Summary: Mrs X complained about the standard of care her mother, Mrs Y, received from Tenchley Manor Nursing Home in July 2023. The care provider is at fault causing injustice. It accepted it failed to deliver consistent suitable care to Mrs Y. It has already apologised, offered to refund 50% of Mrs Y’s care fees and amended its processes to learn from the complaint which is an appropriate remedy for the impact on Mrs Y. In addition, the care provider should make a payment to Mrs X to acknowledge the distress and time, and trouble caused to her by its failings.

The complaint

1. Mrs X complained about the standard of care her mother, Mrs Y, received from Tenchley Manor Nursing Home in July 2023. She says a staff member was abusive to Mrs Y, the care home had poor hygiene practices and delivered inappropriate personal care. Mrs X says the care home failed to make changes to its practices following her complaint. She wants the care home to learn from its mistakes and ensure all residents receive a suitable standard of care.

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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. 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

5. I have discussed the complaint with Mrs X and considered the information she provided. I have also considered information provided by the council.
6. Mrs X and the care provider have had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Fundamental Standards of Care

7. 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. The standards include:
• providers must make sure each person receives appropriate person-centred care and treatment based on an assessment of their needs and preferences (regulation 9).
• providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints (regulation 16).
• providers must securely maintain accurate, complete and detailed records about each person using their service (regulation 17).

What happened

8. The following is not intended to be a full account of everything that happened in this period, nor does it refer to all the records I have considered. It is a summary of the key events and facts relevant to this complaint.
9. In 2023 Mrs Y received care in hospital which resulted in her needing a stoma. On 4 July 2023 Mrs Y was discharged to Tenchley Manor Nursing Home (the care home), operated by Healthcare Homes (the care provider). The care home was asked to provide full nursing care, and to support Mrs Y’s use of the stoma, while she regained her independence in readiness for a reablement placement from early August 2023.
10. The care home carried out several assessments of Mrs Y in the days following her move. This included a continence plan, diet plan and skincare assessment. The care home did not immediately develop a stoma plan or bed rails plan for Mrs Y.
11. On 19 July Mrs Y contacted her daughter, Mrs X, to say a carer had been rude to her when she had asked to go to the toilet. Mrs X reported this to the care home manager who met with Mrs X and Mrs Y. The manager said they would investigate the issue and ensure the carer no longer provided Mrs Y with care. The manager interviewed all members of staff who had been on shift but could not identify the carer.
12. On 23 July the care home finished Mrs Y’s care plan, including a stoma plan and bed rails plan. It also carried out a mental capacity assessment and confirmed Mrs Y had capacity to make decisions about her care. On 26 July a specialist stoma nurse reported Mrs Y’s stoma site had improved and they no longer needed to check it.
13. In late July, Mrs X raised concerns about Mrs Y’s care and shortly after moved Mrs Y out of the care home. In August 2023 Mrs X complained to the care home about Mrs Y’s care. The main points of Mrs X’s complaint were:
• Staff ignoring Mrs Y’s wishes and leaving her bed rails up.
• Staff not answering toilet calls and leaving Mrs Y in wet pads for an unacceptable length of time.
• Not enough staffing and aggression from a carer on 19 July.
• Inadequate stoma care.
• Poor oral care and showering.
14. Following Mrs X’s complaint, the care home made a safeguarding referral to the local council, reporting Mrs X’s concerns. The council said the concerns did not meet its safeguarding threshold but were quality concerns.
15. The care home responded to Mrs X’s complaint on 25 August 2023.
• It accepted it had not completed the bed rail documentation until 23 July and there were times when staff had left both bed rails up, against Mrs Y’s wishes.
• It said its staff had followed Mrs Y’s continence plan by using continence pads and supporting Mrs Y to use the toilet when needed. While there were occasions where her pads became wet overnight, this was due to her sleeping and staff not wishing to wake her.
• There were only three occasions where it did not have enough staff, because of sickness. It could not identify the rude staff member but had spoken to all staff about suitable language.
• All staff were trained in stoma care and Mrs Y’s stoma site had improved throughout her stay at the care home
• It accepted inadequate oral care but it had supported Mrs X to shower when she wished, and ensured staff carried out a bed wash at other times.
16. The care home apologised for its shortfalls and offered to meet with Mrs X to discuss the issues further. It assured Mrs X it would learn from the complaint. Mrs X asked the care home to escalate her complaint to stage two of its process. She said she felt its stage one response was dismissive and contained several errors.
17. The care provider responded at stage two in October 2023. It clarified the care home’s response and repeated its apology. Mrs X remained unhappy and asked the care provider to carry out an external review. The care provider offered Mrs X an impartial review from its Operational Managing Director, in line with its complaint policy. Mrs X initially refused this but agreed to the impartial review in early 2024.
18. The care provider carried out the review and wrote to Mrs X in March 2024. It accepted shortfalls in Mrs Y’s care, including compromising Mrs Y’s dignity in her personal care, a failure to promote Mrs Y’s independence and ineffective management of Mrs X’s concerns and complaint. It offered to refund 50% of Mrs Y’s care fees and said it would carry out several actions to learn from the complaint. Including:
• Staff training
• Increased staff supervision
• Increased monitoring of the home
19. Mrs X remained unhappy and complained to the Ombudsman. In response to our enquiries the care home confirmed it had mandated all staff to attend relevant training. It said it had appointed a new care home manager, and its operations and regional managers were supporting the care home with supervisions and monitoring. It said it was currently recruiting for a new clinical lead to further support care home staff, monitor performance and carry out supervisions.

My findings

20. The care provider accepts there were shortfalls in Mrs Y’s care. During her stay at the care home, the care provider failed to consistently provide appropriate person-centred care and treatment, in line with the CQC fundamental standards. This is fault. The care provider has offered to refund 50% of Mrs Y’s care fees to recognise the impact of its failings on Mrs Y. While there were shortfalls in aspects of Mrs Y’s care, I cannot say there were failings in every aspect of her care. There were parts of Mrs Y’s care which were suitable and in line with CQC standards. On balance, I consider the care provider’s offer of a 50% refund in Mrs Y’s care fees a suitable remedy for the impact on Mrs Y.
21. The failings in Mrs Y’s care also had an impact on Mrs X. During Mrs Y’s stay at the care home Mrs X had to take steps to ensure Mrs Y’s care remained adequate. She felt she had to remove Mrs Y from the care home a week earlier than planned. Mrs X then complained to the care provider over eight months. The care provider’s failings have caused Mrs X a period of distress and time and trouble pursuing the complaint.
22. Mrs X says she wants the care home to learn from the complaint to ensure all residents receive a suitable standard of care. The care provider has outlined the steps it has taken to learn from Mrs X’s complaint. This includes training, new staffing and increased oversight of the care home. I am satisfied the care home has taken suitable steps to learn from Mrs X’s complaint.

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Agreed action

23. Within one month of the final decision, the care provider has agreed to:
1. Repeat its offer of a 50% refund in Mrs Y’s care fees to Mrs X and Mrs Y.
2. Pay Mrs X £300 to recognise the distress, time and trouble she has faced as a result of its failings.
24. The care provider should provide us with evidence it has complied with the above actions.

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Final decision

25. I have completed my investigation, finding injustice caused by fault, which the care provider has agreed to remedy.

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Investigator's decision on behalf of the Ombudsman