Summary: the care provider did not adhere to the care plan to keep Mrs X’s nails clean, and did not adhere to its complaints procedure. It should apologise formally for its shortcomings, ensure its compliance with the care plan and make a payment of £250 in recognition of the unnecessary time and trouble Mr and Mrs A were caused in making a complaint.

The complaint

1. Mrs and Mrs A complain that the care provider upheld their complaint that it had failed properly to attend to the personal hygiene of Mrs X, but then failed to put in place the agreed actions.

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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))

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How I considered this complaint

4. I considered all the information I received from the complainant and the care provider. We spoke to Mr A. Both the care provider and Mr and Mrs A now have the opportunity to comment on this draft statement before I reach a final decision.

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What I found

Relevant law and guidance

5. 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)
6. 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.
7. Regulation 9 says care provided to residents must be appropriate and meet their needs.
8. Regulation 10 says care users must be treated with dignity and respect.
9. 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)
10. The care provider’s complaints procedure says verbal complaints should either be resolved immediately or passed to a manager. “Serious or written complaints” should be acknowledged, investigated within 14 days and a full explanation supplied (either in writing or at a meeting). The complaints procedure signposts dissatisfied complainants to us.

What happened

11. Mrs X, an elderly lady with dementia, became resident in the care home in 2015.
12. In August 2018 Mr and Mrs A raised a safeguarding concern with the local council about the care of Mrs X. In particular Mrs A was concerned about faeces under her mother’s fingernails. She said a manicurist visited the home every two weeks but Mrs X’s fingernails were not cut regularly.
13. The local council made safeguarding enquiries and the care provider devised a care plan in response to concerns. The plan was for improved communication with Mr and Mrs A, regular checking of Mrs X’s nails after toileting (Mrs X is mobile and manages her own toilet needs) and before meals, and a detailed record of the manicurist’s attendances.
14. At the safeguarding review meeting in January 2018, Mrs A was concerned there were still sometimes traces of faeces under her mother’s nails although the home manager said she had introduced a policy of cleaning all residents’ hands with wet wipes before meals (so as not to single out Mrs X). The home’s records showed Mrs X’s hands were being cleaned several times a day. The care home managers asked Mr and Mrs A to approach them directly if they had concerns.
15. The council noted the care home manager was “defensive” in her attitude but concluded it was satisfied the safeguarding plan was being implemented and closed the case. The notes of the meeting record the safeguarding manager suggested Mrs A consider moving Mrs X to another home if she felt her mother’s needs were not being met, although Mrs A said she did not want to move Mrs X.

The complaint

16. The manicurist’s records show Mrs X’s nails were cut on 8 January, 29 January and 8 February. Mrs X was admitted to hospital subsequently and returned to the care home on 27 February, after the manicurist’s next visit.
17. On 8 March Mrs A noticed faeces under the nails of both Mrs X’s hands when she went into lunch. She tried to complain to the care home manager but the manager (sitting in the lounge with other residents) said she was “sick” and so not working. The manager asked Mr and Mrs A to speak to her son (the deputy manager) but the care home says they refused to do so.
18. Mr and Mrs A complained in person to the care home manager on 9 March about the length and condition of Mrs X’s nails. They say the care home manager was “adamant”, without checking the records, that Mrs X’s nails had been cut by the manicurist on 25 February.
19. On 11 March the deputy manager emailed Mr A saying he would find out what had happened about the missed visit and invite them to a meeting to discuss the next steps. On 13 March he emailed again suggesting some days for a meeting. Mr A responded that he would check with Mrs A and asked who else would be attending. On 25 March the deputy manager emailed saying “we have dealt with the issue internally and as we haven’t heard from both of you to arrange a meeting we have closed this complaint down”.
20. Mr A responded. He said he did not realise there was a time limit on arranging a meeting (and the care provider’s complaint procedure did not say there was). He asked for a full explanation of what had happened.
21. The deputy manager replied. He said there was a simple explanation which was that staff had overlooked cleaning Mrs X’s nails. He acknowledged the care home could have arranged to have Mrs X’s nails cut on her return from hospital. He reminded Mr A the safeguarding meeting had recommended Mr and Mrs A bring their complaints to staff members when there was a concern, but Mrs A had not done so on her visits. He said because Mrs X took herself to the toilet they could not guarantee cleanliness at all times. Finally he said they should consider the option of moving Mrs X if they thought her needs were not being met.
22. Mr A complained to the Ombudsman that the care provider had failed to adhere to the plan agreed at the safeguarding review meeting in January, and had not complied with its own complaints procedure. He said Mrs A was reluctant to raise concerns with staff because of the care provider’s attitude towards her.
23. The care provider says as it did not hear from Mr A after his holding reply of 13 March it concluded he did not want to pursue the complaint further. It says it admitted there had been an occasion when Mrs X’s nails were not manicured as stipulated and the manicurist had failed to record the missed occasion. It acknowledges it should have told Mr A of his options to pursue the complaint in writing.
24. The care provider updated Mrs X’s care plan to reflect Mrs A’s wishes that Mrs X’s nails are cut every two weeks and kept as short as possible. The care plan also says, “It has further been agreed with her daughter that if faeces are noted under her nails then her hands are to be soaked in warm water with Zero Base in it, and a nail brush used to remove any dirt. Again record on CMS. Also check again if faeces reported on toilet seat. Staff to monitor her bed and toilet daily, as these can sometimes need attention as her eyesight is not good.”

Analysis

25. There was a failure on the part of the care provider to adhere to the agreed safeguarding plan, both in respect of the missed manicurist visit which was not rectified, and the failure to ensure Mrs X’s nails were clean before meals. That caused injustice and a loss of dignity to Mrs X, as well as failing to meet her needs.
26. The care provider also failed to comply with its complaints procedure: it did not provide a full explanation before it tried to close down the complaint. It was poor practice to include in the complaints response the suggestion that Mr and Mrs A look for another home. Mr and Mrs A should not have had to pursue the complaint for so long over a matter such as the cleanliness of Mrs X’s nails.

Recommended action

27. Within one month of my final decision the care provider will review its manicurist’s records for the last 6 months and confirm to me its compliance with the care plan;
28. Within one month of the final decision the care provider will offer a payment to Mr and Mrs A of £250 to recognise the unnecessary time and trouble they were put to in pursuing the complaint.

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Final decision

29. I find that the actions of the care provider caused injustice which the actions recommended in paras. 27 and 28 will remedy.

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Investigator's decision on behalf of the Ombudsman