Summary: We upheld some of Mr X’s complaints about his relative Mr Y’s care. Communication with Mr X was poor, particularly around ending the contract. And Mr Y did not receive healthy snacks in line with his nutritional needs. The Care Provider has already taken appropriate action by apologising and offering a payment.

The complaint

1. Mr X complained for his relative Mr Y that the Care Provider:
1. Ended the contract without following a proper process;
2. Did not have an effective care plan to manage Mr Y’s behaviour and was overly reliant on family for support;
3. Did not offer appropriate snacks;
4. Did not offer appropriate activities and refused to take Mr Y on trips outside the home;
5. Did not support Mr Y to use his hearing aids;
6. Did not take appropriate action when Mr Y refused medication and creams; and
7. Failed to communicate with the family.
2. Mr X said this caused avoidable distress and placed Mr Y’s health at risk.

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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. (Local Government Act 1974, sections 34B and 34C)
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 this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered the complaint to us, the Care Provider’s response and documents in this statement. I discussed the complaint with Mr X.
7. 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

8. 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.
9. Care and treatment should 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. (Regulation 9)
10. A care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents. (Regulation 12(i))
11. The nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed. (Regulation 14)
12. Standard dietary advice on the NHS website for people with type 2 diabetes says they can eat many foods. They should keep fat, sugar and salt to a minimum, avoid missing meals and eat a wide range of food including fruit and vegetables and some starchy food like potatoes and rice.

What happened

13. The Care Provider’s service agreement says it will give four weeks’ notice to leave following consultation and attempts to prevent this from happening. It may end the contract without notice if a resident became violent, seriously antisocial or disruptive.

Care plans

14. The Care Provider kept care plans for Mr Y describing his care needs and preferences. These were reviewed and updated regularly as needed.
15. The activities care plan said Mr Y could choose what he wanted to eat, he liked going for long walks and gardening and carpet golf. He needed his hearing aids but often refused to wear them. He tended to seek chocolates and sweets from other residents. When this happened, staff were to offer him a snack.
16. The communication care plan said Mr Y could not use the call bell. His communication was affected by tiredness or hunger. He should wear hearing aids, but he removed them when staff inserted them. Not being able to hear increased Mr Y’s agitation.
17. Mr Y had a behaviour support plan in place. This gave information about triggers that could prompt aggressive and impulsive behaviour in Mr Y. It included noisy and crowded environments and his hearing aids. The care plan described how staff could calm him (so-called de-escalation techniques). He needed hourly snacks and liked yoghurts, sandwiches or a piece of fruit between meals. Food he could eat while walking. He could have a sedative or his son could be called for support.
18. The nutrition care plan said Mr Y needed a low sugar diet because of diabetes. He liked yoghurt and fruit as snacks and staff should provide these regularly as he would often go into other rooms searching for chocolate and sweets.
19. The food records indicate Mr Y did have juice, biscuits, cake and desserts on a regular basis. There is no evidence he was offered fruit regularly.
20. The care plan for medication said Mr Y often said he did not want his medicine, staff needed to explain what it was for and he would then take it. He was known to store tablets in the side of his mouth, due to forgetfulness. There were three occasions between February and April and many occasions in May and June when Mr Y is recorded as refusing to take medication.

Daily care records

21. The care records show the activities Mr Y was offered and took part in. They included time with family in the garden, with dogs, a number of walks around the park with the activities co-ordinator, listening to music, taking part in a quiz, going to the pub on the ground floor, bingo, indoor bowling, dominos, armchair exercises and cards.
22. The Care Provider told me Mr Y was a flight risk and so needed one to one supervision during trips out, therefore it put in place more walks to ensure he was still getting out of the home.
23. The care records note Mr Y often didn’t want his hearing aids in. Staff checked them regularly.
24. The Care Provider’s case notes show its staff discussed Mr Y’s care needs with Mr X and gave him updates about incidents and any healthcare interventions. For example, in June:
• Staff spoke to Mr X about an incident of aggression. They explained Mr Y was refusing to take a sedative. He later took it.
• There was an incident in the garden. Mr Y was trying to escape through bushes, following staff around and picking up a chair trying to throw it. Staff could not calm him despite using calming techniques. Mr X was called and managed to calm Mr Y down.
• An Occupational Therapist from the NHS Dementia Outreach Service attended. Mr Y became aggressive to staff. Mr X attended and Mr Y calmed instantly. Staff were to discuss a covert medication plan with the clinical team, trial regular pain relief and laxatives. The OT was going to discuss this with the psychiatrist.
• Staff met with Mr X to discuss Mr Y’s placement. They had said Mr Y’s needs could no longer be met. Mr Y was noted to be in pain. Mr X said this had been the case for a week, but staff had not noted any signs. Staff called an ambulance at Mr X’s request.

The Care Provider’s complaint response

25. The Care Provider’s first response to the complaint said:
• It accepted it should have consulted with him before giving notice and it did not follow its procedures;
• Challenging behaviour was recorded. It should have made a referral to its in-house dementia specialist;
• Professionals thought Mr Y might need nursing care;
• It was sorry he was not consulted;
• It provided healthier options for food and snacks;
• Mr Y often refused to take part in activities that were on offer. He spent time in the garden, watching TV, taking part in a quiz and went on trips with family;
• Staff offered him the hearing aid, he refused on occasion. It agreed call bells were disturbing, but they were unavoidable.
• The home should have communicated more effectively and this may have resulted in a more positive outcome;
• It was sorry he was not updated about Mr Y refusing to take his medication. He did have a medication review and there was a meeting about a covert medication plan.
26. The second complaint response offered a refund of £2500 which was equivalent to the cost of two weeks contractual notice that was missed.

Findings

Ending the contract without following a proper process

27. The Care Provider has already upheld this complaint and apologised. It should have discussed the matter with Mr X before giving notice and it should have given 28 days’ notice to be in line with the contract/agreement. I uphold this complaint. It caused avoidable distress. The Care Provider has already apologised for this and offered a payment of £2500. This is an appropriate remedy.

Lack of an effective care plan to manage Mr Y’s behaviour and was overly reliant on family for support

28. The behaviour care plan is detailed and sets out strategies to reduce Mr Y’s challenging behaviours. The plan says Mr X could be called if strategies did not work and he appears to have found this acceptable when he was called. Had he said he was not available for this support (or was no longer available/did not want to be contacted), then it would have been fault for the Care Provider to call him. I do not uphold this complaint. The records show staff tried de-escalation techniques and offered sedation and only called Mr X if these were not successful. Staff also involved the specialist NHS dementia team. Care was in line with Regulations 9 and 12(i) and there is no fault.

Did not offer appropriate snacks

29. Sugar is not banned for patients with diabetes, but dietary advice from the NHS is to try and limit it. The food records show little evidence of fruit and yoghurt being offered as snacks and frequent provision of biscuits and sugary desserts. This is not in line with Mr X’s overall nutritional needs as set out on his care plan. Nor is it in line with general dietary guidance from the NHS for patients with diabetes. Care was not in line with Regulation 14. I uphold this complaint. It does no appear to have caused Mr Y harm. So I am not making any recommendations for a remedy.

Did not offer appropriate activities and refused to take Mr Y on trips outside the home

30. The records show Mr Y was offered and took part in a variety of activities in the home and had supported walks in the park. While Mr Y did not go out on many home-organised trips because of risk, but he did benefit from supported walks outside the home. This was in line with his care plan. Care was in line with Regulation 9 and there is no fault.

Did not support Mr Y to use his hearing aids

31. The care plan said Mr Y often refused to wear his hearing aids. He could not be forced. Care was in line with Regulation 9 and there is no fault.

Did not take appropriate action when Mr Y refused medication and creams

32. The records show Mr Y refused medication on three occasions in February, March and April. And more regularly in May and June 2023. The Care Home discussed this with the specialist OT from the dementia team and the plan was for them to discuss a covert medication plan with his consultant. The Care Provider acted in line with Regulation 12(i) and there is no fault.

Failed to communicate with the family

33. The Care Provider upheld this complaint and I agree. There should have been an agreed plan of communication with the family. The decision to serve notice came as a shock. Something was therefore missing in terms of communication and updates. The Care Provider has already apologised for poor communication and has offered an appropriate payment to recognise this. So I am not making a recommendation for a further remedy.

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Final decision

34. We upheld some of Mr X’s complaints about his relative Mr Y’s care. Communication with Mr X was poor, particularly around ending the contract. And Mr Y did not receive healthy snacks in line with his nutritional needs. The Care Provider has already taken appropriate action by apologising and offering a payment.
35. I completed the investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman