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Countrywide Care Home (2) Limited (18 019 078)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 25 Oct 2019

The Ombudsman's final decision:

Summary: Mrs X complains about the level of care the care home gave Mrs M, it’s failure to respond to the concerns she raised and its decision to evict her. The care provider is at fault for causing an injury to Mrs M with jewellery in October 2017, not protecting Mrs M’s dignity in August 2018, not ensuring it met Mrs M’s personal care needs and for not keeping her room clean. It was not at fault for how it reached it decision to evict her. It should pay Mrs M £500 to acknowledge the distress caused and pay Mrs X £250 for the distress caused and to acknowledge her time and trouble in pursuing the complaint.

The complaint

  1. Mrs X complains about the level of care provided to Mrs M at Argyle House Care Home (the care home).
  2. Mrs X says the care home did not address her complaints, and it took no action to rectify the problems she identified.
  3. Mrs X says the care home issued a notice of eviction on the grounds the family had complained about the care provided.

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The Ombudsman’s role and powers

  1. 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)
  2. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
  3. 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.
  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. Mrs X has power of attorney for Mrs M and is a suitable person to represent Mrs M.
  6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
  7. Mrs X complained to us in March 2019. She complained about the level of care provided for Mrs M from July 2015 onwards but Mrs M had significant concerns about the care provided from September 2017. Therefore, I exercised discretion to start my investigation in September 2017. Mrs M moved to a new care home in January 2019.
  8. If we are satisfied with a care provider’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

  1. I considered the information provided by:
    • Mrs X, including diaries she had kept throughout the period investigated;
    • the care provider, in response to my enquiries;
    • the council where the care home is situated, which considered safeguarding referrals relating to Mrs M during the period investigated.
  2. I also considered:
    • the Care Quality Commission’s (CQC) Fundamental Standards; and
    • our guidance on remedies.
  3. I gave Mrs X, the care provider and the council an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Relevant law and guidance

Fundamental Standards of Care

  1. 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 not fall.
  2. The standards include the right to person-centred care, to be treated with dignity and respect, to receive safe care, to be protected from any form of abuse or improper care, and that the premises where you receive care and the equipment used in it should be clean, suitable and looked after properly.
  3. The standards say the care provider must have a system in place to handle and respond to complaints. They must investigate complaints thoroughly and take action if problems are identified.
  4. The CQC carries out regular inspections of care providers. It makes announced and unannounced visits, and it publishes reports of its findings on its web-site. It rates the care provider on whether the service is safe, effective, caring, responsive, and well-led.


  1. A council must make 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)
  2. Concerns can be referred to a council by a family member, concerned member of the public or by the care provider itself.

What happened

September to November 2017

  1. Mrs M moved into the care home in July 2015. By September 2017 she needed nursing care and was confined to bed. She needed support for all her care needs.
  2. Mrs X raised concerns about the level of care with the care home manager and with the area manager in October 2017 and sent the area manager photos she had taken.
  3. Mrs X met the area manager in early November 2017. Her diary shows she was concerned about:
    • the standard of personal care provided;
    • unexplained bruises that she thought were due to rough handling by carers;
    • a small tear on Mrs M’s arm caused by the ring a carer wore when giving personal care in early October 2017;
    • dressings not changed regularly and allowed to get dirty;
    • Mrs M lying in wet bedding after the care home had left her unsupervised with a cup of tea, which had spilt;
    • Mrs M again lying in wet bedding two days after reporting the previous incident, due to being left unattended with a milkshake.
  4. The area manager wrote to Mrs X to confirm the action the care home would take to address her concerns, including:
    • ensuring Mrs M would not be left alone in the room with a drink;
    • reviewing the care plan;
    • specific actions to improve communication between the care home and the family;
    • discussions with staff about how to minimise the risk of bruising.
  5. The care home investigated the incident with the ring and reminded staff about its uniform policy. It reported the incident to the council’s safeguarding team and to CQC. The council investigated and wrote to Mrs X to say the complaint was substantiated. It closed the case because the care provider had taken appropriate action.
  6. Care home records show Mrs M was aggressive towards staff when they tried to give personal care. The records show the care home discussed the difficulties with Mrs X and the G.P and took account of their views. The records show staff were asked to distract Mrs M and, if she was not willing to accept support, to try again later. Mrs X says the care home agreed not to shower Mrs M to avoid causing her distress but continued to do so. The care home records state Mrs M’s distress with showers was discussed with Mrs X and it was agreed showers would only be given by staff members that Mrs M was comfortable with.
  7. Mrs X considered moving Mrs M to a new care home in November 2017 but was worried this would be disruptive for Mrs M so decided not to move her.


  1. In early February 2018, Mrs X noticed a new unexplained bruise on Mrs M’s hand. The following day, Mrs M had a skin tear on the same hand. The new care home manager reported this to the council’s safeguarding team. The council investigated. It noted Mrs M had very frail skin when she moved to the care home. It decided the care home had taken appropriate action and closed the case.
  2. In March 2018 Mrs X reported concerns about the bathroom being dirty and Mrs M’s dentures sitting in dirty water to the care home manager. She says the care home told her staff were not cleaning Mrs M’s teeth because she was aggressive when they tried to do so. The care home does not have a record of this complaint. It acknowledged the difficulties with personal care and said it worked with the family and G.P to address this. In late March 2018 the G.P agreed to prescribe sedatives to enable personal care to be given.
  3. In April 2018 Mrs X reported Mrs M was sitting in a very soiled pad. She says a carer apologised and changed it.
  4. In June 2018 Mrs X reported Mrs M’s room was dirty.
  5. In early July 2018 Mrs M started sucking on soft toys and bedding, and was at risk of choking. This was recorded in Mrs M’s care plan.
  6. On late August 2018 a relative told Mrs X she had seen a carer feeding Mrs M, who had no clothes on her lower body at the time. When questioned about this, the carer told the relative the care home had run out of pads. Mrs X reported her concerns to the council’s safeguarding team in September 2018.
  7. Council records show the care home accepted Mrs M was not properly clothed but had explained the reasons this occurred, which the Council accepted. It advised the care home to ensure Mrs M was dressed at all times to protect her dignity and, where this was not possible, to record the reasons for this.
  8. In response to my enquires, the care home explained it did not have Mrs M’s usual continence products due to a problem with delivery that was outside its control and the underwear available was too big to secure the pad used. It also said that Mrs M did not like to wear dresses or trousers when she was in bed.
  9. In late August and again in early September 2018, Mrs X says she reported concerns about the bathroom being dirty to the care home manager. Mrs X says the care home did not address this so she spoke to the care home manager again in late September. Mrs X met with the care home manaqer on 1 October 2018 to discuss her concerns. The care home could not provide a record of this meeting.
  10. On 5 October 2018 the care home wrote to Mrs X giving 28 days’ notice for Mrs M to leave. It said: “Following the meeting with you on 1st October 2018, we feel that the relationship has broken down, and the placement has become strained and a lack of trust has built up”. The care home said when it sent the notice letter it had been informed the family were looking for an alternative provider and one provider had assessed Mrs M but could not meet her needs.
  11. Mrs X contacted the council’s safeguarding team on 8 October 2018. Council records state she sent it photos that showed bruising, skin tears from rough handling, and poor hygiene. The council spoke to the care home manager.
  12. A council officer met with Mrs X and the care home manager on 23 October 2018. The Council did not make a formal record of this meeting. However, it’s client file indicates the care home accepted the complaints were substantiated and agreed a plan of action to address the concerns. The plan included the following actions:
    • ensure towels and flannels were removed after every personal care task;
    • change the small towel Mrs M chewed on and to wipe clean her hands at each hourly check;
    • ensure dental hygiene needs were met.

Mrs X says the then care home manager told her after the meeting she would withdraw the eviction notice. The care home has no record of this.

  1. Council records show an officer visiting the care home around this time saw Mrs M’s room was “not free from dirt”.
  2. The care home appointed a new manager (manager 3) in early December 2018. Mrs X raised concerns with manager 3 about:
    • Mrs M lying in dried faces that was stuck to her bottom and the sheets;
    • Mrs M lying on a soiled sheet and the mattress not wiped;
    • carers using an unsafe method for moving Mrs M in bed;
    • Mrs M being given a gift with a ribbon that was a choking risk that care staff did not remove;
    • Mrs M being showered and left with wet hair when she was full of cold. The same day the GP diagnosed a chest infection and prescribed antibiotics.
    • manager 3 deciding Mrs M should be checked every two hours, when previously Mrs M was checked every 30 minutes because of the high choking risk.

Mrs X made a formal complaint about the first three issues and about the frequency of checks.

  1. In late December 2018 Mrs X contacted the council’s safeguarding team again. The council made further enquiries and decided to increase its monitoring of the care home.
  2. On 4 January 2019, the care home responded to the formal complaint. It said:
    • it had provided care according to Mrs M’s care plan;
    • Mrs M was known to remove her continence products and staff monitored her through the day to ensure she was not left in soiled bedding;
    • all staff had appropriate training for moving and handling – the carers involved in the incident complained about were agency staff and agency staff were no longer used;
    • 30 minute checks were agreed by a previous manager in November 2017 for a limited period. This was reviewed and discontinued in April 2018.

Mrs X says Mrs M was no longer capable of removing incontinence pads and had not done so for 12 months prior to the incidents she complained about.

  1. Care home records show it had agreed to check Mrs M every 30 minutes in November 2017 to ensure she was comfortable and free from pain. The record states this was for a limited period. The care plan was reviewed in April 2018 and checks every 30 minutes stopped. In July 2018 the care home identified Mrs M was now at risk of choking because she was chewing bedding and soft toys. Its choking assessment stated Mrs M should be closely monitored but did not say this should be every 30 minutes. In response to my enquiries, the care home said checks were based on each resident’s individual needs and were not every two hours for all residents. It said Mrs M’s room was close to the nurses’ station so they were able to see and hear her at all times. It also said there were no choking incidents from November 2017 to December 2018.
  2. On 4 January 2019, the care home wrote to Mrs X to say that although more than 28 days had passed since it gave notice for Mrs M to leave, the notice still stood. It asked Mrs X what progress she had made to find an alternative care home for Mrs M. It asked Mrs X to provide details of a new placement by 28 January.
  3. In response to my enquiries, the care home said it had implemented the actions recommended by the council’s safeguarding social worker and had tried to mediate with the family. However, the family continued to raise concerns with the care home and did so in an aggressive manner. The care home considered its relationship with the family had broken down.
  4. The care home’s contract says it may terminate the occupancy on four weeks’ notice. The contract does not set out any specific grounds for termination. Its termination policy says it should hold a meeting with the resident or their representative and the manager should address their concerns where possible.
  5. The CQC inspected the care home in April and September 2018 and said it required improvement. Whilst it is clear the CQC identified serious failings at the care home, a poor inspection does not mean every resident in the care home had poor care.

My findings

  1. In reviewing the daily records, I note care home staff were not recording the specific care provided nor when care was refused, and what action was taken following refusal. This is fault. The Council gave the care home advice about improving its records in December 2018. The care home has provided documents to show how it implemented the Council’s recommendations.

September to November 2018

  1. Care home records show Mrs M was not happy for staff to support her personal care. The care home took appropriate steps to encourage Mrs M to accept personal care. It consulted the family and the GP about what action to take. It agreed that showers would only be given by staff Mrs M was comfortable with to minimise her distress.
  2. Mrs M was injured in early October 2017 by a carer wearing a ring. This was fault. The carer apologised for the accident and the care home took appropriate action. However, the injury did cause some distress to Mrs M and Mrs X.
  3. Care home records show it accepted failings in October 2017 when Mrs M was twice found in wet bedding due to spilt drinks. It agreed not to leave Mrs M alone with a drink in future. I have noted only one further incident of a spilt drink. This is not sufficient to make a formal finding of fault.
  4. Mrs X accepts the care home responded to her concerns at this point and the level of care improved between November 2017 and January 2018.


  1. Mrs X reported an unexplained bruise in February 2018. The council’s safeguarding team investigated. It concluded the care home had taken appropriate action. There is insufficient information for me to determine what caused this bruise and whether it was due to fault by the care home.
  2. Mrs X’s diaries record a further complaint in March 2018 about the state of the bathroom and Mrs M’s dentures. The care home has no record of this complaint. I note there were difficulties in providing personal care at this time and later that month the GP prescribed sedatives to ensure personal care could be provided. There is insufficient evidence to reach conclusions on this aspect of the complaint.
  3. The care home accepted it had fed Mrs M on one occasion when she was in bed and not fully clothed. Its records show Mrs M did not like to wear clothing on her lower body when she was in bed. It did not have the correct continence products and the underwear available was too large to secure the alternative pads. It is not clear why the usual continence products were not available. On balance, I consider the care home was at fault for not protecting Mrs M’s dignity or recording the reasons why it could not do so on this occasion. This was fault that caused distress to Mrs M and her family.
  4. Overall, the records show Mrs M’s needs were generally met. However, there were incidents where the care provided was not up to standard, particularly in relation to personal care. Council records show the care home accepted failings in relation to personal care and cleanliness in Mrs M’s room in October 2018. This was fault. This fault caused distress to Mrs M and to her family. The care home agreed an action plan with the council and the council has monitored to ensure the actions were implemented and so no further procedural recommendations are required.
  5. Mrs X thought the care home had agreed to carry out checks on Mr M every 30 minutes. However, the records show it agreed to check Mrs M hourly from April 2018. There is no record the care home agreed to 30 minute checks, specifically because of the choking risk, and there is no record of a choking incident in the period I am investigating. I am satisfied the care home considered the risk of choking and made regular checks.
  6. The contract allows the care home to terminate the placement on 4 weeks’ notice. There is nothing in the contract that restricts the grounds on which it can do so. Its policy says it will meet with the resident or their family to try to address their concerns and the care home did this. It is clear the care home had not addressed the concerns to the family’s satisfaction and considered the relationship between them had broken down. The notice was effectively suspended whilst the council investigated Mrs X’s safeguarding complaint. However, the relationship between the parties had not improved so manager 3 asked Mrs X to find an alternative care home for Mrs M. The care home allowed Mrs X four weeks to do this, which was in line with its contract. It was not at fault for terminating the placement.

Agreed action

  1. The care provider will, within one month of the date of the final decision, apologise to Mrs X for the distress caused by its faults in causing an injury to Mrs M with jewellery in October 2017, not protecting Mrs M’s dignity in August 2018, not ensuring it met Mrs M’s personal care needs and for not keeping her room clean.
  2. The care provider will, within one month of the date of the final decision, pay Mrs M £500 for the distress caused to her as a result of these failings. It should also pay Mrs X £250 to acknowledge the distress the faults caused her and her time and trouble in pursuing the complaint.
  3. The care provider has already implemented the action recommended by the Council in relation to the safeguarding referrals so I make no further recommendations.

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Final decision

  1. I have completed my investigation. I have found fault leading to injustice. I have recommended action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman

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