Summary: We upheld complaints about mouthcare and spectacles. The Care Provider accepted our recommendations to apologise and make changes to record-keeping.

The complaint

1. Ms X complained for her relative Ms Y about Ms Y’s care in one of Care UK Community Partnerships Ltd (the Care Provider) care homes – Winchcombe Place: She said the Care Provider did not deal with her concerns and complaints properly.
2. Ms X also complained about Ms Y’s care, in particular:
1. She found an unused toothbrush and toothpaste. One time, Ms Y’s teeth were black
2. One pair of glasses went missing. These were replaced, but still Ms Y was not often wearing her glasses
3. Ms Y was sitting by herself often. She was not supported to attend activities
4. The sensor beams in Ms Y’s room were often not switched on
5. Ms Y’s bedroom was unclean.
3. Ms X also complained:
1. Ms Y was dressed in warm socks and slippers when it was a very hot day
2. Staff did not help Ms Y apply cream or perfume
3. A blanket went missing
4. The lift area was smelly
5. Illegal handling was going on
6. The manager shouted at care staff and did not go into suites to discuss matters.
4. Ms X said this caused her avoidable distress.

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The Ombudsman’s role and powers

5. We provide a free service, but we 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))

6. 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)
7. 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)
8. 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

9. I have investigated the complaints in paragraphs one and two. I have not investigated the complaints in paragraph three because there is no significant injustice.

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How I considered this complaint

10. I considered the complaint to us, the Care Provider’s responses to the complaint, Ms Y’s care plans and other care records described in this statement. I discussed the complaint with Ms X
11. Ms Z 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

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
13. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
14. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

What happened

15. The Care Provider does not keep any mouthcare records or record when staff have offered a resident their spectacles.
16. The Care Provider keeps charts of room cleaning. I have looked at charts for three months. Ms Y’s room was cleaned each day.
17. Activities records indicate Ms Y offered or took part in a range of activities including yoga, pet therapy, birthday events, one-to-one time, nailcare, movement, doll therapy and flower arranging.
18. The Care Provider keeps a record of checks on equipment including sensor beams. I have seen charts for three months and they indicate staff checked sensor equipment every day.

Ms Y’s care plan

19. The Care Provider shared copies of Ms Y’s care plan with us. This has been reviewed and amended following the responses to Ms X’s complaint and further reviewed after the Care Provider’s complaints process had ended due to changes in Ms Y's needs. The care plan said:
• Ms Y liked poetry, music literature and big band music. Ms Y was to be told each day about the activities available in the home and to invite her if any entertainers. She preferred individual reminiscence rather than group activities and liked going to the coffee shop. She enjoyed yoga but her daughter said it was too much for her. She liked pet therapy and she enjoyed the knitting club. The care plan was reviewed regularly and updated with a summary of activities Ms Y had taken part in
• She was mobile and needed supervision as she was at risk of falls. A sensor beam was in place and must be on and aim in the right direction when she was in her room.
• She had her own teeth and needed support to clean them
• She had a sensor beam on the left side of her bed to alert staff of movement. She had been known to turn this off at night. Four hourly checks were in place at night
• She could walk short distances with discreet supervision by staff. She used the rails in the corridor for support. For longer distances, her wheelchair.

The complaint to the Care Provider and its responses

20. In the middle of September, Ms X and a member of staff from the Care Provider’s complaints team spoke on the phone. The complaints advisor emailed Ms X after the call with a summary of what she had said. She raised the concerns about Ms Y’s care I have summarised in paragraphs two and three.
21. The Care Provider’s first response to the complaint said:
• It was sorry Ms X felt she needed to visit every day. There was no record of any serious incidents or concerns about Ms Y which would warrant this;
• The sensor beam plugs into the wall and is connected to the nurses’ station. There may have been a connection issue, but this could not be established. There weren’t any entries saying she was wandering around the corridors unaided. The Care Provider was sorry if Ms X had found her in this way on occasions. Equipment would be checked daily and staff would be reminded in a meeting to check it was working;
• The records for the past month noted staff had assisted Ms Y each day with cleaning her teeth by putting toothpaste on her brush. Sometimes Ms Y would refuse;
• It had looked at activities records for the past month and Ms Y took part in one- to-one sessions and sometimes refused to take part in house activities. The lifestyle team would meet with her to discuss the types of activities Ms Y would enjoy; and
• On some days for the past three months, the cleaning schedule was not signed. The head housekeeper would investigate this and it was sorry for this.
22. Ms X was unhappy with the first response to her complaint. She met with a manager. At the end of October, the manager emailed Ms X after the meeting where Ms X had raised some further concerns. The manager offered a further meeting and suggested Ms X meet an NHS dementia nurse to learn more about Ms Y’s dementia. Ms X replied to say she had worked with adults with dementia and had received support from the local memory clinic. Ms X said she had concerns about communication and record keeping of concerns, complaints and compliments and creating an environment for Ms Y that was tidy and socially and emotionally fulfilling.
23. The Care Provider’s second response to the complaint said:
• It found there were no serious incidents requiring investigation
• The manager of the home was not aware Ms Y’s glasses had gone missing. In future, staff would record at the end of each shift that Ms Y had her glasses
• She had complained the Care Provider had misled her. There was no intention to mislead her.
24. Unhappy with the response, Ms X contacted us.

Findings

Complaint handling

25. The complaint responses were adequate and addressed the issues raised in appropriate detail. The Care Provider also met with Ms X to speak about her complaint. This is good practice. I do not uphold this complaint.

Ms X found an unused toothbrush and toothpaste. One time, Ms Y’s teeth were black. One pair of glasses went missing. These were replaced, but still Ms Y was not often wearing her glasses

26. The Care Provider does not keep records of mouthcare or of care around glasses. This is poor record keeping and is fault. It cannot demonstrate it offered or delivered mouthcare or support with Ms Y’s glasses. Care was not in line with Regulation 9 or 17. I uphold this complaint.

Ms Y was sitting by herself often. She was not supported to attend activities

27. We expect care homes to have regular activities for residents and to be offered opportunities to socialise, have fun and do things which they enjoy. I am satisfied the Care Provider did this based on the records of activities. There is no fault. Care was in line with Regulation 9.

The sensor beams were not always switched on

28. Ms X had sensor beams in place in her room to alert staff when she is moving around so staff can check on her to minimise the risk of falls. The records indicate sensor equipment in Ms Y’s room was checked and was working when it was checked. So I do not uphold this complaint.

Ms Y’s bedroom was unclean

29. The Care Provider has noted there were gaps in its records and upheld this complaint. The charts I have seen indicate room cleaning took place daily. I do not uphold this complaint as I do not regard a failure to sign a record to have caused a significant injustice.

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Agreed action

30. I have upheld a complaint about mouthcare and glasses. Within one month of my final decision, the Care Provider will take the following actions:
1. Apologise. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
2. Review record keeping so the Care Provider’s daily records include a means of recording when staff have offered and given mouthcare and prompted/supported a resident to put on their spectacles.
31. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

32. I have upheld complaints about mouthcare and spectacles. The Care Provide will apologise and change its record-keeping.
33. I completed the investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman