Summary: Miss X complained about the quality of care provided to her mother at the care home. There were some faults with the care provided as the care provider failed to change Mrs Y’s bedding, left a dirty pad in Mrs Y’s room, did not always record when it checked Mrs Y’s incontinence pad and fingernails, and it did not complete a choking risk assessment despite Mrs Y’s tendency to put things in her mouth. It also failed to fully follow its complaints procedure. The care provider has already taken action to address the faults with the quality of care. It should apologise and make a payment to Miss X to acknowledge the frustration and uncertainty she was caused. It should also remind staff to respond in writing to formal complaints.

The complaint

1. Miss X complained about the quality of care provided to her mother Mrs Y at Riverside Care Home. Her complaints included staff not changing wet bedding, a failure to properly manage Mrs Y continence care and that Mrs Y’s fingernails were not properly cared for or kept clean. She said the care home’s failure to fully meet Mrs Y’s care needs caused her frustration and distress.

Back to top

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. 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)
3. 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)
4. 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)
5. Under our information sharing agreement, we will share the final decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

6. I have considered the information provided by Mrs X and have discussed the complaint with her on the telephone. I have considered the information provided by the care provider in response to our enquiries and information from the local council that carried out a safeguarding enquiry into Miss X’s concerns.
7. I gave Miss X and the care provider the opportunity to comment on a draft of this decision. I considered any comments I received in reaching a final decision.

Back to top

What I found

The relevant law and guidance

8. 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).
9. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

The care home’s complaints’ procedure

10. Stage one: the care home manager considers the complaint. The procedure states the manager may arrange to discuss the issue by telephone or arrange to meet the complainant. It states ‘we will provide the complainant with a formal written response within 20 working days’.
11. Stage two: the complaints manager will carry out a formal investigation of the complaint and provide a formal response within 20 working days.
12. If the complainant is not satisfied, the procedure states they should be advised to complain to the Council if they receive funding support or to the Local Government and Social Care Ombudsman if they are self-funding their care.

What happened

13. Mrs Y moved into the care home in 2022 and paid for her own care. She has dementia. In May 2024 Miss X complained to the care home that she had visited Mrs Y and found her bed wet with urine with dirt at the bottom of the bed and on the pillow. Miss X said she had raised issues about Mrs Y’s bedding the previous year. Miss X also said Mrs Y needed changing as she had soiled her incontinence pad, which was evident from the smell. She said there was also faeces under Mrs Y’s fingernails which were long.
14. The care home manager responded by email and said they had put in place extra continence checks and would be fully addressing the issue of Mrs Y’s fingernails with staff. They said they would investigate and then arrange to meet with Miss X to discuss the outcome.
15. The care home manager investigated the complaint. The records show they interviewed relevant staff members and checked the daily care records. The care home manager asked to meet with Miss X to discuss the outcome, but Miss X asked for the outcome to be provided over the telephone. The care home manager told Miss X a carer had forgotten to check and change Mrs Y’s bedding after providing personal care. They could not explain why her fingernails were dirty. They said Mrs Y would be checked hourly for faecal incontinence. During the discussion the care home manager also told Miss X that Mrs Y would sometimes go into contaminated bags and advised these were now kept locked away. The manager noted Miss X was happy with what was put in place and that she hoped the standards would be maintained by the staff team. Miss X says she understood the care home manager would be further investigating her concerns.
16. Miss X emailed the care provider’s complaints team a week later. She said she understood the care home manager was now on holiday and she considered the complaints process was not completed. She said she was unhappy with the explanations given and felt the manager should have investigated further and contacted her again before going on leave.
17. A senior manager of the care provider responded to Miss X in early June. They advised they had contacted the care home and checking Mrs Y’s bedding was now part of the daily management walk round; fingernail care had been given, hourly continence checks were in place and there were no current issues. They offered to arrange a meeting with Miss X and the care home manager to discuss the complaint. Miss X asked the care provider to put the meeting on hold as she had contacted the local Council’s safeguarding team.
18. The local Council undertook a safeguarding enquiry. The council officer spoke with the care home manager and reviewed Mrs Y’s care plans and the daily records. They noted staff had properly supported Mrs Y in the morning and provided personal care. It was possible the wet and dirty bedding occurred between this time and Miss X’s visit. They noted from the daily logs and speaking the staff that staff checked Mrs Y’s incontinence pad regularly but did not record if it was dry. The manager had added a prompt to the daily log to ensure staff recorded every time they checked the pad. The council officer suggested some additions to Mrs Y’s care plans including a behaviour care plan regarding wandering, scratching and picking things up with tactics/distraction efforts to be made by staff, and incontinence and nails to be checked throughout the day.
19. The council officer concluded, on the balance of probabilities, there was no evidence Mrs Y was caused harm or neglect but there were acts of omission by the care home. They had identified learning and actions to be taken to safeguard Mrs Y with staff conducting more frequent pad checks and logging when they had done so. The council officer also suggested that Mrs Y be reassessed as her needs may be better met in an EMI unit (elderly, mentally infirm unit offering specialist support for residents living with advanced dementia). The notes record Miss X did not feel a reassessment was needed at that time. Miss X was happy for the safeguarding to be closed as she had noticed changes and improvements at the care home. The Council notified the care home it had closed the safeguarding.
20. In late July 2024 Miss X raised concerns about Mrs Y’s care with the care quality commission who contacted the Council. Miss X said Mrs Y’s bathroom floor was dirty. She had raised this with staff who had said cleaners would attend to it the next day so she did it herself. She said she found a dirty incontinence pad in Mrs Y’s room and Mrs Y had removed her pain patch and staff had not identified this. Also, there was a chair with a hole in the lounge which Mrs Y was picking foam from. She was concerned Mrs Y would put this in her mouth, having previously had a hospital admission following choking on an object she had put in her mouth. Miss X said she had asked for Mrs Y to be moved to the care home’s EMI unit but was advised Mrs Y did not need this.
21. The Council undertook a safeguarding investigation. A council officer visited the care home and met with Miss X and staff at the care home. The care home reported Mrs Y picked at chairs and caused the hole. It accepted a pad was wrongly left in Mrs Y’s bedroom by a staff member who had been spoken to.
22. The care provider supplied some further information to the Council. It said it had rewritten the care plan as previously discussed. It gave its account of what happened regarding the dirt on Mrs Y’s floor and that staff had offered to clean it up but Miss X had done so. It said staff would have noted the pain patch being removed when they next gave personal care. The council officer visited again to review its records and spoke with staff.
23. The council officer also carried out a care act assessment to determine Mrs Y’s needs for adult social care. They noted Mrs Y did not have capacity to make decisions about her care and support needs. They decided it was in Mrs Y’s best interests to move to a residential EMI unit due to the level of support she required and the progression of her dementia. They recommended a small unit where Mrs Y could move around, where staff could monitor her behaviours and proactively intervene when she was picking and scratching. They noted after exploration of the EMI unit at the care home it was considered inappropriate due to its layout and noise. Miss X declined the offer.
24. In the safeguarding findings, the council officer noted the staff member who had left a dirty pad in Mrs Y’s room was spoken to and their performance was being monitored. They noted there were limited records of Mrs Y picking at chairs and was no choking assessment. They advised the care home about the importance of recording incidents and completing care plans and risk assessments for behaviours and risks. They noted there was a difference of opinion about what happened when Mrs Y’s floor was dirty. The manager agreed to discuss the situation with staff and ensure they were proactive going forward. Staff said they checked Mrs Y’s pain patch each time Mrs Y had personal care.
25. Mrs Y moved to an alternative care home in August 2024.
26. The council officer closed the safeguarding. They noted there were areas of concerning practice and they had recommended action to address these. Mrs Y had moved care home and the new care home was advised to ensure appropriate care plans and risk assessments were in place so Mrs Y was no longer at any risk.
27. In August 2024 the care provider wrote to Miss X to confirm the complaint was closed as safeguarding had investigated and fed back the outcome to Miss X and it had fully cooperated with the investigation. Miss X remained unhappy and complained to us.
28. In early September 2024 the council officer closed the safeguarding and advised the Care Quality Commission of the outcome. They emailed the care home noting they had given advice including:
• Carers to ensure they were documenting tasks especially issues with continence care and dirty fingernails.
• The need to record incidents and complete care plans and risk assessments for behaviours and risks.
• To discuss with staff the way they responded to the cleaning issue regarding Mrs Y’s bathroom and ensure they were proactive going forward.

Findings

29. The local Council conducted a robust investigation of Miss X’s concerns through its safeguarding procedures, so I have not found it necessary to reconsider the care provider’s records. The safeguarding investigations found no evidence Mrs Y was caused harm or neglected. However, they identified omissions in care which we would call fault and recommended actions to improve practice. The investigations found the care home:
• Failed to check and change Mrs Y’s wet bedding.
• Failed to always record when it had carried out incontinence checks, cleaned Mrs Y’s fingernails and checked her pain patch.
• Left a dirty continence pad in Mrs Y’s room.
• Failed to complete a choking risk assessment given Mrs Y’s tendency to put things in her mouth.
30. These faults were not in line with the CQC fundamental standards and left Miss X with a sense of uncertainty over whether Mrs Y was receiving appropriate care. I have seen no evidence these faults had a significant detrimental impact on Mrs Y and she no longer lives at the care home.
31. The records show the care provider took action in response to the advice given by the Council. It amended Mrs Y’s care plan and spoke to the relevant staff involved. I am satisfied the care provider has taken appropriate action to address the concerns identified through the safeguarding investigations and no further recommendations for service improvements to address these concerns are required.
32. The records show the care home manager properly investigated Miss X’s complaint when she first raised it. They also sought to arrange a meeting with Miss X but as requested by her, agreed to explain the outcome over the telephone. Following the call the care home’s notes suggest Miss X was satisfied with the outcome, although Miss X disagrees. The care provider’s complaints procedure says it will provide the complainant with a written response within 20 working days. The care provider failed to respond to Miss X’s complaint in writing. The failure to do this was fault. This caused Miss X some frustration as she believed the manager was still investigating her complaint. However, when Miss X raised her continued concerns with the care provider it agreed to consider it at stage two of its complaints procedure, which was appropriate. It placed a hold on this at Miss X’s request.
33. When Miss X asked for it to respond at stage two following completion of the safeguarding investigation, the care provider’s response was short and did not address Miss X’s concerns. This was not in line with its complaints procedure. It also failed to offer an apology or other remedy for any of the shortcomings identified. These issues amount to fault and added to Miss X’s frustration.

Back to top

Recommended action

34. Within one month of the final decision I recommend the care provider:
1. apologises to Miss X and pays her £200 to acknowledge the frustration and uncertainty caused by its failings. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The care provider should consider this guidance in making the apology I have recommended.
2. Reminds relevant staff to respond to formal complaints in writing to ensure both sides understand the outcome and any agreed actions.
35. The Care Provider should provide us with evidence it has complied with the above actions.

Back to top

Final decision

36. I have completed my investigation. On the evidence considered there was fault causing injustice for which I have recommended a remedy.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman