Summary: Mr X complained low staffing levels meant his mother, Ms Y, received inadequate care during a two-week period at a care home run by Barchester Healthcare Homes Limited. The Care Provider was at fault for failing to have records of checking on Ms Y for several nights and for failing to alert staff of her increased need for support. This caused Mr X avoidable frustration and uncertainty for which the Care Provider will apologise. It will also provide evidence it has carried out staff training and issued reminders.

The complaint

1. Mr X complained low staffing levels meant his mother, Ms Y, received inadequate care during a two-week respite stay at a care home managed by Barchester Healthcare Homes Limited in October 2023. Mr X said this had a negative impact on Ms Y’s wellbeing, meant she paid for care she did not receive and caused him distress.

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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. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an 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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What I have and have not investigated

7. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide any injustice is not significant enough to justify our involvement. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
8. Mr X’s complaint included that the care home’s reception was hardly ever staffed, meaning it took a long time to get in and out of the home. I have not investigated this matter because it did not cause a significant personal injustice to Mr X or Ms Y.

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How I considered this complaint

9. I have considered:
• all the information Mr X provided and discussed the complaint with him;
• the Care Provider’s comments about the complaint and the supporting documents it provided; and
• the relevant law and guidance and the Ombudsman's guidance on remedies.
10. Mr X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) 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.
12. Regulation nine says care providers must design care and treatment to meet a person’s needs. Associated guidance notes that to do this, care providers should create a care plan.
13. Regulation eighteen notes care providers must have enough suitable members of staff to deliver care and support to their service users.
14. Government guidance “Infection prevention and control (IPC) in adult social care: acute respiratory infection (ARI)” notes visitors to care homes should be warned of any ongoing outbreak of COVID-19 and any symptomatic residents so they can decide whether to visit.

What happened

15. Ms Y moved into a care home managed by Barchester Healthcare Homes Limited for a two-week respite stay in early October 2023. Ms Y moved into a newly opened floor, with only two other residents. Two more residents moved onto the floor the following week.
16. Care plans prepared by the Care Provider noted Ms Y could shower herself as long as towels and soap were available and she could dress herself independently and pick her own clothes.
17. Care records from Ms Y’s stay show:
• care workers checked on Ms Y and helped her frequently during the day time;
• except on one day where there is no record a care worker checked on Ms Y between 15:09 and 23:00;
• on seven nights, there were periods of at least five hours where care workers did not record they had checked on Ms Y.
• Ms Y refused help getting dressed or showered on four days. On several of those days, Ms Y later accepted help from one of her visitors to get washed. Ms Y accepted help with a shower from a care worker four times and reported she had washed independently on three days.
18. Mr X was unhappy with the care Ms Y received and complained to the Care Provider at stage one and two of its complaints procedure. His complaint included that:
• there had been several times he visited Ms Y and found she had not showered;
• there had also been times he saw she had been wearing the same clothes for days;
• he had found dirty clothes in Ms Y’s cupboard;
• Ms Y had been seen undressed and standing at her bedroom window with the curtains open twice;
• the Care Provider had not told Ms Y’s family she had COVID-19 until after they had arrived for a visit; and
• there were not enough staff on Ms Y’s floor.
19. The Care Provider responded to Mr X’s complaint to say:
• Ms Y’s dementia meant she needed reminders and encouragement to do personal care and go to the toilet. She was sometimes reluctant to accept help and support from care workers, but they had offered it. The Care Provider said it would remind staff to update relatives when someone was refusing care;
• Ms Y sometimes put dirty clothes on again if they had not been removed promptly;
• it was sorry he had found dirty clothes in Ms Y’s cupboard. The Care Provider said housekeeping had confirmed they checked Ms Y’s laundry bag twice a day but that Ms Y may have put dirty clothes back in the cupboard. It had reminded its care teams to check cupboards for dirty clothes;
• it checked on Ms Y’s welfare regularly but it was sorry he had seen her undressed. Staff had not observed that behaviour;
• there had been a small number of COVID-19 cases in the home and it was sorry it had not told Ms Y’s family of this;
• it was satisfied its staffing levels were adequate;
• the care home manager would share learning from the complaint with the staff. The Care Provider said the manager would also deliver refresher training on how to keep daily records of care given because the Ms Y’s records were not as detailed as they should have been.
20. In response to my enquiries, the Care Provider said:
• there was no record Ms Y had COVID-19 while staying at the care home. It was, however, sorry that it had not told her family other residents had COVID-19 before they visited. The Care Provider accepted this was not in line with government guidance. It had recently delivered training to remind staff of the need to update visitors when a resident develops COVID-19;
• the care home had an action plan to improve documentation and staff had guidance about how to keep proper care records. The Care Provider is introducing electronic care records which would further improve documentation;
• it did not have evidence to show staff had been reminded to check resident’s cupboards for dirty clothes or about the need to tell relatives if a resident was refusing care. It would ask the care home’s manager to issue the reminders; and;
• in general, there were three or four care workers in the home during the day and three at night. This was to support between 20 to 22 individuals. On one occasion there were six care workers during the day.
21. Mr X sent me voice recordings between him and family members after they had visited Ms Y. The recordings note:
• on several occasions, Mr X had told care workers Ms Y was wearing dirty clothes she had worn for a number of days;
• Mr X told a care worker Ms Y was not wearing underwear. He said a care worker had said they thought Ms Y was independent with getting dressed. Mr X had disagreed;
• there were several days when Ms Y had not showered. She accepted help from the relative visiting; and
• on several visits, the floor Ms Y lived on did not have any care staff present.

Findings

Staffing levels

22. Regulation eighteen sets out that care providers must have enough members of suitably skilled staff to meet people’s needs for care and support. The Care Provider ensured a minimum of three care workers were on site at all times to support between 20 and 22 individuals. This is not an unusual care worker to resident ratio for a care home and the Care Provider is satisfied it was suitable to meet the resident’s needs. It was not at fault.
23. When Ms Y moved into the care home there were two other residents on her floor. Later, two more residents joined, making a total of five. The remaining three quarters of the residents lived on the ground floor. Mr X says when he visited he rarely saw staff on Ms Y’s floor. This is supported by the voice recordings he sent me. However, Ms Y’s care records show that for the most part, during the day, care workers regularly checked in on her. It is likely staff would carry out checks before returning to the ground floor where other residents needed support.
24. However, there were seven days where there were no night checks recorded. This was fault. It is not clear if care workers checked on Ms Y and did not record it, or whether they did not complete any checks. While I note there was no evident impact on Ms Y, the fault nonetheless caused Mr X avoidable uncertainty about whether her care needs were met in those periods. I welcome the action the Care Provider has taken already to improve how it records care given to residents and am satisfied this is sufficient to prevent future fault.
25. Mr X says Ms Y was seen standing at her window without clothes on twice. Care workers did not observe these incidents because Ms Y was not assessed as needing one to one care. Mr X feels that if the floor was better staffed, Ms Y would not have been able to get undressed without someone seeing her and preventing it. I cannot say this even on balance as even with more staffing there Ms Y would have spent periods of time on her own.

Personal care

26. Ms Y’s care plan noted she could choose what clothes to wear and get washed without support. However, the care records show staff sometimes helped Ms Y shower or offered help which Ms Y refused. This indicates care workers were aware Ms Y needed more help washing than her care plan set out. In addition, care staff were aware Ms Y sometimes put dirty clothes back on. Despite this, the Care Provider did not either alert staff about Ms Y’s different care needs or update her care plan to reflect that she needed extra support to take a shower and make good choices about what to wear. This was fault.
27. The fault meant care workers did not consistently offer Ms Y support to have a shower or prompt her to take one, and there is no evidence from the records that care workers identified Ms Y was re-wearing dirty clothes or offered to help her get changed. However, given Ms Y sometimes refused support from care workers I cannot say, even on balance, that but for the fault she would have had a daily shower and not re-worn dirty clothes. The fault caused Mr X further uncertainty about whether Ms Y could have had better care in the home.
28. The Care Provider accepts there were sometimes dirty clothes in Ms Y’s cupboard, which it thinks Ms Y might have put there. That type of behaviour is not unusual in someone who has dementia and was not Care Provider fault.
29. In its complaint response the Care Provider said it had reminded staff they should make relatives aware when someone was refusing help with personal care and to check residents’ cupboards for dirty clothes. In its response to my enquiries, the Care Provider accepted it had no evidence of those reminders. This was fault and caused Mr X frustration. Where an organisation says it has taken action in response to a complaint, it is important it keeps evidence of that action. The Care Provider told me it would ask the care home manager to issue the reminders. I have made a recommendation below to ensure the reminders are issued.

COVID-19

30. The Care Provider says Ms Y did not have COVID-19 while resident in the care home. However, Mr X says a passing care worker told Ms Y’s relatives she had COVID-19 when they were in the reception area. As a result, several of the party left the care home. There is no other documented evidence showing Ms Y had COVID-19. Therefore, on balance, I am satisfied Ms Y did not have COVID-19 and the care worker misspoke.
31. Regardless, the Care Provider accepts it did not act in accordance with government guidance when it failed to tell Ms Y’s family there had been COVID-19 cases in the care home. This was fault but it did not cause Mr X an injustice because he was not one of the visitors.
32. The Care Provider says it recently delivered training to staff on the need to update resident’s families when they develop COVID-19. It did not provide evidence of this training, so I have made a recommendation below to ensure it is carried out.

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Agreed action

33. Within one month of the date of my final decision, the Care Provider will take the following actions.
1. Apologise to Mr X for the uncertainty and frustration he felt due to the fault identified in this decision. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Care Provider will consider this guidance in making the apology.
2. Provide evidence it has:
1. reminded staff they should make relatives aware when a resident refused help with personal care;
2. reminded staff they should check residents cupboards for dirty clothes; and
3. delivered training to staff on updating families of residents when they develop COVID-19.
34. The Care Provider will provide us with evidence it has complied with the above actions.

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Agreed decision

35. I have completed my investigation. I have found fault leading to personal injustice. I have recommended action to remedy that injustice and prevent reoccurrence of this fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman