The Ombudsman's final decision:
Summary: Mr S complained about the quality of care provided to his late father, Mr X, at the Council commissioned care home. The care provider was at fault when it failed to ensure Mr X’s sensor mat was always in position, Mr X was dressed in the wrong or dirty clothes and staff left dirty crockery in his room. The care provider also failed to advise the Council of the complaint so Mr S did not have recourse to the Council’s complaints procedure. The care provider has made a charity donation and made some service improvements to address the faults identified, which is an appropriate remedy, and it should provide the Ombudsman with evidence it has done this. It should also review its complaints procedure.
- Mr S complains about the quality of care provided to his late father, Mr X, at the Council commissioned care home, Willow Lodge Care Home. Mr S says Mr X was in dirty clothes when he visited and food trays piled up in his room. He complains the care home failed to maintain his father’s dignity at the end of his life and placed him at risk by not ensuring he had access to a call bell and not ensuring a sensor mat was in place by his bed. Mr X owes outstanding care costs and Mr S wants the care provider to pay the equivalent of these to charity.
The Ombudsman’s role and powers
- We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
- If we are satisfied with a council’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)
How I considered this complaint
- I have considered the information supplied by Mr S and have spoken to him on the telephone. I have considered the information supplied by the care provider and Council in response to my enquiries.
- I have given Mr S, the Council and care provider the opportunity to comment on a draft of this decision. I considered their comments before I reached a final decision.
- Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.
What I found
- The Council commissioned Mr X’s placement in the care home and so this complaint is registered against the Council, as the care provider was acting on the Council’s behalf.
- The charging rules for residential care are set out in the “Care and Support (Charging and Assessment of Resources) Regulations 2014”, and the “Care and Support Statutory Guidance 2014”. When the Council arranges a care home placement, it has to follow these rules when undertaking a financial assessment to decide how much a person has to pay towards the costs of their residential care.
- The rules state that people who have over the upper capital limit are expected to pay for the full cost of their residential care home fees. However, once their capital has reduced to less than the upper capital limit, they only have to pay an assessed contribution towards their fees.
- The council must assess the means of people who have less than the upper capital limit, to decide how much they can contribute towards the cost of the care home fees. The amount they pay towards the fees is known as the client contribution.
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 sets out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) has issued ‘Essential Standards of Quality and Safety’ as guidance on the outcomes adult social care providers should achieve.
- The Essential Standards contain outcomes for each regulation. These outcomes detail what providers should be doing to meet the requirements of each Regulation.
- Outcome 5 addresses meeting nutritional needs. It requires that people are encouraged and supported to have sufficient food and drink that is nutritional and balanced, and a choice of food and drink to meet their different needs (Regulation 14).
- Mr X moved into the care home in July 2017. The care provider recorded Mr X required assistance with washing, bathing, dressing and grooming. He had poor mobility and was at risk of falls. He needed a wheelchair for transfers and needed assistance to mobilise a few steps. He had a very limited diet and fluid intake. The care provider put a food and fluid chart in place. It recorded Mr X required a lot of encouragement to eat with supervision and had lost a lot of weight. In the daily records staff noted they encouraged Mr X to eat and drink. On his admission the care provider noted on a body map that Mr X had a bed sore.
- In September 2017 the care provider noted another sore area and contacted the District Nurse who provided advice to the care provider and dressed the area. The care provider noted Mr X’s skin was at high risk and he had an airflow mattress in place. The care provider continued to monitor Mr X’s skin integrity.
- Mr S visited Mr X on 2 October. He says he found Mr X in the dining room with food still in his mouth. He asked staff to call the GP. A staff member took Mr X’s blood pressure which was low and called the GP. The GP visited and the notes record they spoke with Mr X’s next of kin who did not want him admitted to hospital. The GP advised Mr X now required end of life care.
- The care provider put a repositioning chart in place and records show they repositioned Mr X every two hours. The GP advised staff to provide Mr X with food supplement drinks. The records show the care provider monitored Mr X’s food intake and his fluid intake and output.
- Mr S visited Mr X on 3 October. His call bell was out of reach and his sensor mat was not in place. Mr X was not wearing his hearing aids and cups containing old food supplements were not cleared from his room.
- On 5 October staff recorded in the daily records that Mr X had fallen out of bed. He was last checked at 6am and found on the floor on top of his duvet at 7.35am. Staff completed an incident report. It recorded a skin tear to Mr X’s hand and advised the District Nurse of this and dressed his hand. It also told Mr X’s family of the fall.
- Mr X died on 6 October 2017.
- Mr S complained to the care provider on 11 October. He complained Mr X was not always dressed in his own clothes and they were sometimes dirty. He was not always wearing his hearing aids. The sensor mat was under his bed and not in place and Mr X was left without access to his call bell, his diet was appalling with food and dirty cups left in his room and he developed bed sores. He complained about finding Mr X unwell on 2 October. On 26 October 2017 the care provider acknowledged Mr S’s concerns and asked to meet to discuss them.
- Mr S met with the care provider on 8 November. In the notes of the meeting the care provider apologised that Mr X did not always have his hearing aids. It had updated the daily records to make sure staff checked residents who used hearing aids had them in. It said Mr X usually wore an apron at mealtimes but on occasions removed it. The carer apologised when Mr S visited and found Mr X in dirty clothes and ensured he was changed immediately. It accepted Mr X’s clothes could have got mixed up with other residents. It was buying new net bags for each resident to stop this happening in future.
- The care provider said the call bell was attached to the sensor mat and was usually in front of Mr X. It said staff advised they sometimes moved the mat when family visited as the alarm would sound. It already had checks in place to ensure sensor mats and call bells were in place. It had also added this to senior checks for those who spent a lot of time in their rooms.
- It said the bed sore was already there when Mr X entered the care home and was monitored closely. When another sore started developing it alerted the District Nurse and recorded the incident. In relation to Mr X’s nutrition it said Mr X had a poor diet when he arrived at the care home. He had a nutrition chart in place, staff encouraged as much as they could and it introduced a food supplement to boost his nutrition on the GP’s advice. It apologised that staff had left used cups and crockery by Mr X’s bed. It had put in the communication book to all staff the need to ensure used items are removed from rooms.
- In relation to 2 October, Mr S was unhappy staff had not noticed Mr X was unwell. The care provider said it had allocated a staff member to remain in the dining room at meal times to assist and encourage residents to eat. It was monitoring residents’ blood pressure and blood sugars on a weekly basis.
- After Mr X fell out of bed on 5 October, staff had told the family. The care provider said it had not used a cot side as Mr X had not previously rolled out of bed and a cot side could be seen as an unnecessary restraint. It could also increase the risk if Mr X tried to climb over it.
- Mr S said he wanted the outstanding client contribution, owed by Mr X to the care provider, donated to charity. The care provider said this needed to be paid as this was Mr X’s client contribution owed for his stay.
- The care provider wrote to Mr S following the meeting. It summarised the record of the meeting. It accepted the sensor mat was sometimes under the bed when family visited suggesting it was accidentally moved. It reiterated the additional checks it had put in place. It said the meeting was very productive in terms of highlighting the issues raised so improvements could be made to the care provided at the care home. It said it could not donate the outstanding balance to charity. Mr X’s financial contribution needed to be paid in line with the Council’s policy and procedures. It advised it would be donating a defibrillator to the community and would make a donation to two charities
- Mr S responded in November 2017. He was satisfied the care provider had put actions in place to avoid such matters happening to other residents. He said he was happy to pay but remained unhappy with the substandard care. He said he would settle what was owed when he received confirmation of the charity donations.
- The care provider contacted Mr S in December 2017 to say it had identified a defibrillator and would make charity donations. It sent him another email in February 2018 to advise the defibrillator was on order and it would make the charity donations.
- In April 2018 the care provider confirmed the defibrillator was in place and it had made donations of £135 to each of two charities on Mr S’s behalf.
- Mr S was unhappy with the amount donated and the time taken for this to happen and complained to the Ombudsman.
- The Council became aware of Mr S’s concerns in July 2018 when the care provider told it Mr S had not paid Mr X’s client contributions. A social worker visited the care home and was given minutes of the meeting with Mr S and copies of the email correspondence between him and the care home.
- As the care home is across the Council border it contacted the neighbouring authority who confirmed it had no safeguarding concerns. The Council was satisfied with the action the care provider took to address Mr S’s concerns.
- Mr S told the care provider he would pay the client contributions if the care provider paid the equivalent amount to charity. The care provider responded in June 2018. It did not agree to pay the full client contribution owed to charity but had made donations as agreed.
- Councils have a legal duty to charge people for residential care. The client contribution is the amount an individual is calculated as being able to afford to pay towards the cost of their care. The Council calculated Mr X’s client contribution based on his income. He received care from the care provider and so was required to pay for it.
- Mr S was unhappy with the standard of care provided to Mr X. There were faults in the care provided to Mr X and the care provider acknowledged this when it met with Mr S. It accepted:
- Mr X did not always have his hearing aids in;
- There were occasions when Mr X’s sensor mat was not in place;
- Mr X’s clothes could get mixed with other residents and he was wearing dirty clothes when Mr S visited on one occasion; and
- Used cups and crockery were left in Mr X’s room.
- Putting checks in place regarding hearing aids and the position of call bells and sensor mats;
- Reminders in the communication book to ensure staff removed used cups and other used crockery from residents’ rooms;
- The introduction of new laundry bags for residents’ clothes;
- A staff member remaining in the dining area when residents ate their meals to provide support and encouragement; and
- Weekly observations of residents’ blood pressure and blood sugars.
- The care provider has already taken action to address the concerns raised by Mr S. Within one month of the date of the final decision, it should provide the Ombudsman with evidence to show the action it has taken.
- In addition, within two months of the date of the final decision, the care provider should review its complaints procedure to ensure where a resident is provided with Council commissioned care, they are appropriately referred to the Council’s complaints procedure if the resident remains dissatisfied once the care provider has responded to the complaint.
- I have completed my investigation. There was fault leading to injustice. I have made some recommendations in addition to the remedy already provided to address the injustice caused.
Investigator's decision on behalf of the Ombudsman