Summary: there is no evidence that the care provider attempted to improve the late Mrs X’s interaction with other residents or to increase social stimulation. The care provider also acknowledged to Mr A that the response time to the call bell was poor. On one occasion another resident was able to enter Mrs X’s room unnoticed while she was in bed and sat on her legs; Mrs X had to summon help herself. The care provider should review its practices in terms of residents’ activities and interactions; reconsider the way in which it protects residents within the home and offer a sum to Mr A and Mrs B in recognition of the distress caused by the shortcomings identified here.

The complaint

1. The complainant, Mr A, says the care provider failed to offer appropriate care for his late mother Mrs X who had dementia. He says the staff did not try to involve her in social activities and often left her call bell ringing without attending promptly. He also complains that on one occasion a male resident was able to enter Mrs X’s room and sit on her legs before staff intervened.

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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. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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.
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)
6. 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

7. I considered the information provided by Mr A and by the care provider. Both the care provider and Mr A had the opportunity to comment on a draft of this statement and I considered their comments before I reached a final decision.

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What I found

Relevant law and guidance

8. 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.
9. Regulation 9 says the care and treatment of service-users must be appropriate, meet their needs and reflect their preferences.
10. Regulation 10 says service users must be treated with dignity and respect.
11. Regulation 13 says service users must be protected from abuse and improper treatment.

What happened

12. Mrs X was admitted to the care home in May 2023 direct from hospital. She had dementia. Her pre-admission assessment (with information gathered from the ward staff) showed she was at high risk of falls, was doubly incontinent but fully compliant with care. She explained to care staff during the first week that she could not empty her bladder properly, so she asked for frequent help with accessing the commode.
13. Care notes for the next months show that Mrs X had most of her meals served in her room. The care provider uses a standard phrase “chatted with staff or residents” to denote social interaction but most of these referred to Mrs X talking to staff. A sample of her activity charts shows that these chats formed most of Mrs X’s social activity, other than having her hair brushed and seeing family visitors. There is the occasional reference to “entertainer” or “dominoes”. Her care plan says “(Mrs X) loves watching out of her panoramic windows…. going out into town with her daughter…. enjoys a game of dominoes”. The plan says Mrs X enjoyed her own company and declined joining in with activities: “Staff to continue encouraging (Mrs X) to participate in the homes activity or spend time outside her bedroom.

Staff to continue respecting (Mrs X) wish e.g. spending most of her time in her bedroom”.

The complaints

14. By October Mr A and his sister Ms B started to complain to the care provider about the length of time Mrs X was spending alone in her room (which Mr A attributed to staff shortages) and the length of time it took to answer her call bell. A manager responded to the complaint and said that having reviewed the response times, he acknowledged staff were taking too long to answer call bells. He said this had been a technical issue with the pager system used and he expected the situation to improve. He also said the home was fully staffed based on individually assessed needs.
15. Ms B complained again in December. She said on a recent occasion when she had been visiting, it had taken care staff an hour to enable Mrs X to access the commode, and another 30 minutes before they returned to move her from the commode. The following day Mrs X had been so agitated by needing to use the commode that Ms B had personally helped her move onto it: but by that time Mrs X had already defecated. Ms B wrote, “Mum has told me she doesn’t want to drink because she does not like having to wait long times for a commode”. She pointed out this meant the risk of urinary retention.
16. Mr A also complained. He said the home appeared to operate on two levels – the ground floor where residents were generally mobile and able to make their own decisions, and the first floor (where Mrs X had her room) where residents were “more challenging” and many had dementia. He also expressed concerns that key staff were being moved to the care provider’s other home.
17. The Chief Operating Officer replied. He said he believed call bell response times had improved overall since the complaint in October but added they had noticed in the last few weeks a problem with the system again, when there was a delay in the system notifying staff via their pagers of residents’ call bells. He said an engineer had been on site for three days investigating. He added that they would add call bell response times to the “monthly KPI meeting with the management team”. He denied that staff were being moved to the other home.
18. The COO added in a separate response to Mr A’s concerns about the lack of outings, that “We encourage our residents to participate in outing that we arrange at Shipston Lodge via our activity meeting. However, most of our resident tend to decline outings hence we try our best to bring the local community at Shipston Lodge. For example, our recent Christmas fete, wherein we brought the local Christmas market at Shipston Lodge, weekly Dementia Café group, weekly knitter natter group etc.” He said that staff supported residents who wanted to go on outings after a risk assessment to see how long they could sit in a wheelchair, use of toilet facilities and so on. He did not comment on Mrs X’s activity level.
19. There was a care review meeting on 5 January 2024 which Ms B attended. The notes of the meeting again note Ms B’s concerns that call bells took too long to be answered. The agreed action was “RN/CP to take responsibilities in checking/answering the call bells.” Ms B also expressed concerns about social interaction with other residents: the action planned was “Looking at the outings as suggested : carers involved ,incontinence care risk assessment , how far the trip will be, taxi with wheelchair access needed.”
20. On 16 January there was an incident in Mrs X’s room. Care notes say, “Emergency bell rang in (Mrs X’s) room. Staff immediately attended and saw (another resident) sitting on the feet of (Mrs X). (Mrs X) was the one who pressed the emergency buzzer. (The other resident) was immediately help and assisted by CP… to stand up on the bed [sic]. (Two carers) assessed the feet of (Mrs X) for any possible injury. Nothing was seen. NOK (Mr A) was informed and reassured that no harm was done. (Mrs X) is on the list for tomorrow to assess her swollen legs.”
21. On 19 January Ms B complained to the care home and asked for details of what had happened. The manager responded with an apology and said that Mrs X had been in bed with the bedrails up and the bedroom door open as she requested. She said there was no indication of sexual abuse and no skin damage caused.
22. Ms B asked what steps the care home was taking to prevent a recurrence of the incident. The manager replied that due to the nature of the residents on the dementia unit, some residents could wander and become confused. She said there were no reports of this resident going into any other rooms: “we will continue to monitor the whereabouts of residents to prevent further recurrences of this incident”.
23. On the completed complaint investigation form, in the record of actions planned, the care provider wrote:

“1) 22.01.24 Safeguarding team -notified.

2) CQC notification

3) Offered alternatively room, where other clients do not have access

4) We put a sensor (PIR), who will cover the door area. In case somebody will walk in, sensor will alarm the staff (ringing)”.

24. On 26 January Mrs X was admitted to hospital with suspected internal bleeding. The care home manager wrote to Mr A and Ms B that evening: “following your telephone conversation with (a member of staff) today, you feel that we cannot meet your mothers needs at Shipston Lodge despite all our effort for several months. Therefore, we will be unable to readmit your mother back at Shipston Lodge as maybe another service could probably meet your mother’s needs and your expectations.”
25. Sadly Mrs X died the following day.
26. Mr A had complained to the Ombudsman in December about the lack of social stimulation and the poor response time to call bells. He wrote to us again in January after Mrs X’s death. He said his mother’s account of the incident on 16 January was very different from the care home’s report; she said the other resident had lain on top of her and she had called out repeatedly before staff arrived. He said, “our complaint is that our mother's room is at the end of a corridor with only a few other rooms, and that the main control desk, which is supposed to be manned 24/7, is in the middle of this well-lit corridor and sits between it and the rest of the rooms on that floor. At 8.30pm, most of the residents on this floor, which is where dementia patients reside in the home, would be in bed. This leads one to conclude that the desk was most likely unmanned at the time the male resident walked up the corridor to my mother's room and climbed into/onto her bed with her in it.”
27. The care provider provided the daily care notes and Mrs X’s care plan which it said showed how staff encouraged her to join in activities. Although the records show what activities Mrs X undertook (see paragraph 11 above) there is no evidence that staff encouraged her to join other activities or documented evidence that she declined.
28. In response to my draft decision the care provider says in “January 2024 Mrs X had a total of 163 one to one visit from staff in 25 days, there are also 3 outings, 1 hairdresser visit, 1 make up day, 2 walk (garden) and 1 visit from pet animals. Hair brushing is included in our activity report as it is a part of our therapeutic activity.” Mr A says the “outings” were when he or his sister took Mrs X out, and it was his sister who arranged the hair and make up days.
29. The care provider says it believed the staff had met Mrs X’s needs “very well” while she was resident.
30. In response to my draft decision the care provider has also provided copies of records showing what it says was Mrs X’s actual fluid intake. Mr A says in response that his mother would often pour her drink away into a vase. He says “Staff did not have the time to wait with her to check whether she actually drank the liquids given to her, despite this being pointed out to the management team. However, they would regularly remove part-drunk beakers and replace them with full ones, creating a misleading reading of her overall fluid intake.”
31. The care provider says on average the amount of time taken to respond to call bells is just over 3 minutes. It says sometimes relatives press the ‘attend’ button instead of the ‘call’ button which causes confusion. Mr A says in reality what usually happened was that they would press the call bell, a carer would appear after some time to switch it off, they would ask for a commode and the carer would say she would have to find another carer as Mrs X required two carers to hoist her. He says very often the call bell would have to be used several times to request the commode.
32. In respect of the incident on 16 January, the care provider says “prior to the incident on 16 January 2024 there was no risk identified in relation to other resident entering Mrs X room hence no equipment is in place.” Mr A says there were many occasions on which two other residents in particular entered Mrs X’s room, but they were regarded by staff as of no threat to her.
33. The care provider says the individual who entered Mrs X’s room on the 16 January was resident on the same floor as she and in a nearby room. It says it would have been very difficult to see anyone entering her room from the nurses’ station. The care notes for that evening state the bedrails were raised as usual although Mr A has raised concerns about how the other resident could have lain on Mrs X ‘s bed as he would have had to climb over the bedrail.

Analysis

34. There is insufficient evidence to support the care provider’s statement that Mrs X was encouraged but declined to join in activities. Its use of formulaic statements in its care notes (eg “Chatted with staff or residents”) does not provide a clear enough picture of how staff encouraged her to join activities, which activities were offered, and whether she declined. It is noteworthy that Mrs X asked for her bedroom door to remain open because otherwise she felt isolated. Mr A said that his mother spent “the entire day between rising and retiring sitting in her chair”. The care provider’s description of hair-brushing as a social activity is questionable. My view is that the failure of the care provider to offer sufficient meaningful activity to Mrs X caused her significant injustice. That view has not changed with the care provider’s response to my draft decision.
35. The care provider accepted that its response to the call bell was often slow. It is not acceptable that it should take an hour to provide a vulnerable resident with a commode, to the extent that Mrs X began to limit her fluid intake. That is not treating someone with “dignity and respect” and is a potential breach of regulation 10. There is sufficient doubt over the validity of the records for me to decide on the balance of probability that there was fault on the actions of the care provider.
36. It is difficult to see how, with the geography of the home as Mr A described and the bedrails in place, a resident was able to enter Mrs X’s room during the evening without staff noticing. There was no door sensor to the room which would have alerted staff sooner to the presence of another person. In my view the care provider failed to protect Mrs X as it should have done.

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Recommended action

37. Mrs X has now died and so there is no remedy to the injustice she personally suffered. However, Mr A and Ms B spent several months complaining to the care provider about poor social activity levels and the call bell response times and suffered the distress of seeing that their mother’s needs in those respects went unmet.
38. Within one month of my final decision, the care provider should offer £500 each to Mr A and Ms B in recognition of the anxiety caused by its failure to act properly on the complaints brought to its attention.
39. Within one month of my final decision the care provider should review the level of activity it offers for residents who otherwise spend all day alone in their rooms and provide me with details.
40. Within one month of my final decision the care provider should review the way care notes are completed to ensure they give a full and accurate picture of the care provided.
41. Finally, within one month of my final decision, the care provider should review the way in which residents’ rooms are able to be accessed by other residents and present an action plan to prevent recurrences of this incident as far as possible.
42. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

43. I find the actions of the care provider caused injustice to Mrs X and her family which the recommendations at paragraphs 37 – 40 will remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman