Summary: The Care Provider is at fault for failing to support Mr D with dignity and respect, manage his urostomy bag correctly, protect his property, and respond to complaints effectively. The Care Provider has apologised for some of the faults identified and made some procedural changes. The Care Provider has also agreed to pay £400 to the complainants to acknowledge their personal injustice, provide staff training, and review procedures to prevent a recurrence of the failings.

The complaint

1. The complainant who I refer to as Ms C complains in her own right and on behalf of her sister. Ms C complains Cantley Grange, a care home operated by Burlington Care (Hull) Limited, the “Care Provider”, did not care for her late father, who I refer to as Mr D, properly. The Care Provider:-
1. failed to properly care for Mr D’s urostomy bag;
2. failed to properly monitor and act on Mr D’s weight loss;
3. did not take due care and attention of Mr D’s belongings while he was at Cantley Grange and when packing his belongings after he died;
4. lost Mr D’s property;
5. support Mr D’s mental health especially after his wife passed away;
6. did not treat Mr D with dignity and respect;
7. failed to deal with the complaint properly.
2. As a result of the poor care Ms C says her father’s health worsened. Ms C says her grief of losing Mr D was exacerbated by the disrespectful manner the Care Provider dealt with Mr D’s belongings and responded to her complaint.

Back to top

The Ombudsman’s role and powers

3. 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 an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
4. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome. (Local Government Act 1974, section 24A(6))

5. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
6. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
7. If we are satisfied with a Care Provider’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)

Back to top

How I considered this complaint

8. I spoke with Ms C and read the information she provided. I made enquiries of the Care Provider and considered its response. I also considered:-
• Mr D’s case notes and complaint correspondence;
• the Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences. I have used the fundamental standards as a benchmark for considering this complaint.
9. Ms C and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

Background information

10. Mr D went into Cantley Grange on 29 June 2020 after his wife and main carer became ill and could not care for him. Mr D went into hospital on 13 August 2020 with acute kidney injury and dehydration. Mr D later died in hospital.

What should have happened

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve.
12. Regulation 10 says people using the service are always treated with respect and dignity. Care providers must make sure they provide care and treatment in a way that ensures people's dignity and treats them with respect.
13. Regulation 12 says care providers must assess risks to people's health and safety during any care and make sure staff have the qualifications, competence, skills and experience to keep people safe.
14. Regulation 14 says care providers must meet service user’s nutritional and hydration needs. They must include people's nutrition and hydration needs when they make an initial assessment of their care and complete reviews.
15. Regulation 16 says people can make a complaint about their care and treatment. All complaints must be investigated thoroughly, and any necessary action taken where failures have been identified.
16. Regulation 17 says care providers should have an “accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user ….”.

What happened

17. On 24 August Ms C told the care home Mr D needed nursing care and would not be returning. On 28 August Ms C removed Mr D’s television, a cardboard box and four bin liners of his belongings.
18. Following Mr D’s death on 30 August the family opened the bags. They were disturbed by:-
• the state in which care staff had packed the belongings, clothing smelt of urine even after washing;
• a bin liner which included a used urostomy (urine) night bag and the stand. The stench of which was unbearable.
19. At this point Ms C noticed Mr D’s wedding ring, clothing, money, electrical equipment, and a tin of sentimental value were missing.
20. Ms C complained on 5 September. She also complained about the Care Provider’s poor management of Mr D’s urostomy bag which resulted in frequent leakage which caused Mr D upset. Care staff often contacted the family for extra urostomy supplies instead of planning and ordering them in advance. Ms C recalls Mr D contacting her distressed saying a staff member had “shoved a towel down his trousers”. Ms C says prior to Mr D entering the care home he only needed a weekly change of the urostomy bag. It was therefore unclear why the care home needed so many supplies.
21. Due to COVID-19 restrictions the family were only able to visit twice. One of these visits was to tell Mr D that his wife had died. At the visit they saw Mr D in trousers stained with urine. This was distressing for both Mr D and his family.
22. The Care Provider responded to the complaint on 1 October 2020. It:-
• apologised for the way in which care staff had packed Mr D’s belongings. It offered to refund the cost of the holdall;
• advised care staff had found some of the missing belongings but money and other items remained outstanding. It apologised for the missing items and said it had reviewed its admission process;
• accepted there was an inability by care staff to fix the urostomy bags but this was due to inadequate information about how to prepare the bags for use. This resulted in care staff not attaching them properly which caused leakage and the bags detaching themselves;
• apologised for Mr D’s stained clothing when family visited but said Mr D would often refuse help with his urostomy bag.
23. On 7 October the Care Provider contacted Ms C to advise they had found what looked to be Mr D’s ring in an envelope marked with his first name and asked for her to confirm this.
24. Ms C was unhappy with what she considered was a poorly written response and made a further complaint which included inaccurate care records. A senior manager:-
• recognised and apologised for the poorly worded complaint response;
• accepted there were errors in the recording because of the computer system. Care staff could not input certain words such as urostomy;
• accepted there were frequent requests for emergency supplies of urostomy bags and they would implement staff training on recording and planning for supplies;
• apologised for the state of the returned clothing;
• said staff were aware of Mrs D’s death and although not recorded were sensitive to Mr D at this time.

Was there fault causing injustice?

25. The Care Provider has accepted service failure on several matters, apologised and agreed to make a payment for some missing/damaged items. The early acceptance of fault and the Care Provider’s actions in trying to resolve the complaints are welcomed. I do not intend to re-investigate complaints (c), (d) and (g) as I cannot add to the Care Provider’s response including the actions it has agreed to take. I also acknowledge that Mr D was not always receptive to care and had capacity to make decisions about his support.

(a) Failed to properly care for Mr D’s urostomy bag

26. The Care Provider is at fault for failing to support Mr D with his urostomy bag. There is no risk assessment or care plan which details how care staff should support Mr D in correctly securing the urostomy bag. This is a potential breach of regulations 10, 12 and 17 and is fault. This resulted in physical pain for Mr D and frequent leakages which was degrading for Mr D. Ms C has the anger and distress that Mr D was not properly supported.

(b) Failed to properly monitor and act on Mr D’s weight loss;

27. The Care Provider recorded Mr D’s daily fluid and food intake. This is good practise. However there are multiple consecutive records where Mr D’s fluid and nutrition intake was poor especially prior to him going into hospital. There was no initial assessment about how much fluid and food intake Mr D needed and therefore nothing to measure the daily recordings against. The Care Provider failed to consider whether Mr D was eating and drinking enough to sustain him. This is fault and not in line with regulation 14. As a result Ms C has the uncertainty of not knowing whether Mr D was eating and drinking properly and whether any further actions to prevent a deterioration could have occurred.

(d) Lost Mr D’s property

28. The Care Provider accepted some items were lost at the care home. The failure to compile an inventory is fault and a potential breach of regulation 17. The family were put to additional time and trouble when they were already grieving. The loss of the wedding ring would have had increased sentimental value at the time.

(e) Support Mr D’s mental health especially after his wife passed away

29. The Care Provider says it provided emotional support to Mr D both prior to and following Mrs D’s death but acknowledges the actions were not recorded. The Care Provider is at fault for failing to record interventions. This is not in line with regulation 17. The family have the uncertainty and distress of not knowing what, if any actions, the Care Provider took at the time and how Mr D was affected.

(f) Did not treat Mr D with dignity and respect;

30. The Care Provider is at fault for failing to notice and act when Mr D met with his family in soiled trousers. This would have been distressing for both Mr D and his family at an already difficult time. I also consider it is more likely than not given the state of Mr D’s clothing the family received after his death this was not an isolated incident. This is a potential breach of regulation 10.

Back to top

Agreed action

31. I have found service failure by the Care Provider which has caused Mr D, Ms C and her sister injustice. I am unable to remedy the personal injustice caused to Mr D as he has died. The Care Provider has agreed to complete the following actions to remedy the injustice caused to Ms C and her sister; and to improve future practice:-
1. apologise to Ms C and her sister for the failings I have identified in this statement;
2. pay £400 to Ms C and her sister to acknowledge the distress, anxiety and frustration these faults have caused them and a further £100 in recognition of the loss and damage of some of Mr D’s possessions;
3. provide evidence of the procedural reviews/changes and staff training the Care Provider has taken because of this complaint and as proposed in its complaint responses;
4. review the following procedures and practices:-
1. recording and analysis of food and fluid intake;
2. recording accurately using the computer system in place;
5. remind staff about creating and updating accurate care plans for continence management, where to get advice, and having systems in place to prevent the need for emergency ordering of aids;
6. remind staff about the importance of getting advice/training for tasks that are different from the usual day to day tasks.
32. The Care Provider should complete (a) to (b) within one month of the final decision and (c) to (f) within three months of the final decision.

Back to top

Final decision

33. I have now completed my investigation and closed the complaint based on the agreed actions above. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

Back to top

Investigator's decision on behalf of the Ombudsman