Summary: The care provider failed to provide proper care and treatment to the late Mr X. As a result, he suffered the development of a pressure sore, and a loss of dignity; his family suffered from knowing Mr X did not receive the care they expected. The care provider will now review its staff training and offer a payment to Mr X’s family.

The complaint

1. Mrs A (as I shall call the complainant) complains that the care provider failed to provide proper care for her father, the late Mr X, when he was in Brookview Care Home in 2018 for respite. In particular she complains that the care provider failed to attend to her father’s continence needs and left him in a soiled condition.

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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 the information provided by Mrs A and by the care provider. I spoke to Mrs A. Both Mrs A and the care provider had an opportunity to comment on an earlier draft of this statement before I reached a final decision.

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What I found

Relevant law and guidance

5. 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.
6. Regulation 9 says that a care provider must provide care and treatment which is appropriate and meets people’s needs. It adds that care and treatment must not be given if to do so it would act against the consent of the person receiving the care.
7. Regulation 10 says that people should be treated with dignity and respect and be supported to “wash, bath and use the toilet”.
8. The Mental Capacity Act 2005 says a person must be presumed to have capacity to make a decision unless it is established that he or she lacks capacity. A person should not be treated as unable to make a decision:

• because he or she makes an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

What happened

9. Mr X had stayed in Brookview for a respite stay in 2017 without any problems. Mrs A says when she arranged his respite stay for November 2018, she explained clearly to the care provider his need for assistance with personal care and hygiene. She says her aim was to ensure he showered regularly.
10. The pre-admission assessment completed by the care provider says Mr X needed “minimal assistance” with showering and using the toilet. The pre-admission assessment describes him as Band 3 – “requires assistance with most activities of living with a focus on the essentials of care”. He also needed assistance to administer rectal medication.
11. Mr X’s care plan said he “needs prompting – encourage showers on alternate days and change clothes daily”. It said his personal hygiene had been neglected at home due to his deteriorating condition. It noted he had full capacity and understood risks.
12. Mrs A says every time she visited her father in the care home she voiced her concerns about the lack of personal care given. She says his room smelled badly and he had been left in his bathroom in a soiled state for some time on one occasion when she visited. She says when she complained, carers told her the care home was short-staffed or carers had been busy, and promised to shower him later. After admission to the home on 16 November, the first record of a shower was on 25 November. A note for 29 November records, “(Mr X) is self-caring, refusing any assistance”.
13. A carer’s record for 5 December notes Mr X had spent the night upright in his chair. The carer offered assistance to move him to bed and discovered he had been incontinent. When changing his pad she noticed he had a grade 3 pressure sore. The body map describes the area as “very red and sore with two broken areas, Grade2/3 pressure sore.”
14. Mr X suffered a cardiac arrest on 5 December and died later in hospital.

The complaint

15. In January 2019 Mrs A complained to the care provider about the lack of personal care provided to her father during the respite stay.
16. Following an initial response from the home manager, Mrs A made a further complaint. The regional director responded in April. She said Mr X was being helped with his personal care but “on occasion” would refuse help. She said staff were asked to return later and offer help again if he declined assistance. She agreed with Mrs A the odour in his room was unpleasant but said it had become difficult for him to use the toilet and he was incontinent of faeces. She said on 5 December the nurse on duty “had to insist” Mr X accepted personal care.
17. Mrs A complained to the Ombudsman.
18. The care provider says when residents refuse personal care, staff are trained to offer later, or ask another member of staff to try. They should record a refusal in the resident’s notes.
19. The care provider says it has been difficult to comment on the complaint as the care home has had many new members of staff as well as a new manager. The care provider is unable to say, for example, why staff generally accepted Mr X’s refusal of care but on one occasion a nurse “had to insist” he accepted.
20. Mrs A says her father’s final days were “horrendous”. She said the care provider has dismissed her concerns and chased the family for payment.
21. Following my draft decision the care provider says “The Home Manager of Brookview has already requested the training via the Learning & Development team for the care staff to assist them with residents who have stressed and distressed behaviours around personal care and how to manage when a resident does not accept the care when offered.”

Analysis

22. Mr X’s needs were made clear to the care provider before he was admitted. The care plan was specific that the care provider should “prompt” and “encourage” Mr X to take showers because of his increasing neglect of his hygiene.
23. The care provider failed to record Mr X’s refusals, except on one occasion, and avoided addressing the issue by describing him as “self-caring” and “independent”. The care provider did not provide the service Mr X needed.
24. The care provider says carers could not insist on providing care because Mr X had capacity to make his own choices. However, there is no evidence of carers prompting or encouraging Mr X to accept care, as stipulated in his care plan. That he could be prompted to accept care is demonstrated by the ability of the nurse who attended him on 5 December to do so.
25. One result of the failure to provide appropriate care was the development of a pressure sore, which was unnoticed until the morning of Mr X’s death. In addition, he was left soiled for long periods of time, Mrs A says, and his family was left with the overriding impression that Mr X suffered as a result of poor care.

Agreed action

26. Within one month of my final decision the care provider will let me have details of the staff training in respect of managing distressed behaviours.
27. Within one month of my final decision the care provider will review staff training on completion of care records;
28. Within one month of my final decision the care provider agrees to offer a payment of £1000 to Mrs A in acknowledgement of the distress caused to her family by the poor care Mr X suffered.

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Final decision

29. The actions of BUPA caused injustice to the late Mr X and to his family, which the agreed recommendations will remedy.

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Investigator's decision on behalf of the Ombudsman