Summary: Mr Y complains about the residential care provided to his late mother, Mrs X. The Ombudsman finds fault because the Home did not properly assess or monitor Mrs X’s weight loss, causing distress in the form of uncertainty. The Home then delayed in responding to Mr Y’s complaint causing avoidable time and trouble. The Council will pay £350 to Mr Y and complete the actions listed at the end of this statement to remedy the injustice caused by fault.

The complaint

1. The complainant, whom I will call Mr Y, complains about many aspects of the care provided by Sovereign House (‘the Home’) to his late Mother, Mrs X.
2. Mr Y also raises general concerns about standards within the Home, as well as concerns about the quality and timeliness of its response to his complaint.

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The Ombudsman’s role and powers

3. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. Part 3A covers complaints about care bought directly from a care provider by the person who needs it or by a representative, and includes care funded privately or with direct payments under a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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. (section 26A or 34C, Local Government Act 1974)
5. 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)
6. 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)

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How I considered this complaint

7. During my investigation, I have:
• discussed the complaint with Mr Y by telephone and considered any information he submitted;
• made enquiries of the Council. The Council obtained information from the Home. I considered the response before writing this draft decision;
• consulted any relevant law and guidance about standards of care, particularly the standards published by the Care Quality Commission (CQC); and
• issued a draft decision and invited comments from Mr Y, the Council and the Home. I considered any comments received before making a final decision.
8. 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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What I found

9. Mrs X entered the Home in April 2018 for a temporary stay following her discharge from hospital. Her placement was funded and arranged by the Council, and so the Council is the body in jurisdiction for this complaint.
10. Mr Y describes the care provided by the Home as ‘appalling’. He says the Home’s actions caused Mrs X to decline; she lost a significant amount of weight, became dehydrated and was admitted to hospital in June 2018 with malnutrition and a Urinary Tract Infection (UTI).
11. Mrs X died in September 2018. Shortly before her death, Mr Y complained to the Home with his concerns about the quality of care it had provided. He raised several concerns, which I will summarise and address under the headings below.

Nutritional intake and weight loss

12. The Home’s ‘Nutritional Screening Policy’ says, “… depending on the outcome of the [initial pre-admission] assessment a nutritional risk management plan is devised and included in the service user’s plan”
13. The NHS publishes a ‘Care Home Guide’ for ‘Malnutrition Universal Screening Tool’ (MUST) assessments. It confirms the purpose of any such assessment is to consider and address any underlying causes of malnutrition. When doing so, the guidance says care homes should undertake the following steps:
• step one: measure service-user’s height and weight to calculate BMI score
• step two: note percentage of unplanned weight loss and score using the tables provided
• step three: establish acute disease effect and score
• step four: add scores from steps one to three to obtain the overall risk
• step five: use management guidelines and local policy to develop a plan
14. Those considered low risk should be weighed every four weeks. If the service-user’s weight or food input does not improve, they should be escalated to medium risk with an aim to increase their daily intake by 500 calories. If the service user continues to lose weight, then they should be considered high risk and provided with extra fortified meals and snacks and weighed every two weeks.
15. Mr Y says that Mrs X would often refuse food, and although the Home recorded her food refusal, it never escalated the matter or sought medical intervention. He says the Home failed to accurately record Mrs X’s fluid and food intake, and wrongly recorded that she lost just one pound in weight during her stay there.
16. When responding to the complaint, the Home said it was aware, following the pre-admission information provided by hospital staff, that Mrs X needed encouragement to eat small high calorie meals often. The hospital discharge notes say Mrs X had reduced appetite and oral intake. Her recorded weight upon admission to the Home on 23 April 2018 was 53.4 kilograms.
17. The Home also noted the hospital had prescribed a seven-day supply of fortified meal drinks. The short-stay care plan completed by the Home included a nutritional assessment. This concluded that Mrs X was of ‘average’ body type, had a reduced appetite and could eat independently but needed encouragement. It records a brief summary of Mrs X’s medical history, which included, “very poor diet – lost 1.5 stone in 12 months”.
18. The OT’s assessment recorded, “Please encourage patient to eat smaller meals more often but high calorie options as per advice”. The dietician also advised, “staff to encourage both food and fluids and weigh weekly as a short-term resident”. The dietician reported that Mrs X preferred to eat in private because of previous trauma to her mouth, which sometimes meant that mealtimes were ‘messy’.
19. On 5 June the Home recorded Mrs X’s weight at 53kg. The Home said Mrs X refused to eat and drink, despite encouragement. On 11 June the Home requested a GP visit due to Mrs X’s low mood and reduced intake.
20. Meanwhile, Mrs X’s daughter visited. She relayed concerns about Mrs X. The Home agreed to contact the GP again. It also tested Mrs X’s urine on 17 June and found signs of a UTI. The GP later visited Mrs X and prescribed a seven-day course of antibiotics. The NHS ‘111’ helpline also advised the Home to encourage fluids and administer paracetamol.
21. On 19 June the Home made a referral for support from the community dietician and recorded Mrs X’s weight at 47.3 kilograms. This represented a six-kilogram loss in a two-week period. The Home’s notes from this day show it considered calling 999 when Mrs X was confused, calling out and refusing all food and fluids. Its records show that care staff discussed with Mr Y the possibility of calling an ambulance, but he expressed a preference for the GP to review Mrs X first. The GP visited later that evening and decided to call for an ambulance. Mrs X was then admitted to hospital.
22. Based on the information seen, I find fault with the following:
• a failure to weigh Mrs X every week, despite the dietician’s instructions
• a failure to evidence that staff encouraged Mrs X at mealtimes, according to the dietician’s instructions
• a failure to complete a ‘Nutritional Management Plan’ in line with the Home’s internal policy
• a failure to record Mrs X’s BMI, her percentage weight loss and risk score, according to the ‘MUST’ guidelines.
23. In response to my draft decision, the Home said:

“The home has ensured that staff are aware and follow the nutritional management plan in place; the management team will continue to monitor this in line with requirements and ensure a needs based level of care, responding timely to professional advice and guidance”

“Staff have completed training in Nutrition and Hydration, both through E learning and provided by the Community dietician through the completion of training on site in relation to the nutrition food fortification pathway, How to manage residents at risk of malnutrition (3-2-1 Pathways) Coventry and Rugby clinical commissioning”

24. It is not possible to determine, had the Home completed the above steps as it should have done, whether Mrs X would have lost as much weight as she did in such a short space of time. I recognise that Mr Y feels the Home is solely responsible for his mother’s decline, but I am not able to make this causal link. It is clear from the records that Mrs X had a chronic illness at the time of her admission to the Home, but Mr Y points out this illness was being appropriately managed. I am also aware that Mrs X had already lost a significant amount of weight in the preceding months, although Mr Y says his mother’s weight loss had stabilised and the only reason for her previous hospital admission was due to mobility issues and recurrent falls.
25. The Ombudsman is not qualified to make a link between the actions of the Home and Mrs X’s decline in health. We can however conclude that there is uncertainty around whether the Home’s actions added to Mrs X’s decline, and to what extent.
26. The Ombudsman cannot recommend a personal remedy for the person affected if they have died. However, we can instead consider the impact on the person bringing the complaint; Mr Y. The Council will arrange, with the Home, to remedy the effects of the distress to Mr Y with the actions listed at the end of this statement.

Cleanliness and general hygiene standards

27. Mr Y also raised concerns about general hygiene standards in the Home. For example, he says Mrs X was rarely given the opportunity to wash her hands after using the toilet. Mr Y also complains about the general cleanliness of Mrs X’s room and says that carers would sometimes deposit dirty gloves into Mrs X’s laundry basket. He also says that Mrs X’s soiled clothes were sometimes left in bags, without first being rinsed, for family members to take home.
28. I have considered the daily care records. These do not detail every time Mrs X washed (or did not wash) her hands, but I would not expect the Home to record such level of detail. The notes do however show that Mrs X received a full bed bath most days. I am also aware that Mrs X sometimes refused personal care.
29. The Home apologised on behalf of care staff for depositing dirty gloves in Mrs X’s laundry and said this “should not happen”. However, it said that it did not have the facilities to rinse heavily soiled clothing, and so its procedure was to place any such items in special red bags for family members to take home.
30. Based on the evidence seen, I do not uphold this part of the complaint. This is because the contemporaneous records show that Mrs X received full body washes most days. Although there were some concerns about dirty items in Mrs X’s room, the records suggest that, overall, Mrs X received a satisfactory level of personal care.

Physiotherapy and Occupational Therapy

31. Mr Y complains the Physiotherapy and Occupational Therapy (OT) that Mrs X received was ‘sporadic’ and any progress was not communicated by the Home. Mr Y says that Mrs X was supposed to be performing daily exercises, but this was not encouraged or monitored by the Home.
32. I have considered Mrs X’s care plan and hospital discharge notes. These make no reference to daily exercise. I have also considered the notes recorded by the Physiotherapist on 20 May. These refer to a mobility assessment, whereby it was decided that Mrs X needed the use of a full hoist for transfers. Again, there is no reference to any form of exercise plan for Mrs X.
33. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened. However, we can only do this where there is enough evidence to reach a view either way.
34. Mr Y says that Mrs X had a daily exercise sheet in her room. I have not seen any evidence of this. As an impartial Investigator, I can only make a finding based on the evidence available to me. For this reason, I am unable to make a finding on this part of Mr Y’s complaint.

Accidents and injuries

35. Mrs X’s care plan said she needed the help of two carers to help her with all personal care needs as well as the use of a ‘mo-lift’ raiser to help elevate Mrs X from a sitting position. The falls assessment concluded that Mrs X was at ‘high risk’ of falling.
36. The OT also decided in May that Mrs X required the use of a full hoist for all transfers. However, the care records show that Mrs X refused to use the hoist, and so care staff continued to assist Mrs X with the ‘mo-lift’.
37. In his complaint, Mr Y said his mother often had to wait too long for carers to assist her to the toilet. Mr Y also says the call bell in Mrs X’s room was defective. As a result, Mr Y says Mrs X was sometimes unable to summons help from carers and would try to use the toilet without the assistance she needed.
38. The Home’s records show that Mrs X fell on four occasions. These falls were reported through accident and injury forms:
• 8 May 2018. Mrs X suffered three ‘tears’ to her right arm. Dressing applied and District Nurse notified.
• 18 May 2018. Mrs X suffered a cut to her upper lip and a tear to her elbow.
• 19 May 2018. Mrs X suffered a friction burn to her left knee.
• 30 May 2018. Mrs X sustained no injuries.
39. The daily care records show that Mrs X was regularly assisted to the toilet by carers, as per her care plan. But on some occasions, Mrs X refused the use of the ‘mo-lift’. Mrs X sometimes insisted on toileting independently and without assistance. According to the records, most of the falls listed above were a result of Mrs X attempting to independently access the toilet.
40. As part of my enquiries, I asked the Council to obtain a copy of the Home’s ‘Accident and Injury’ policy or procedure. The document sent in response relates to accidents and near misses suffered by staff members, visitors and members of the public. It does not refer to the procedure to be followed by care staff in the event of an accident or injury suffered by a service-user.
41. In response to my draft decision, the Home told us that it has an ‘Ill, Injured or Unresponsive Service User’ policy which was in force at the time of the matters complained about. I have not seen a copy of this policy.
42. Based on the evidence seen, I cannot conclude that Mrs X’s falls were preventable. The daily care records refer to at least three occasions whereby staff responded to Mrs X’s call bell. This suggests that the bell was functioning. The Home has also provided a sheet to show its monthly checks of the bell’s function. The records show Mrs X was usually always helped to the toilet, but that she sometimes refused assistance.
43. I appreciate Mr Y says there are times when he witnessed the call bell not working. He says he always reported this to the Home, but the bell was not always fixed promptly. But as an impartial investigator, I can only make decisions based on the evidence available to me. It appears the bell worked at times, but I cannot reach a view on whether the bell always worked.
44. However, the Ombudsman has not yet seen evidence that the Home has a policy in place which outlines a procedure for staff members to follow in the event of an accident, injury or emergency in the Home. Within four weeks of my final decision, the Council will provide evidence to the Ombudsman that the Home has a policy or guidance document in place.

Admission to hospital and lost belongings

45. Following advice from the GP, Mrs X was admitted to hospital by ambulance at 2am on 19 June. Mr Y says he was distressed to find that Mrs X had gone to hospital wearing only her night clothes, and without any overnight provisions.
46. I understand the Home contacted Mrs X’s daughter to inform her that Mrs X would be transferred to hospital following the GP’s advice. I also note from the records that Mrs X was calling out due to her general state of illness and confusion. Although I appreciate it would have been the family’s preference for Mrs X to have been fully dressed at the time of admission, I am mindful that it was 2am and Mrs X was unwell and confused. It may not have been appropriate for the Home to change Mrs X’s clothes in those circumstances. Furthermore, the Home would not have known how long Mrs X would remain in hospital. It informed Mrs X’s family of the admission so they could make any necessary arrangements to facilitate her stay in hospital.
47. Mr Y also complains that his mother lost some belongings whilst in the Home: an earring and a mobile phone. Mrs X’s daughter notified the Home of the missing items by email. Mr Y also raised the matter in his complaint to the Home. The Home says it tried to locate the items, without success. In response to his complaint, it asked Mr Y for a description of the missing items. I have not seen any evidence that Mr Y (or his sister) responded to the Home with the requested details.
48. Whilst I cannot say the Home is responsible for the loss of the items, I have considered how the Home dealt with the matter once reported. I appreciate Mr Y remains dissatisfied with the efforts made by the Home to locate the items; however, the Home did what it could to find them. I do not find the Home at fault.

Complaint handling

49. The Home’s complaints policy says that it will acknowledge any formal complaints within two days of receipt and aims to respond to the complaint within 28 days. The Home says its response should outline the action it has taken – or will take – to resolve the complaint made.
50. Mr Y made a written complaint on 24 August which clearly set out his concerns about the care provided to Mrs X. When Mr Y received no response, he chased the Home on 14 September. It responded to apologise for the delay, and confirmed its investigation remained ongoing.
51. The Home wrote to Mr Y again on 10 October. It again apologised for the delay, and said it aimed to respond by 20 October. The Home eventually responded on 8 February 2019, yet its response is dated 10 October 2018.
52. Although the Home’s policy says that, in some complex cases, it may take longer than 28 days to respond to the complaint made, I consider the delay in this case is significant and unwarranted.
53. Mr Y also complains about the quality of the response. Having reviewed the Home’s complaint response, it is my view that this offers a general narrative of the care provided to Mrs X. It does not offer any useful analysis of the individual complaints made by Mr Y.
54. The Home has already apologised for the delay in its complaint handling. But the delay was significant, and Mr Y had to chase the response several times. The Council has agreed with my recommendation to pay £100 in recognition of the avoidable time and trouble this delay caused.

Agreed action

55. Within four weeks of my final decision, the Council has agreed to:
• Apologise and pay £250 to Mr Y for the uncertainty caused by the fault identified in paragraph 22;
• Apologise and pay a further £100 to Mr Y for the avoidable time and trouble he experienced as a result of significant delay in the Home’s handling of his complaint; and
• Provide a copy of the Home’s guidance or policy document regarding the reporting of accidents or injuries sustained by service-users
56. Within twelve weeks of my final decision, the Council has also agreed to:
• Ensure the Home issues guidance to its staff about the importance of completing ‘MUST’ assessments and seeking appropriate and timely medical intervention for service users at risk of malnutrition.

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Final decision

57. I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. The above recommended actions appropriately remedy the injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman