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Burlington Care (Yorkshire) Limited (18 016 639)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 09 Aug 2019

The Ombudsman's final decision:

Summary: Mrs D complains about the standard of care provided to her late mother in a care home, including verbal abuse. The Ombudsman has found the care provider’s actions were fault causing injustice. We have recommended the Care Provider apologise, refund the care fees and make a payment to Mrs D to acknowledge the distress caused.

The complaint

  1. Mrs D complains about the standard of care provided to her late mother, Mrs J, in the Hawthornes Care Home (the Home), operated by Burlington Care (the Care Provider). In particular, she complains the Care Provider failed to meet her mother’s care needs, there was verbal abuse and rough handling, and her mother was left unattended for long periods.
  2. Mrs D says this caused distress to Mrs J and the family and they had to move Mrs J urgently to a different care home.

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The Ombudsman’s role and powers

  1. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)
  2. 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. (section 26A or 34C, Local Government Act 1974)
  3. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
  4. 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.

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How I considered this complaint

  1. I spoke to Mrs D about her complaint and considered the information she sent. I considered the Care Provider’s response to my enquiries and made enquiries of Kirklees Council. I also considered the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the Regulations”).
  2. I sent Mrs D and the Care Provider my draft decision and considered the comments I received.

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What I found

  1. The Regulations set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet these standards. The standards include:
    • Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
    • Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
    • Safeguarding from abuse (Regulation 13): Service users must be protected from abuse and improper treatment, this includes neglect.
    • Food and drink (Regulation 14): Service users must have enough to eat and drink to keep them in good health while they receive care and treatment.
    • Premises and equipment (Regulation 15): Providers must make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located.
    • Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

Safeguarding adults

  1. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)

What happened

  1. Mrs J was elderly and had been diagnosed with dementia. She had been an amputee since childhood and used a wheelchair or crutches. She lived with her husband, Mr J, who helped care for her.
  2. In the summer of 2018, Mr J became seriously ill and went into hospital. Mrs D and her sister initially moved in to help care for their mother, but as they did not live locally this was unsustainable. They looked for possible residential care homes and found the Home.
  3. The Home assessed Mrs J. The assessment says she had “early dementia”, her mental capacity had been assessed and she could make informed choices. It notes she used pain relief for her amputation. I have seen no evidence it referred to her personal care or nutrition needs. Mrs D says she provided detailed information to the Home about Mrs J’s care needs.
  4. The Home said it could meet Mrs J’s needs and she moved in on 31 July 2018. The family paid for this care privately.
  5. I have seen no evidence a care plan was written on admission. The Home accepts it did not weigh Mrs J on admission. There are conflicting weight records for Mrs J in August 2018; one document has no weight recorded, another says it was 36kg.
  6. Mrs J’s husband passed away a few weeks after Mrs J moved into the Home. Mrs D says they had concerns about their mother’s care but put these down to the upheaval of the move and her grief. She says Mrs J was often fully clothed in bed, her clothes and room smelt of urine and they informed staff of this. On one occasion faeces was seen under Mrs J’s nails. Mrs D says Mrs J was not eating properly, she had visible weight loss and her pad was not changed regularly. The family also witnessed one incident of rough handling. The Home’s manager says Mrs J refused help with personal care and did not have a bath for the first two weeks of her stay.
  7. The Home completed a respite admission assessment on 18 September 2018. This said Mrs J wanted to maintain her own personal care and could manage her own mobility. Mrs J’s weight was recorded as 36.9kg.
  8. Mrs D says she visited Mrs J on 30 September 2018 and was concerned she had deteriorated. She spoke to the Home manager who said it was unlikely the Home would be able to meet Mrs J’s needs in the long term as her dementia worsened. It was agreed Mrs J should move to a home for the elderly mentally infirm in the new year.
  9. A relative visited Mrs J on 10 October 2018. Staff spoke to her about Mrs J’s condition, although she was not next of kin. They told her Mrs J would need to move urgently as the Home was unable to meet her needs; there had been a rapid decline in her capacity since Mr J’s death and she was agitated. There is no evidence this discussion was held with Mrs D or her sister.
  10. The family became increasingly concerned about Mrs J and the care she was receiving. They found her to be very distressed and in pain. Mrs D says Mrs J had lost weight, had reddened areas on her amputation and sacrum, and creams were not were being applied as prescribed. The family also felt the way Mrs J was treated by carers lacked empathy, compassion and respect.
  11. They left a recording device in Mrs J’s room overnight on 17 October 2018. When they listened to the recording, it contained verbal abuse of Mrs J by a carer and indicated she had had no interaction with staff from 1pm to 1am.
  12. The family immediately moved Mrs J to a different care home and a safeguarding alert was raised with Kirklees Council. Mrs J’s weight was recorded as 38.3kg on 18 October 2018. Mrs D says Mrs J’s weight on 19 October 2018 at the new home was 37.2kg.
  13. Mrs D says, as she and her sister do not live locally, they incurred significant expenses in dealing with the matter as they had to travel to meetings and to move Mrs J. Mrs J sadly passed away in November 2018.

Mrs D’s complaint

  1. The family made a formal complaint to the Home about the verbal abuse and quality of care Mrs J had received. The Home’s investigation found there was:
    • A lack of documentation
    • A very poor care plan
    • No evidence Mrs J’s room had been deep cleaned or beds changed
    • Evidence Mrs J often put herself to bed fully clothed and it was likely she slept in her clothes. Staff had wrongly assumed she dressed herself daily.
    • Faeces found under Mrs J’s nails due to a lack of personal care.
    • No evidence of interaction between carers and Mrs J, so the Home accepted there had been a lack of empathy by staff.
    • No evidence of communication with the family about Mrs J’s care planning or that the family were kept fully informed of the need to seek a more suitable placement when Mrs J’s mental capacity deteriorated.
  2. The Home said there was no evidence of weight loss or pressure sores. It could make no finding about an incident of rough handling due to lack of evidence. It concluded the Home had failed to maintain Mrs J’s care and wellbeing and had not acted on the concerns raised. The carer had been dismissed and the manager later resigned. The Home apologised and offered a week’s refund of care fees to the family.
  3. The Council carried out a safeguarding investigation and discussed its findings with Mrs D in March 2019. The safeguarding enquiry said there had been poor care provision, inadequate leadership, probable neglect and a disregard for residents’ dignity. There was a lack of written evidence and it was likely that the daily records were not an accurate reflection of Mrs J’s changing care needs. It was also found that during internal home inspections staff were encouraged to “keep Mrs J out of [the inspector’s] way”.

The Care Provider’s response

  1. In response to my enquiries, the Care Provider set out the action it had taken in response to Mrs D’s complaint. It said:
    • A carer had been dismissed.
    • A new manager had been appointed.
    • Intensive senior management support was being given to the Home’s management.
    • Work had started to change the culture of the Home, including a greater understanding of caring for people with dementia.
    • Training was being given to staff on the fundamental standards of care, supervision, dementia awareness, medication and data protection.
    • There was an improved level of documentation in relation to pre-admission assessments, care plans and the gathering of accurate information.
  2. The Care Provider said Kirklees Council had recently completed its quality assurance inspection at the Home and was found to be compliant with the local authority contract.

My findings

  1. There is a lack of written records in this case, which makes it difficult for me to determine whether Mrs J received adequate care. However, the Home has accepted there was fault in its actions and the safeguarding enquiry found poor care provision and probable neglect.
  2. There is evidence Mrs J was verbally abused and left unattended on at least one occasion. This is a potential breach of Regulation 13 of the fundamental standards, below which care must not fall.
  3. There was no care plan when Mrs J moved into the Home and the Home’s records are not a complete and comprehensive record of her condition. This is a potential breach of Regulation 17.
  4. The Home has accepted there is no evidence Mrs J’s room was deep cleaned or her bed changed. This is a potential breach of Regulation 15.
  5. The Home has accepted it did not keep the family fully informed. This is a potential breach of Regulation 9.
  6. The Home says Mrs J often refused help with personal care and did not have a bath for the first two weeks of her stay. The Home cannot force a resident to do something that they refuse to do. The law says it must be first assumed a person can make their own decisions and they have a right to refuse care and treatment. However, neglecting someone's personal care needs can put someone's health at risk. Care plans and policies should be in place to deal with this situation. In these circumstances I would expect to see a care plan setting out what actions carers should take, such as seeking advice from senior staff. The Care Provider says it aimed to build up Mrs J’s confidence in the staff so she would agree to care. I have seen no evidence of how this was being done. I cannot say whether adequate personal care was provided, but I note faeces was found under Mrs J’s nails and her sacral area was reddened and sore.
  7. Mrs D says Mrs J was losing weight and not eating properly. The food charts the Care Provider has sent are hard to interpret. They appear to indicate that Mrs J ate and drank every day but did not always eat everything. There are conflicting and unclear weight records, but I cannot say there is evidence Mrs J lost weight during her stay.
  8. Mrs D says Mrs J was treated without compassion or dignity. The Care Provider and the safeguarding enquiry found this was likely to be true, and I note the Home accepts it tried to ensure its internal inspector did not visit Mrs J. This is a potential breach of Regulation 10.

Did the Care Provider’s actions cause injustice?

  1. The Care Provider did not give Mrs J the care her family expected. She was subjected to verbal abuse, a lack of compassion and probable neglect. Mrs J may have refused help with personal care, but the Care Provider should have acted promptly to deal with this.
  2. There were potential breaches of the fundamental standards and this is fault. I find these faults caused injustice to Mrs J. Mrs D says they caused significant distress to Mrs J as she knew she was being badly treated.
  3. The poor record keeping has caused injustice to Mrs J’s family as there is uncertainty about whether the care provided to Mrs J was adequate, causing distress and anxiety.
  4. The Care Provider has taken appropriate actions to improve practice and prevent reoccurrence of these faults affecting other residents. However, the Care Provider’s offer to refund one week of Mrs J’s care fees is not an appropriate remedy for the injustice caused.
  5. Where injustice has been caused to someone who has died, we will not normally seek a substantive remedy in the same way as we might for someone who is still living. However, the Ombudsman's guidance on remedying injustice says that, if there is clear evidence of a quantifiable financial loss arising from fault, we would recommend a financial remedy to repay that loss to the deceased person's estate. I have found the Care Provider has failed to provide care that meets the fundamental standards. This is a loss of service.
  6. In response to my draft decision, the Care Provider accepted the care and support provided to Mrs J did not always meet the expected standards. This was due to poor practice and a poor culture in the Home inherited from the previous provider. It said the Home manager should have sought support from a specialist service and the Care Provider had been unaware of concerns about the care of Mrs J at the time. The Care Provider noted Mrs D’s desire for action to be taken to ensure nobody else has a similar experience. It had taken immediate, robust action in response to the safeguarding investigation.

Recommended action

  1. Within one month of my final decision, the Care Provider should:
    • refund Mrs J’s full care fees for her stay
    • apologise to the family and pay Mrs D £250 as a remedy for uncertainty and distress caused to her by its faults.

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Final decision

  1. The Care Provider’s actions have caused a quantifiable loss of service for Mrs J and injustice to Mrs D.

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Investigator's decision on behalf of the Ombudsman

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