Gracewell Healthcare 3 Limited (19 000 193)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 07 Feb 2020

The Ombudsman's final decision:

Summary: Ms X complains her mother, Mrs Y did not receive the service or quality of care that she expected to receive and had paid for. There were failings in Gracewell of Bookham’s care for Mrs Y which caused Mrs Y and Ms X an injustice. Gracewell of Bookham has made an appropriate offer to remedy this injustice.

The complaint

  1. The Complainant, whom I shall refer to as Ms X complains her mother, Mrs Y did not receive the service or quality of care that she expected to receive and had paid for. Ms X’s complaints include concerns that Gracewell of Bookham care home:
    • did not provide suitable equipment to meet Mrs Y’s needs. She states Mrs Y was bed bound and isolated for two months as Gracewell of Bookham care home did not provide a suitable chair. Mrs Y was also unable to shower or bathe regularly due to a lack of equipment.
    • were not suitably qualified to care for Mrs Y;
    • did not meet Mrs Y’s dietary requirements or adhere to SALT recommendations;
    • did not assist Mrs Y in accessing appropriate daily activities;
    • did not record Mrs Y's weight weekly;
    • did not implement the physiotherapist's recommendations;
    • did not reposition Mrs Y or monitor her skin integrity as recommended; and
    • did not provide appropriate personal hygiene care or oral care.
  2. This is not ana exhaustive list.

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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. 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)
  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. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

  1. As part of the investigation, I have:
    • considered the complaint and the documents provided by Ms X;
    • made enquiries of the Care Home and considered the comments and documents the Care Home provided;
    • discussed the issues with Ms X;
    • sent a statement setting out my draft decision to Ms X and the Care Home and invited their comments.

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What I found

Key facts

  1. Mrs Y moved to Gracewell of Bookham care home in September 2018, having spent several months in hospital following a stroke. Mrs Y had capacity to make her own decisions but needed assistance with all aspect of her personal and daily care. She was at risk of choking and needed a pre-mashed diet and encouragement to eat and drink. Mrs Y was also immobile and needed a specialist chair, wheelchair and shower chair.
  2. As the care home did not have the equipment Mrs Y needed, staff initially cared for her in bed. Ms X was concerned Mrs Y was isolated in her room and could not take part in any activities at the home. She was also concerned that without the proper equipment Mrs Y could not shower or use the commode. Ms X asserted this affected Mrs Y’s wellbeing, and physical health. Ms X also raised concerns that Mrs Y was not being given a choice of meals and that she was bored of having the same foods.
  3. At Ms X’s request the care home reduced its fees for this period to reflect the reduced level of care Mrs Y was receiving until the equipment was in place.
  4. In November 2018 Ms X’s sister, Ms Z made a formal complaint about the level of care Mrs Y was receiving. Ms Z raised concerns about:
    • Mrs Y’s diet and choice of foods,
    • Mrs Y’s positioning and a lack of supervision when she was eating and drink;
    • the failure to monitor Mrs X’s food and fluid intake;
    • the failure to record Mrs X’s weight each week;
    • a lack of oral care;
    • not routinely assisting Mrs Y to wash or bathe;
    • not repositioning Mrs Y regularly;
    • no passive movement and incorrect use of Mrs Y’s support boot
    • no social interaction or stimulation while Mrs Y was bed bound for six weeks;
    • and staff were unaware of Mrs Y’s nursing/care needs.
  5. The care home acknowledged the complaint and confirmed it would respond within 14 days in accordance with its complaint procedure.
  6. Ms Z was not happy to wait, and she escalated her complaint to the Chief Executive. In addition to her original complaints Ms Z raised concerns about an incident a few days earlier when carers found Mrs Y unresponsive and her face had drooped to one side. The family were unhappy that the carer had wanted to call an ambulance but had been overruled by the nurse on duty and that the care home had not monitored Mrs Y’s condition over the following days. Ms Z complained the care home had not informed the family of the incident at the time or provided an incident report. This incident was also the subject of a safeguarding investigation.
  7. Ms X and Ms Z met with care home to discuss their concerns. The care home amended Mrs Y’s care plan in relation to Mrs Y’s meals, weight management and personal care.
  8. Ms X remained concerned about the level of care Mrs Y was receiving and raised further concerns about a lack of personal care and failures to reposition Mrs Y. Ms Z also raised concerns about Mrs Y’s positioning and a failure to assist or supervise her while she ate. Ms X asked the care home for financial compensation or a further adjustment to the fees to reflect the poor level of service it was providing. The care home apologised and agreed to implement further measures to safeguard Mrs Y and alleviate the family’s concerns.
  9. In late December 2018 Mrs X complained to the care home about further incidents and failings in Mrs Y’s care. She noted the care home had received £18,456 in fees for Mrs Y’s care in the twelve weeks since she had moved in and advised she expected a substantial refund. The care home responded in early January 2019, addressing each of Mrs X’s concerns. Ms X did not accept the care home’s explanations and asked for a further meeting. She also chased a response regarding financial compensation.
  10. There was a further discussion of Ms X’s concerns at a safeguarding meeting on 1 March 2019 and an action plan was developed.
  11. In March 2019 the care home agreed to refund one month's care fees, which equates to £6,912.60. The care home states it discussed this with the local authority and proposed to deduct the local authority and NHS contribution and refund the balance of £3384.77 to Mrs Y.
  12. Ms X was prepared to accept the offer of one month’s care fees but disputed the proposed deductions. She asked that the full £6,912.60 be credited to Mrs Y’s bank account. The care home did not agree to refund Mrs Y the full amount and credited £3384.87 to her account. It also agreed to fund six sessions of physiotherapy.
  13. As Ms X rejected this offer, the care home offered, as a gesture of good will to increase its offer to £5000. Ms X remained dissatisfied and asked the Ombudsman to investigate the adequacy of the proposed remedy. Ms X has since asked the Ombudsman to consider the level of care provided as well as the remedy. Ms X states that although the care home agreed to fund physiotherapy it did not pay for and Mrs Y did not receive this service.
  14. In response to my enquiries the care home acknowledges there was a period when Mrs Y first moved to the home where they were waiting for a specialist wheelchair and shower chair. Mrs Y was cared for in bed during the period and the home agreed to a reduction in fees to reflect the reduced level of care she received.
  15. In terms of the qualifications of its staff to care for Mrs Y, the care home states qualified nurses, registered with the Nursing and Midwifery Council work on the nursing floor of the home 24 hours a day. The care home also requires nursing and care staff to undertake a range of training and eLearning so they hold the correct skills to provide direct care.
  16. The care home states Mrs Y was discharged from hospital on a pre-mashed diet. It states it was working with SALT to reduce the risk of malnutrition and aspiration. The care home’s risk assessment notes that Mrs Y sometimes choses to eat regular diet food or her family give her regular diet food. It records that Mrs Y had mental capacity and understood the risks of eating regular diet food, but still chose to.
  17. In relation to Mrs Y’s daily activities the care home states Mrs Y was content to stay in bed and enjoyed watching TV. There were few activities she chose to get involved in but latterly joined seated yoga. The care home acknowledges Ms Y expected Mrs Y to be rehabilitated but states her deteriorating condition and her own choices conflicted with this expectation.
  18. The care home has provided a record of Mrs Y’s weight during her stay, which shows she was weighed regularly, but not always weekly. It states there was a discrepancy in her weight on 17 and 24 December 2018 as the scales were faulty. They were recalibrated and Mrs Y’s weight was accurately recorded on 28 December 2018. On arrival at the care home Mrs Y’s weight was recorded as 50.1Kg and in June 2019, shortly before her death it was 46.3Kg.
  19. The care home states the hospital discharged Mrs Y with a passive movement exercise plan. However, it states Mrs Y would often decline passive movement due to her pain intolerance and care staff were uncomfortable to pursue this when she clearly refused. The care home arranged for a physiotherapist to assess Mrs Y and then paid for six sessions. It also arranged for the physiotherapist to train the care staff so they could continue the exercises.
  20. The care home states it repositioned Mrs X and monitored her skin integrity throughout her stay. Mrs Y did not suffer from any skin integrity concerns while at the care home and was free from pressures sores. The care home also states Mrs X was given appropriate support with personal and oral care throughout her stay.
  21. In terms of the remedy offered, the care home has confirmed it is now willing to reimburse the full sum of £6912.60 and would credit the balance of £3527.83 to Mrs Y's bank account. The care home has also offered to apologise and pay £500 to reflect the time taken to resolve this matter, the effort, inconvenience and stress that has been caused to Ms X.
  22. In response to the draft decision Ms X has reiterated her concerns that the care home failed to provide Mrs Y with an appropriate level of care to meet her complex needs. She maintains that staff were not adequately experienced or trained to deal with Mrs Y’s care needs and were unable to manage her pain.
  23. Mrs X disputes that Mrs Y chose to decline care or support. She asserts the care home’s the failure to manage Mrs Y’s pain meant there were occasions when she was unable to tolerate being moved or touched. Ms X also states Mrs Y had only limited capacity to make her own decisions. She states Mrs Y was able to make basic decisions but unable to make more complex decisions relating to her health, care or safety.
  24. In addition, Ms X does not consider the care home’s offer is adequate redress for the injustice caused to Mrs Y during her time at the care home. She believes the care home should refund a further two months’ care fees, totalling £13,825.20 in addition to the £6912.60 it has offered.


  1. There is no dispute there were shortcomings in Mrs Y’s care while at the care home. The care home has acknowledged and accepted this in its correspondence with Ms X. The issues were also discussed at the safeguarding meeting in March 2019 and actions were identified to improve the service.
  2. Notwithstanding these shortcomings, it is also clear from the care notes that there were times when Mrs Y chose not to accept support, where for example she did not want to get out of bed or did not want to have a shower or oral care. These are decisions Mrs Y was entitled to make and I would expect the care home to respect Mrs Y’s wishes.
  3. Ms X disputes Mrs Y’s capacity and believes any refusal was based on Mrs Y becoming increasingly unable to tolerate being touched or moved. The minutes of the safeguarding meeting note there was a discussion around Mrs Y declining offers of care or support. The notes state the family suggested that rather than just accepting Mrs Y has declined support, staff could be more forceful in their encouragement. The Chair advised that Mrs Y had capacity and that if she said no, staff had to respect her response. The Chair also noted that Mrs Y had advised them she hated showering.
  4. The failings in the care have caused Ms X and Mrs Y an injustice. The main injustice of the home’s actions would be to Mrs Y. As Mrs Y has died, I am unable to recommend a practical remedy for any injustice caused to her. The care home has however made a financial offer to redress this injustice. I consider this to be an appropriate remedy.
  5. I recognise Ms X does not consider the care home’s offer to be adequate, but our guidance on remedies does not support an increased remedy. Our guidance states that where the injustice is distress, harm, or risk, we will not normally seek a substantive remedy in the same way as we might for someone who is still living.
  6. I consider the care home’s failings have also caused Ms X an injustice. Ms X has experienced distress and anxiety in relation to the failings in Mrs Y’s care; and has been put to unnecessary time and trouble to trying to resolve the matter.

Agreed action

  1. The care home has agreed to reimburse a further £3527.83 to Mrs Y’s estate in respect of her care fees.
  2. The care home has also agreed to apologise and pay Ms X £500 in recognition of the distress and unnecessary time and trouble she has been put to in trying to resolve this matter.
  3. The care home should take this action within one month of the final decision on this complaint.

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Final decision

  1. There were failings in Gracewell of Bookham’s care for Mrs Y which caused Mrs Y and Ms X an injustice. Gracewell of Bookham has made an appropriate offer to remedy this injustice.

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Investigator's decision on behalf of the Ombudsman

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