and drank what was offered. On other occasions it stated that Mrs M was provided encouragement. There were also times where it just stated Mrs M did not eat or drink anything.
26. The family raised concerns about this issue after Mrs M had been at the care home for two weeks. In an email to the Care Provider, they said the feeding support was “haphazard” and they had witnessed staff helping only sometimes. The family were clear that Mrs M needed help and encouragement, especially with drinking.
27. The family raised this again in a complaint in July. The Care Provider responded by saying records evidenced that Mrs M had a poor appetite and often ate and drank small amounts or declined food and drink despite staff and family encouragement.

Mrs M was dehydrated when she left the care home

28. I saw no evidence of an initial assessment about how much fluid intake Mrs M needed. The Care Provider did record Mrs M’s daily fluid intake, however, there was nothing to measure the daily recordings against.
29. These records also pointed out that Mrs M’s fluid intake was significantly low. On average, Mrs M only drank 220ml of fluid per day.
30. The care plan risk assessment had an entry on 16 June stating “fluid watch”. This however stated the “assessment was not scored”. This gave Mrs M a fluid target of 1500ml. Records highlighted that during her three week stay, there were only two occasions where staff offered Mrs M 1500ml or more fluid in a day.
31. On 19 June, records showed that staff only offered 300ml of fluid and Mrs M only drank 50ml of this. This was significantly below the fluid target of 1500ml.

Mrs M was left to wear incontinence pads all day

32. The pre-admission assessment recorded in handwritten notes “no pads day time”. It also said that Mrs M would need prompting to use the toilet and that she wore pull up pants at night. Mrs M’s care plan contained the same information.
33. The family raised concerns that Mrs M appeared to be wearing pads all day, although staff assured them they were taking her to the toilet regularly.
34. The family also said they were unhappy that one carer had said that Mrs M would say “no” when asked if she needed the toilet. The family reiterated they felt Mrs M did not have the mental capacity to decide this and so she needed to be prompted to go to the toilet.
35. In the stage one complaint response, the Care Provider said that following this complaint, it provided staff with timings that Mrs M should be taken to the toilet.
36. The Care Provider also explained that in the care review meeting, evidence was provided that indicated Mrs M had been incontinent throughout the day and that pads were offered to maintain dignity.
37. The Care Provider provided a pad changing record which begins from 6 June and does not provide information about why this was started.

Mrs M lost 3.25kg of weight in three weeks

38. There are inconsistent recordings of Mrs M’s weight and the associated care required upon admission to the Care Home.
39. An entry on the care plan dated 2 June states “16, high risk, consider recording dietary intake daily, weekly weigh in, giving dietary supplements as appropriate”. It was also recorded that Mrs M had an average body mass index (BMI).
40. In contrast, a different nutritional assessment recorded that Mrs M had an above average BMI.
41. I have also seen a copy of a Malnutrition Universal Screening Tool (MUST) which was completed on 2 June. This stated that Mrs M was a new admission and not yet screened. It gave a MUST score of 0 which concluded that she was “Low risk” and would require “routine checks” and to be reviewed again on 7 July.
42. The pre-admission assessment stated that Mrs M weighed approximately 57/58kg.
43. The care plan showed Mrs M’s weight was 58.8 kg with a BMI of 23.3 however, there is no date recorded for this. There is a graph within the care plan which showed Mrs M’s weight to be 62.6kg a couple of days after 4 June and 58.8kg around 20 June.
44. In response to the family’s complaint, the Care Provider said that staff implemented ‘nutrition watch’ to closely monitor Mrs M’s dietary intake and monthly checks. It also said that it had reviewed meal records and there was evidence of poor appetite and Mrs M declining food.
45. It stated Mrs M was weighed again on 20 June prior to discharge and weighed 58.8kg, which would have triggered a referral to the dietician if she had remained at the care home due to the weight loss.
46. The Care Provider partly upheld this complaint, acknowledging that Mrs M did lose weight during her admission. The Care Provider implemented a service improvement where it would complete weekly weigh-ins for new admissions for the first four weeks.

Mrs M did not have a bowel movement for 12 days

47. The Care Provider has already acknowledged fault about this part of the complaint. It said the bowel monitoring charts should have been reviewed sooner to ensure a timely review by the GP.
48. In response to this it said that all staff would be given guidance in relation to the importance of monitoring bowel movements.
49. The Care Provider stated that staff were administering laxative medication as prescribed and it contacted the GP on 19 June to assess Mrs M.
50. Mrs M’s medication administration records indicate that when Mrs M became a resident at the home, she had a prescription for two different laxatives, one which was prescribed to be taken twice per day as and when required.
51. However, according to records this was not given to Mrs M until she had not had a bowel movement for four days, and even then, it was only given to her once per day rather than the prescribed twice.
52. On 17 June, despite Mrs M not having a bowel movement for nine days, staff failed to give her any of one of the prescribed laxatives.
53. On 19 June the GP prescribed a different laxative and said the home should stop using the two previous ones. However, Mrs M’s records show staff continued to give her one of the previous laxatives and did not use the newly prescribed one.

The Care Provider lost Mrs M’s denture

54. The pre-admission assessment referred to Mrs M having a partial (top) denture. Mrs M’s care plan says that Mrs M should have worn her denture during the day and removed them at night.
55. Mrs M’s denture was lost two weeks after she moved into the Care Home. Therefore, the Care Home was unable to follow the care plan regarding Mrs M’s denture.
56. The family complained the Care Provider lost Mrs M’s denture and refused to pay in full for a replacement.
57. In the Care Provider’s complaint response, it apologised that Mrs M’s denture had been misplaced and agreed it would remind staff about the importance of caring for residents’ belongings.
58. Prior to Mrs M moving to the care home, one of her daughters signed a ‘resident agreement’. This stated that the home manager should be informed if any one item has a value of more than £200 and that in this case, the resident may take out additional personal insurance at their own expense.
59. The family state that the denture would cost £700-£800 to replace. The Care Provider offered to pay £200 towards a replacement denture which would be claimed via its insurance as per the resident agreement.

The Care Provider billed Mrs M the full amount for the planned stay despite not providing the promised care

60. There is an outstanding invoice of £3342.86 for 18 days care fees.
61. Mrs M’s family said that they would not be paying the invoice due to the severely lacking care provided.
62. The Care Provider responded to say that it felt Mrs M received “adequate care” during her admission, however it did agree that some areas of care could have been improved.
63. It stated that accommodation and care was still provided for Mrs M and requested the invoice be paid in full. The invoice remains outstanding.

Was there fault causing injustice?

The Care Provider wrongly assured the family the home could meet Mrs M’s care needs

64. There was a meeting between the family and Care Provider prior to Mrs M becoming a resident, a pre-admission assessment was completed and both parties then agreed on Mrs M’s admission. Therefore, the family made its own informed decision and I do not find any fault in the actions of the Care Provider.

Failed to provide a proper standard of care during Mrs M’s 3-week stay at Westfield House

Mrs M was often left with food and drinks near her but unable to access them

65. The Care Plan adequately reflected that Mrs M needed support and encouragement with food and drinks. However, the care records did not consistently record whether staff provided support to Mrs M in terms of nutrition.
66. The Care Provider is at fault for having inconsistencies in recording around nutrition. Other parts of the care records consistently recorded how much support Mrs M was given for example with personal care. However, this was not the case for nutrition, and it is therefore difficult to assess to what extend staff followed Mrs M’s care plan. This is fault and a potential breach of Regulation 17 and 14. This caused Mrs L and Mrs M uncertainty in the care that was provided.

Mrs M was dehydrated when she left the care home

67. The Care Provider was at fault for failing to notice and act on Mrs M’s significantly low fluid intake. This is fault and a potential breach of Regulation 14.
68. Although the Care Provider completed a fluid chart, it failed to record the levels of fluid Mrs M needed for adequate hydration, until 16 June. This is fault.
69. Even after 16 June, when the Care Provider recorded that Mrs M needed 1500ml of fluid per day, she was only offered this amount on one occasion and on two occasions throughout her whole stay. This is fault and not in line with Mrs M’s care plan and is a potential breach of Regulation 9.
70. The Care Provider failed to seek medical advice about Mrs M’s low fluid intake. This is fault and a potential breach of Regulation 12.
71. These faults caused a significant injustice to Mrs M as she did not receive the care she should have been in line with her needs or that she was paying for. This would also have been distressing to both Mrs M and Mrs L.

Mrs M was left to wear incontinence pads all day

72. The Care Provider has been clear that Mrs M was offered pads during the day to maintain her dignity. The family said she did not need pads during the day before she moved into the care home.
73. However, it is clear there was a change in the care that was provided from that described in the pre-admission assessment and the care plan.
74. I have seen no evidence that the care plan was updated to reflect that Mrs M should or needed to wear pads during the day so this is fault and a potential breach of Regulation 17(2)(c) which says that providers must be kept accurate and up to date records.

Mrs M lost 3.25kg of weight in three weeks

75. The Care Provider was at fault for failing to act on Mrs M’s weight loss. This is fault and a potential breach of Regulation 14.
76. There is no evidence that despite Mrs M displaying a reluctance to eat, that this prompted the Care Provider to complete a review of her weight or to seek medical advice. This is a potential breach of Regulation 12.
77. There was also no evidence of staff offering Mrs M fortified drinks or weekly weigh-ins as per one of the comments in the care plan. This is fault and not in line with Mrs M’s care plan. It is also a further potential breach of Regulation 14.
78. Furthermore, the Care Provider is at fault for having inconsistencies in records around Mrs M’s weight, BMI and a plan for her nutrition. This is fault and is a potential breach of Regulations 9 and 14.
79. This has caused an injustice to Mrs M and Mrs L and uncertainty about how these failings may have impacted Mrs M. Had the Care Provider kept better records it may have attempted more intervention or acted at an earlier time to seek medical advice or increase her nutrition.
80. The Care Provider acknowledges that Mrs M lost weight during her admission and has since implemented a system where it completes weekly weigh-ins for new admissions.

Mrs M did not have a bowel movement for 12 days

81. The Care Provider already acknowledged fault about this part of the complaint. It accepted it should have reviewed the bowel monitoring chart and requested a GP review sooner. It did not and this is fault. This was a potential breach of Regulations 12, 13 and 17.
82. The Care Provider was also at fault for not administering or recording the administration of medication as per GP advice. This is a potential breach of Regulations 9, 12 and 17.
83. This caused Mrs M a significant injustice as she did not receive the care she was paying for or that she was entitled to expect. This is also evidence that her health was not properly managed.

The Care Provider lost Mrs M’s denture

84. The Care Provider apologised that Mrs M’s denture was misplaced and I welcomed it reminding all staff about the importance of caring for resident’s belongings. The Care Provider losing Mrs M’s denture is fault and this has caused her avoidable inconvenience and distress,
85. The Care Provider offered Mrs M £200 towards the cost of replacement for the denture and relied on its contract terms within the resident agreement to limit its liability to £200. One of Mrs M’s daughter signed this resident agreement. This is in line with Regulation 19. This is a decision the Care Provider is entitled to make.

The Care Provider has billed Mrs M the full amount for the planned stay despite not providing the promised care

86. The Care Provider stated that it still expected the full outstanding invoice to be paid.
87. However, as set out above, the Care Provider’s care was not in line with the Fundamental Standards and Regulations. There has been an injustice to Mrs M and this should be reflected in a payment made to her in recognition of the distressed caused, uncertainty and risk of harm.
88. In response to the draft statement, the Care Provider acknowledged the faults and said it has implemented an action plan to reduce the risk of similar incidents. In addition to the action agreed, I welcome further service improvements that the Care Provider said it will complete, which include:

• contracting a new provider of digital policies and procedures which all staff will have access to. A project manager has been appointed to embed the use of this within the care home over the next three months; and
• delivering additional ‘Resident Experience’ training to staff which is being completed on an ongoing basis.

89. The Care Provider also said it will waive the podiatry invoice that Mrs M received at a cost of £39.90.

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Agreed action

90. Within one month of my final decision the Care Provider agreed to:

• apologise to Mrs L and the family for the distress caused to them by the poor care;
• reduce Mrs M’s outstanding care fees invoice by £900 in recognition of the distress caused, uncertainty and the risk of harm. The Care Provider will issue a new invoice to reflect this.
• remind care workers of the importance of following the individual resident’s care plan and keeping accurate records of care made at, or soon after the time the care is given.

91. Within three months of my final decision the Care Provider agreed to:

• review procedures on management of hydration and nutrition needs and ensure staff understand expectations including actions they must take and when contact with a health professional is needed; and
• carry out a training or information session for all care workers to understand the need to accurately record an individual resident’s medication, details of administering and any prescription changes.

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

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Final decision

93. I have completed my investigation with a finding of fault causing injustice.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman