Summary: The Ombudsman upholds Mrs X’s complaint about Fazakerley House Care Home’s failure to protect her late mother’s possessions. The Care Provider did not follow its own procedures for labelling clothes or keeping records of Mrs Y’s belongings. It also failed to follow its own guidance on cleaning and laundry. This caused injustice to Mrs Y as she had to pay to replace the lost and damaged items. To remedy the injustice caused by the faults identified, the Care Provider will pay £536 to Mrs Y’s estate. It will also apologise to Mrs X and pay her £100 to remedy the frustration it caused her. Finally, the Care Provider will ensure other residents’ files are up to date, personal items are labelled and their laundry is being handled correctly.

The complaint

1. Mrs X complains staff at Fazakerley House Care Home, managed by Meridian Healthcare Limited (also known as HC-ONE), failed to look after her late mother’s belongings. Mrs X says staff lost or damaged several items during her mother’s stay. She is unhappy with the financial remedy offered by the Care Provider. Mrs X would like the home to reimburse her for the lost and damaged items and would like reassurance the home will look after other residents’ belongings more carefully in the future.

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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. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (Local Government Act 1974, section 26A or 34C)

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How I considered this complaint

5. I have considered the complaint made by Mrs X and the documents she provided.
6. I considered the provider’s comments about the complaint and the documents it provided in response to my enquiries.
7. I gave Mrs X and the provider an opportunity to comment on my draft decision and I considered their responses.
8. Under our information sharing agreement, we will share the final decision with the Care Quality Commission (CQC).

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What I found

Background

Legislation

9. 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.
10. Regulation 15 applies to property and equipment. The guidance says all equipment used by the service provider must be kept clean and providers should monitor the level of cleanliness. It also says providers should protect personal property.
11. Regulation 17 relates to good governance. The guidance says providers should have systems in place to keep accurate and complete records for each service user.

Care Provider’s policies

12. The Care Provider’s terms and conditions say it will make every effort to provide a secure environment for a resident’s personal possessions. It says it cannot take responsibility for loss or damage to personal effects brought into the home.
13. The terms and conditions also say the resident agrees to be responsible for insuring the full replacement value of personal belongings. It says the Care Provider will only be responsible if it has been negligent or has breached the terms and conditions about the resident’s belongings.
14. The terms and conditions also say if a resident is discharged, the resident or their representatives will be responsible for the removal of personal possessions.
15. The Care Provider has a Belongings Procedure. This says all items brought into the home are marked with the owner’s name, initials or room number. Residents and representatives are advised to use a label tag or initialled button which won’t come loose in the laundry. However, if a resident or representative cannot label clothing, a key worker must ensure they do this for the resident.
16. Key workers should check all items of personal clothing to ensure they are identified with the resident’s name or initials. They should repeat this from time to time.
17. On admission, the care home records a resident’s belongings on a personal possessions and property list. This is reviewed and updated as new items are brought in.
18. The Care Provider also has housekeeping guidance which covers cleaning and laundry.
19. The laundry guidance sets out how it should handle different materials and different items of clothing to minimise the risk of loss or damage. This includes using reduced temperatures, avoiding tumble drying, using bactericidal washing agent and using mesh bags for small and delicate items.
20. The section on cleaning routines includes guidance on cleaning residents’ beds. It says all parts of the bed including the mattress and bed frame should be cleaned daily leaving no visible dirt.

What happened

21. Mrs X’s late mother, Mrs Y, lived at Fazakerley House Care Home for two years before moving into a nursing home in October 2018.
22. Towards the end of Mrs Y’s stay, Mrs X complained to the Care Provider. She said staff had lost or damaged items of clothing belonging to her mother as well as losing her mother’s glasses.
23. The Care Provider accepted a staff member had damaged some jumpers in the laundry cycle. It said this was because it had to wash the jumpers in a particular way due to one of Mrs Y’s health conditions. It said it had found some socks and underwear and had returned Mrs Y’s missing trousers to her wardrobe. It said Mrs Y’s glasses were still missing and staff were checking other residents’ rooms for them. The Care Provider offered Mrs X £40 towards the cost of the damaged jumpers.
24. The provider later increased its offer to £100.
25. Mrs X was not happy with the Care Provider’s response. She said the damage to the jumpers was caused by staff negligence and the trousers had not been returned. She said the financial loss to her mother of the lost and damaged items totalled over £500 and provided a breakdown of these costs.
26. Mrs X also said her mother bought her own bed to use in the home as the bed the Care Provider supplied was worn and uncomfortable. She said staff failed to make the bed correctly using a waterproof mattress cover she had bought and the mattress quickly became damaged. She said on her last visit to the home to collect the last of her mother’s belongings the bed base was still in use by the next occupant of the room.
27. The Care Provider told me the bed base was stained and discoloured and it has disposed of the base and the headboard. It accepted in its complaint response to Mrs X that staff had not been placing the protective mattress cover on the bed.
28. The Care Provider could not provide me with a completed personal possessions and property list for Mrs Y.
29. The Care Provider could not provide me with evidence a key worker had checked and where necessary labelled Mrs Y’s items.
30. The Care Provider could not provide me with any cleaning records from Mrs Y’s stay.
31. The Care Provider could not provide me with records of any discussion with Mrs Y’s representatives about keeping or disposing of her bed.
32. The CQC inspected the care home in June 2018. The inspection report notes the following:
• Parts of the building and equipment were unclean. Schedules in place for cleaning equipment had not been followed.
• The lack of cleanliness to the environment and items of personal equipment undermined people’s dignity.
• People’s personal belongings were not always treated with respect. Several pairs of glasses and items of clothing were found in drawers in the communal lounges.
33. The Care Provider said it introduced the role of head housekeeper in October 2018 to promote standards of hygiene and housekeeping including laundry.

Analysis

34. The Care Provider’s policies on personal belongings, cleaning and laundry are robust. However, it has been unable to show how it followed them. As a result, it cannot evidence that it protected Mrs Y’s personal property, and this was fault.
35. The Care Provider said the damage to Mrs Y’s jumpers was due to the way it needed to wash them. But its own laundry guidance does not support this. It sets out how more delicate materials should be handled. Failure to follow this guidance was fault.
36. The CQC inspection, carried out while Mrs Y was still resident at the home, suggests there were issues keeping residents’ personal possessions secure.
37. These faults caused injustice to Mrs Y as she had to replace the missing items of clothing and her glasses.
38. This was negligence by the Care Provider. Therefore, it must take responsibility for the loss of and damage to Mrs Y’s personal effects.
39. Regarding Mrs Y’s bed, the Care Provider cannot evidence that it carried out its housekeeping processes correctly. However, there was no quantifiable loss to Mrs Y of the bed being damaged or disposed of.
40. However, there was injustice to Mrs X. She had to spend time ensuring staff were consistently using the protective equipment she had provided for her mother’s bed and experienced frustration when they did not.

Agreed action

41. The Ombudsman’s Guidance on Remedies sets out how we should remedy complaints where there was injustice caused to someone who has since died. If there is clear evidence of a quantifiable financial loss arising from the fault, we will normally recommend a financial remedy that repays the loss to the deceased person’s estate.
42. Within one month of the final decision, the Care Provider will:
• Pay £536 to Mrs Y’s estate to acknowledge the quantifiable loss to Mrs Y of replacing lost and damaged items.
• Apologise to Mrs X and pay her £100 to acknowledge the frustration caused by staff not making correct use of the protective items she provided for her mother’s bed.
43. Within three months of the final decision, the Care Provider will:
• audit the files of residents at Fazakerley House Care Home to ensure each contains an up-to-date personal possessions and property list.
• ensure residents’ clothes and personal effects are clearly labelled in line with the Belongings Procedure.
• remind staff with responsibility for laundry of the process for ensuring clothes are handled correctly to minimise the risk of loss or damage.
44. Within three months of the final decision, the Care Provider will also review the Ombudsman’s Guidance on Remedies and consider applying the principles to the remedies offered in its own complaint investigations.

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Final decision

45. I have completed the investigation and uphold Mrs X’s complaint. Mrs X has been caused an injustice by the actions of the Care Provider and it has accepted my recommendation to take action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman